Washington State Intermediate Life Support Manual, Guidelines and Curriculum

EMT-INTERMEDIATE
National Standard Curriculum

Washington State Amended Edition
Revised April 2000
The Washington State EMT-Intermediate Program
Intent:
The purpose of the intermediate life support level of training and certification is to provide
specific, limited life-saving skills to rural areas that cannot yet make the commitment to
develop or maintain full paramedic service. This level is not to substitute for paramedics in
existing services, diminishing the level of existing care. Approval of ILS course and
certification of personnel shall be based on the Regional EMS/TC Plan, and shall result in
an improved level of care. For any patient requiring care beyond the BLS level, it is also
intended that when paramedic service is available, ILS personnel shall contact medical
control for advice about rendezvous with paramedics as soon as possible.
EMT-INTERMEDIATE: NATIONAL STANDARD CURRICULUM
Project Director
Walt A. Stoy, Ph. D., EMT-P
Associate Professor and Chair
Emergency Medicine Program
School of Health and Rehabilitation Sciences
Research Associate Professor of Emergency Medicine
Department of Emergency Medicine
School of Medicine
University of Pittsburgh
Director of Educational Programs
Center for Emergency Medicine
Principal Investigator
Gregg S. Margolis, MS, NREMT-P
Assistant Professor, Emergency Medicine Program
Instructor, Department of Emergency Medicine
School of Medicine
Associate Director of Education
Medical Directors
Paul M. Paris, MD, F.A.C.E.P.
Professor and Chairman
University of Pittsburgh School of Medicine
Chief Medical Officer
Medical Director
City of Pittsburgh, Department of Public Safety
Medical Director
Emergency Medical Services Institute
Ronald N. Roth, MD, F.A.C.E.P.

Assistant Professor of Medicine
University of Pittsburgh School of Medicine
Associate Medical Director
City of Pittsburgh, Emergency Medical Services
Medical Director of Paramedic Education
Contract Number DTNH22-95-C-05108
Contract Administrators
EMT-Intermediate: National Standard Curriculum - Washington State Amended Edition
Revised - April, 2000
Debra A. Lejeune, BS, NREMT-P

Coordinator of Publishing
Lecturer
Emergency Medicine Program
School of Medicine
Gregory H. Lipson, MHA, MBA, NREMT

Group Leaders
William E. Brown, Jr., RN, MS, CEN, NREMT-P Steve Mercer, EMT-P
Executive Director National Council of State EMS Training
National Registry of Emergency Medical Coordinators, Inc.
Technicians Education Coordinator
Iowa Department of Public Health
Robert W. Dotterer, BSEd, MEd, NREMT-P Bureau of EMS
Phoenix Fire Department
Emergency Medical Services Section Joseph J. Mistovich, M.Ed., NREMT-P
Phoenix College Chairperson
EMT/FSC Department Department of Health Professions
Associate Professor of Health Professions
Richard L. Judd, PhD, EMSI College of Health and Human Services
President Youngstown State University
Central Connecticut State University
Lawrence D. Newell, EdD, NREMT-P
Baxter Larmon, PhD, MICP President
Associate Professor of Medicine Newell Associates, Inc.
Associate Director, Center for Prehospital Care Adjunct Professor, Emergency Medical Technology
UCLA School of Medicine Northern Virginia Community College
Director, Prehospital Care Research Forum
Jonathan F. Politis, BA, NREMT-P
Kathryn M. Lewis, RN, BSN, PhD Chief
Department Chair Town of Colonie, NY
Emergency Medical Technology/Fire Science Department of Emergency Medical Services
Phoenix College
Chair Bruce J. Walz, PhD, NREMT-P
EMT/FSC Instructional Council Associate Professor and Chair
Maracopa County Community College District Department of Emergency Health Service
University of Maryland Baltimore County
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NATIONAL REVIEW TEAM

Ralph J. DiLibero, MD Lori Moore, MPH, EMT-P
American Academy of Orthopaedic Surgeons Director of Emergency Medical Services
International Association of Fire Fighters
Peter W. Glaeser, MD
American Academy of Pediatrics Debra Cason, RN, MS, EMT-P
Professor of Pediatrics JRC on Educational Programs for the EMT-P
University of Alabama at Birmingham University of Texas Southwestern Medical Center
Mike Taigman, EMT-P Linda K. Honeycutt, EMT-P

American Ambulance Association President
National Association of EMS Educators
Jon R. Krohmer, MD, FACEP EMS Programs Coordinator
American College of Emergency Physicians Providence Hospital and Medical Centers
Medical Director, Kent County EMS
Department of Emergency Medicine, Butterworth Nicholas Benson, MD
Hospital Immediate Past President
National Association of EMS Physicians
Peter T. Pons, MD, FACEP Professor & Chair, Dept of Emergency Medicine
American College of Emergency Physicians East Carolina University School of Medicine
Denver Health Medical Center Linda M. Abrahamson, EMT-P
National Association of EMTs
Scott B. Frame, MD, FACS, FCCM EMS Education Coordinator
American College of Surgeons Committee on Silver Cross Hospital
Trauma
Associate Professor of Surgery Robert R. Bass, MD, FACEP
Director, Division of Trauma/Critical Care National Association of State EMS Directors
University of Cincinnati Medical Ctr Maryland Institute for Emergency Medical Services
Systems
Norman E. McSwain, Jr., MD, FACS
American College of Surgeons Committee on Steve Mercer, EMT-P
Trauma National Council of State EMS Training
Professor of Surgery Coordinators, Inc.
Tulane University School of Medicine Education Coordinator
Iowa Department of Public Health
Ralph Q. Mitchell, Jr. Bureau of EMS
Association of Air Medical Services
Roger D. White, MD, FACC
Edward Marasco National Registry of EMT’s
Association of Air Medical Services Department of Anesthesiology
The Mayo Clinic
Kathy Robinson, RN
Emergency Nurses Association David Cone, MD
EMS Education Coordinator Society for Academic Emergency Medicine
Silver Cross Hospital Chief, Division of EMS
Captain Willa K. Little, RN, CEN, EMT-P MCP-Hahnemann School of Medicine
International Association of Fire Chiefs Allegheny University of Health Sciences
Emergency Medical Services Training Officer
Montgomery County Dept of Fire & Rescue
Services
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TABLE OF CONTENTS
PREFACE ..................................................................................................................... VI
ACKNOWLEDGMENTS................................................................................................ VI
United States Department of Transportation, National Highway Traffic Safety ...................................... vii
United States Department of Health and Human Services, Health Resources and Human Services
Administration, Maternal and Child Health.............................................................................................. vii
Authors .................................................................................................................................................... vii
Subject Matter Experts ........................................................................................................................... viii
ADJUNCT WRITERS .................................................................................................. VIII
Liaisons .....................................................................................................................................................x
In-Kind Services ........................................................................................................................................x
Arizona Pilot Test Site ...............................................................................................................................x
Field Test Sites.........................................................................................................................................xi
Center for Emergency Medicine...............................................................................................................xi
EMT-INTERMEDIATE CURRICULUM - COURSE TOPICS ....................................... XIII
Required Initial Instruction for the Intravenous Therapy Certification .................................................... xiv
Required Initial Instruction for Airway Certification..................................................................................xv
Required Initial Instruction for IV/Airway Certification ............................................................................ xvi
Required Initial Instruction for ILS Certification ..................................................................................... xvii
Required Initial Instruction for ILS/Airway Certification ........................................................................ xviii
Required Instruction to Upgrade from The Old 1985 DOT Module Training & Certification
to the New 2000 ILS or ILS/Airway Certification Level........................................................................... xix
Required Instruction to Upgrade from 2000 IV, AW or IV/AW Training & Certification
Levels to the New 2000 ILS or ILS/Airway Certification Level ................................................................xx
Required Instruction to Transition from OLD 1985 IV, AW or IV/AW Training & Certification
Levels to the New 2000 IV, AW or IV/AW Training & Certification Levels ............................................. xxi
THE EMT-INTERMEDIATE: NATIONAL STANDARD CURRICULUM ..........................1
History....................................................................................................................................................... 1
The Curriculum Development Process .................................................................................................... 1
Curriculum Goal and Approach ................................................................................................................ 2
Description of the Profession ............................................................................................................... 3
Educational Model................................................................................................................................ 3
Competencies........................................................................................................................................... 4
Course Length...................................................................................................................................... 4
Prerequisites as Identified for the Washington State Amended curriculum............................................. 5
EMT-Basic ............................................................................................................................................ 5
Life Long Learning/Continuing Education ................................................................................................ 6
EMT-INTERMEDIATE EDUCATION...............................................................................6
Sponsorship.............................................................................................................................................. 6
Program Planning/Communities of Interest ............................................................................................. 7
Program Goal ........................................................................................................................................... 8
Program Objectives .................................................................................................................................. 8
Use of the Goals and Objectives in Program Evaluation ......................................................................... 9
Course Design.......................................................................................................................................... 9
Didactic Instruction ............................................................................................................................... 9
Skills Laboratory................................................................................................................................. 10
Clinical Education............................................................................................................................... 10
Hospital Clinical ............................................................................................................................. 10
Field Clinical................................................................................................................................... 11
Field Internship................................................................................................................................... 12
Washington State Clinical/Field Internship Rotation Requirements .................................................. 12
Washington State Training Course Forms ............................................................................................. 13
Student Assessment............................................................................................................................... 14
Flow Chart Of The Emt-Intermediate Life Support Course Practical Skill Evaluation Process ............. 17
Narrative Of The Emt-Intermediate Course Practical Skill Evaluation Process .........................................

18
Program Personnel................................................................................................................................. 21
Program Director/Course Coordinator ............................................................................................... 21
Program Faculty/Instructors ............................................................................................................... 22
Course Medical Director..................................................................................................................... 22
Licensure, Certification and Registration................................................................................................ 23
Program Evaluation ................................................................................................................................ 23
Facilities.............................................................................................................................................. 23
Equipment and Supplies .................................................................................................................... 24
HOW TO USE THE CURRICULUM.............................................................................. 25
Unit Terminal Objective .......................................................................................................................... 25
Objectives ............................................................................................................................................... 25
Declarative.............................................................................................................................................. 26
Clinical Rotations .................................................................................................................................... 26
EDUCATING PROFESSIONALS ................................................................................. 28
APPENDICES
APPENDIX A - EMT-INTERMEDIATE: DESCRIPTION OF THE PROFESSION......... A-1
APPENDIX B - EMT-INTERMEDIATE: EDUCATIONAL MODEL................................. B-1
APPENDIX C - FIELD TEST PROGRAM HOURS ........................................................ C-1
APPENDIX D - AFFECTIVE EVALUATIONS................................................................ D-1
APPENDIX E - MODULE AND LESSON OBJECTIVE SUMMARY.............................. E-1
Module and Lesson Objective Summary..................................................................................................E-3
Specific Lesson Objectives.......................................................................................................................E-5
Section 1 - Preparatory .......................................................................................................................E-5
Lesson 1-1: Roles and Responsibilities of the EMT Intermediate...................................................E-5
Lesson 1-2: Medical/Legal Issues and Ethics ..................................................................................E-6
Lesson 1-3: Documentation .............................................................................................................E-7
Section 2 - Essentials ..........................................................................................................................E-8
Lesson 2-1: Overview of Human Systems .......................................................................................E-8
Lesson 2-2: Patient Assessment ...................................................................................................E-11
Lesson 2-3: Clinical Decision Making ............................................................................................E-17
Lesson 2-4: Airway Management & Ventilation for ILS Technicians Only ....................................E-17
Lesson 2-5: Airway Management & Ventilation for Airway Technicians Only ...............................E-23
Lesson 2-6: Assessment and Management of Shock....................................................................E-30
Lesson 2-7: Intravenous & Intraosseous Line Placement and Infusion .........................................E-33
Section 3 - Pharmacology and Emergency Care ..............................................................................E-35
Lesson 3-1: Pharmacology of Emergency ILS Medications ..........................................................E-35
Lesson 3-2: Cardiology ..................................................................................................................E-38
Lesson 3-3: Medical.......................................................................................................................E-42
Section 4 - Special Considerations ...................................................................................................E-48
Lesson 4-1: Pediatrics ....................................................................................................................E-48
Lesson 4-2: Geriatrics....................................................................................................................E-51
APPENDIX F - MINIMAL ESSENTIAL SUPPLIES & EQUIPMENT...............................F-1
APPENDIX G - EMT-INTERMEDIATE COURSE EVALUATION FORMS .................... G-1
APPENDIX H - EMT-I PRACTICAL EVALUATION GUIDELINES & SKILL SHEETS.. H-1
APPENDIX I - TRAUMA TRIAGE TOOL - STUDENT HANDOUT ..................................I-1
APPENDIX J - POSSIBLE ABANDONMENT SITUATIONS - STUDENT HANDOUT ...J-1
APPENDIX K - WASHINGTON ADMINISTRATIVE CODE (WAC) PERTAINING TO
EMT-INTERMEDIATE TRAINING COURSES ...............................................K-1
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PREFACE
The National Highway Traffic Safety Administration (NHTSA) has assumed responsibility for
the development of training courses that are responsive to the standards established by the
Highway Safety Act of 1966 (amended). Since these courses are designed to provide
national guidelines for training, it is NHTSA's intention that they be of the highest quality and
be maintained in a current and up-to-date status from the point of view of both technical
content and instructional strategy.
To this end, NHTSA supported the current project, which involved revision of the 1985
Emergency Medical Technician-Intermediate: National Standard Curriculum, deemed of
high value to the states in carrying out their annual training programs. This curriculum was
developed to be consistent with the recommendations of the National Emergency Medical
Services Education and Practice Blueprint, the EMT and Paramedic Practice Analysis, and
the EMS Agenda for the Future. This course is one of a series of courses making up a
National EMS training program for prehospital care. The EMT-Intermediate: National
Standard Curriculum, represents a core advanced care provider and can be used as either
a terminal objective in itself or a transition to higher levels of education and/or certification.
The EMT-Intermediate: National Standard Curriculum represents the minimum required

information to be presented within a course leading to certification as an EMT-Intermediate.
It is recognized that there is additional specific education that will be required of EMT-
Intermediates who operate in the field, i.e. ambulance driving, heavy and light rescue, basic
extrication, special needs, and so on. It is also recognized that this information might differ
from locality to locality, and that each training program or system should identify and provide
special instruction for these training requirements. This curriculum is intended to prepare a
medically competent EMT-Intermediate to operate in the field. Enrichment programs and
continuing education will help fulfill other specific needs for the EMT-Intermediate’s
education.
ACKNOWLEDGMENTS
From the very beginning of this revision project, the Department of Transportation relied on
the knowledge, attitudes, and skills from hundreds of experts and organizations. These
individuals and organizations sought their own level of involvement toward accomplishing
the goals of this project. These contributions varied from individual to individual, and
regardless of the level of involvement, everyone played a significant role in the development
of the curriculum. It is essential that those who have assisted with the achievement of this
worthy educational endeavor be recognized for their efforts. For every person named, there
are many more individuals who should be identified for their contributions. For all who have
contributed, named and unnamed, thank you for sharing your vision. Your efforts have
helped assure that the educational/training needs of EMT-Intermediates are met so that
they can provide appropriate and effective patient care.
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Special thanks for the knowledge, expertise, and dedication given to this project by the
Project Director, Principal Investigator, Co-Medical Directors, and all the members of the
Writing Groups and the National Review Team.
NHTSA would also like to recognize the following individuals and/or organizations for their
significant contributions to this project. Their order of appearance is no implication of their
relative importance to the success of this monumental project.
United States Department of Transportation, National Highway Traffic Safety

Jeff Michael, Ed.D.
David W. Bryson
United States Department of Health and Human Services, Health Resources and
Human Services Administration, Maternal and Child Health
Jean Athey, MSW, Ph.D.
Mark Nehring, DMD, MPH
Authors
Randall W. Benner, M.Ed, NREMT-P; Youngstown State University
Chip Boehm, RN, EMT-P/FF
Charles Bortle, EMT-P, RRT
Scott S. Bourn, RN, MSN, EMT-P; Beth-El College of Nursing & Health Sciences, University of Colorado
Debra Cason, RN, MS, EMT-P; University of Texas Southwestern Medical Center
Elizabeth A. Criss, RN, CEN, M.Ed; e.a. criss consulting
Alice Dalton, RN, BSN; Omaha Fire Department
Kate Dernocoeur, BS, EMT-P
Philip D. Dickison; National Registry of EMTs
Bob Elling, MPA, REMT-P; Institute of Prehospital Emergency Medicine
Scott B. Frame, MD, FACS, FCCM; Div. of Trauma/Critical Care, University of Cincinnati Medical Center
Mike Gammill, NREMT-P
Jack T. Grandey, NREMT-P; UPMC Health System - Department of Emergency Medicine
Joseph A. Grafft, MS, NREMT; Metropolitan State University
Janet A. Head, RN, MS; Kirksville College of Osteopathic Medicine
Richard Henn, RN, BSN; Northern Arizona Health Care
Linda K. Honeycutt, EMT-P; Providence Hospital & Medical Centers
Derrick Johnson, EMT-P; Phoenix Fire Dept
Neil Jones, MEd, EMT-P; Children's Hospital of Pittsburgh
Gail M. Madsen, NREMT-P; Emergency Medical Services Consultant
Diana Mass, MA, MT (ASCP); Arizona State University Main
Norm McSwain, Jr., MD, FACS; Tulane University School of Medicine, Department of Surgery
Michael O'Keefe, REMTP; EMS Office-Vermont Department of Health
Thomas E. Platt, M.Ed., NREMT-P; Center for Emergency Medicine
John Saito, MPH, EMT-P; Oregon Health Sciences University, Department of Emergency Medicine
John Sinclair, EMT-P; Central Pierce Fire and Rescue
Michael G. Smith, REMTP; Tacoma Community College
Andrew W. Stern, NREMT-P, MPA, MA; Colonie Emergency Medical Services
Paul A. Werfel, NREMT-P; State University of New York at Stony Brook
Michael D. Yee, AS, EMT-P, FAPP; Paramedic - Crew Chief, City of Pittsburgh, Bureau of EMS
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Subject Matter Experts

James Adams, MD, FACEP; Brigham and Women's Hospital & Harvard Medical School
Brent R. Asplin, MD; Affiliated Residency in Emergency Medicine, University of Pittsburgh
Robert R. Bass, MD, FACEP; Maryland Institute for Emergency Medical Services Systems
Nicholas Benson, MD, FACEP; East Carolina University, School of Medicine
Marilyn K. Bourn, RN, EMTP; University of Colorado Health Sciences Center
Gordon VR. Bradshaw, PhD; Phoenix College
Susan M. Briggs, MD, FACS; Massachusetts General Hospital
Jeff J. Clawson, MD; Medical Priority Consultants
Daniel J. Cobaugh, PharmD, ABAT; Univ of Rochester Med Center, Finger Lakes Regional Poison Ctr
Keith Conover, MD, FACEP; Wilderness EMS Institute & Mercy Hospital of Pittsburgh
Arthur Cooper, MD, MS, FACS, FAAP, FCCM; College of Physicians and Surgeons of Columbia Univ.
Eric Davis, MD, FACEP; Department of Emergency Medicine, Strong Memorial Hospital
Collin DeWitt, MPA; Phoenix Fire Department
Joseph J. Fitch, PhD; Fitch & Associates, Inc.
George L. Foltin, MD, FAAP, FACEP
Raymond L. Fowler, MD
Scott B. Frame, MD, FACS, FCCM; Division of Trauma/Critical Care, Univ of Cincinnati Medical Center
Peter W. Glaeser, MD; University of Alabama at Birmingham
James P. Kelly, MD; Rehabilitation Institute of Chicago, Northwestern University Medical School
Alexander Sandy Kuehl, MD,MPH,FACS,FACEP;Cornell University Chaplain Valley Physician’s Hospital
Jeffrey Mitchell, PhD; International Critical Incident Stress Foundation
Paul Pepe, MD, MPH, FACEP, FCCM; Allegheny University of the Health Sciences
Andrew Peitzman, MD; University of Pittsburgh Medical Center
Franklin D. Pratt, MD; Fire Department, County of Los Angeles & Torrance Memorial Medical Center
Daniel Spaite, MD, FACEP; University of Arizona
Michel A. Sucher, MD; Rural/Metro Corporation
Robert E. Suter, DO, MHA, FACEP; Medical-City-Dallas Hospital & East Central Georgia EMS
Robert Swor, DO; William Beaumont Hospital
Owen T. Traynor, MD; EMS Fellow, University of Pittsburgh, Dept of Emergency Medicine
James Upchurch, MD, NREMT-B; Indian Health Service
Vince Verdile, MD; Albany Medical College
Katherine West, BSN, MSEd, CIC; Infection Control/ Emerging Concepts, Inc.
Roger D. White, MD, FACC; The Mayo Clinic
Michael Wilcox, MD
Donald M. Yealy, MD, FACEP; University of Pittsburgh Department of Emergency Medicine
Adjunct Writers
Richard Beebe, RN, REMT-P; Hudson Valley Community College
John T. Bianco; Emergency Medical Service Institute
Michael Buldra; Eastern New Mexico University
Jonnathan Busko, MPH, NREMT-P
Alexander M. Butman, BA, DSc, REMT-P; Emergency Training Institute and Akron General Medical Ctr.
Robert S. Carpenter; DRE, MICP-Instructor, Comprehensive Medic First Aid Instruction
Gregory Chapman, RRT, REMT-P; Hudson Valley Community College
Harold C. Cohen, MS, EMT-P; Baltimore County Fire Department
Steven B. Cohen, BS NREMT-P; Medical/Rescue Team South Authority
Captain Preston Colby; Florida Public Safety
Roy E. Cox, Jr., M.Ed, EMT-P; Patient Care Coordinator, City of Pittsburgh, Bureau of EMS
Elaine Crabtree, MA; Medical Educational Resources Program, Indiana University School of Medicine
Robert Dahm; MN State Fire Marshall Division
Doug DiCicco, BS, EMT-P; Universal-Macomb Ambulance Service
M. Albert Dimmitt, Jr.
viii
Don Doynow, MD; Hudson Valley Community College

James W. Drake, BSLa, NREMT-P
William J. Dunne, BS, NREMT-P; Department of Emergency Health Services, UMBC
Kirsten Elling, REMT-P; Hudson Valley Community College
Nancy Finzel, DO; William Beaumont Hospital
Fred Fowler, REMT-P; Hudson Valley Community College
Michael F. French, BS; Kirksville College of Osteopathic Medicine
Marianne Gausche, MD; UCLA School of Med & Harbor UCLA Med Ctr, Dept of Emergency Medicine
Mary Gillespie, RN, EMT-P; Davenport College
Anglea K. Golden, RN, BSN, CFRN, MNREd
Marshall Goldstein, MD; Roper Hospital, Neonatology Program
David J. Gurchiek, BS, NREMT-P; College of Technology-Montana State University-Billings
Jeffrey M. Helm, BS, NREMT-P
Richard K. Hilinski, BA, EMT-P; Community College of Allegheny County
Brian G. Hollins, NREMT-P; Shreveport Fire Department
Wayne Hollis, PhD, MICT, EMT-P; State of Kansas Board of EMS
Andrew Jackson, BSAS, NREMT-P
Kyle G. Johnson, NREMT-P, PI; S.A.M.E.S., Inc.
Alan Kamis, MBA, MS-MoIS, EMT-P
Howard A. Kirkwood, Jr., JD, MS, NREMT-P; Tualatin Valley Fire and Rescue
Deborah Kufs, RN, REMT-P; Hudson Valley Community College
Judy E. Larsen, RN; Milwaukee County EMS (Paramedic) System
Craig S. Laser, RN, BSN, CEN, PHRN; Rural/Metro Corporation
Daniel Limmer, EMT-P; Town of Colonie, NY EMS Department & Colonie Police Dept
David W. Lindell, MS, NREMT-P; Brandywine Hospital and Trauma Center
David Markenson, MD, EMT-P; Center for Pediatric Emergency Medicine, New York City Medical Center
Dave Martens, M.A., Lakeville Police Department
Denise Martin, B.A.S, EMT-P-I/C; Oakland Community College
M. Allen McCullough, PhD, REMT-P, RN; Dept. of Fire & Emergency Services, Fayette County Georgia,
Thomas McGuire, EMT-P; Berkeley Fire Dept/Chabot College
W. Christopher Miller , EMT
Glenn Miller, BSAS, NREMT-P
William R. Miller; The Mercy Hospital of Pittsburgh
Robert M. Morrison; St. Paul Fire Department
Mike Oaster; St. Joseph Hospital ALSU
Cynthia Osborne, EMT-P; Malcom X College
Gerry Otto, EMT-P; Ridgewater College
Kevin L. Parrish, RN, EMT-P
Fitzgerald Petersen, EMT-P; Salt Lake County Fire Department
Tim Phalen; Prehospital Advanced Cardiology Educators, Inc.
Ronald G. Pirrallo, MD, MHSA, FACEP; Medical College of Wisconsin
John N. Pliakas, NREMT-P; Memorial Hospital of Rhode Island
Kevin Raun, EMT-P; ALF Ambulance
Steve Reissman, MPA; Zebra Management Services
Brent Ricks, REMT-P; Hudson Valley Community College
Sharon Rice-Vaughan; Metropolitan State University
Lou E. Romig, MD, FAAP, FACEP; Pediatric Emergency Medicine, Miami Children's Hospital
Aaron Z. Royston, MS, NREMT-P; Department of Emergency Health Services, UMBC
Ritu Sahni, MD; University of Pittsburgh, Department of Medicine
S. Robert Seitz, ASN, NREMT-P; Center for Emergency Medicine
Paul Seleski, FEO, FF, NREMT-P; Hastings Fire/Rescue/ALS Ambulance Service
Dee Dee Sewell, NREMT-P; Arcadian Ambulance, Inc.
Kenny Shaw, MPA, NREMT-P; Arkansas Department of Health, Division of EMS
Charlene Skaff, MS, NREMT-P; F-M Ambulance
Michael R. Skeels, PhD, MPH, Oregon State Public Health Laboratory
Deborah Mulligan-Smith, MD, FAAP, FACEP; Florida Department of Health & North Broward Hospital
Karen Snyder, RN, CEN, NREMT-P; Cincinnati Fire Division
ix
Charles Sowerbrower, BS, NREMT-P; Lancaster EMS Association

Vernon R. Stanley, MD, PhD; Team Health/ED Medical Director, Plateau Medical Center
Craig N. Story; Polk Community College
Eric M. Swanson, BBA, NREMT-P; Oregon Health Division - EMS
Michael G. Tunik, MD, FAAP; New York University School of Medicine/Bellevue Hospital Center
Mark Tutila, NREMT-P; North Memorial Health Care Center, EMS Education
Richard W. Vomacka, BA; Brimfield OH
Kimberley Walker, NREMT-P, CHT, MA; Divers Alert Network
Elizabeth M. Wertz, RN, MPM, EMT-P, PHRN; Pennsylvania Emergency Health Services Council
Mark J. Willis, BA, NREMT-P; Center for Emergency Medicine
Matthew S. Zavarella, BSAS, NREMT-P
David G. Zietz, BS, NREMT-P; Center for Emergency Medicine
Carol Elizabeth Zempel, PhD; Licensed Psychologist
Liaisons
Dia Gainor; National Association of State EMS Directors
Steve Mercer; National Council of State EMS Training Coordinators, Inc.
Ruth Oates-Graham; National Association of State EMS Directors
In-Kind Services
National Registry of EMTs William E. Brown, RN, MS, CEN, NREMT-P
Robert Wagoner, NREMT-P, BSAS
JRC on Educational Programs for the EMT-P Debra Cason, RN, MS, EMT-P
University of Pittsburgh Department of Emergency Medicine
The Center for Emergency Medicine
Arizona Pilot Test Site

Jack Dillenberg, DDS., MPH; Director, Arizona State Department of Health Services
Arizona Department of Health Services, Bureau of Emergency Medical Services

Toni Brophy, MD, FACEP; Medical Director
John D. Taska, MPA; Bureau Chief
Victor Dominguez; Section Manager, Training and Certification
Ronald P. McCummings, BS, NREMT-P; Advanced Life Support Program Manager
Steve Carlson; President/CEO, Flagstaff Medical Center

Bruce Blankenship; Vice President Human Resources, Northern Arizona Healthcare
Doug Wood; Yavapai College
Flagstaff Medical Center
Maricopa Medical Center
Yavapai Regional Medical Center
Central Yavapai Fire District
Guardian Medical Transport
Life Line Ambulance
Phoenix Fire Department
Sedona Fire Department
Yavapai College
Northern Arizona Healthcare
Richard Henn, RN, BSN; Program Director. Northern Arizona Healthcare
Mark Peterson, D.O.; Medical Director. Flagstaff Medical Center
x
Instructors
James Bratcher, CEP; Manager, Emergency Response Training Associates
Lynn Browne-Wagner, RN, BSN; Education Coordinator, Maricopa Medical Center
Brian Eells, RN, BSN
Mary Frazee, RN, BSN; Department of Obstetrics, Good Samaritan Medical Center
Richard Henn, RN, BSN; Director, Department of Education, Northern Arizona Healthcare
Students
Wilma Gashweseoma; Hopi Tribe EMS
David Herman; Life Line Ambulance
Stetson Navasie; Hopi Tribe EMS
Edward Rudd; Guardian Ambulance, Flagstaff Medical Center
Kenneth Starling; Peabody Western Coal EMS.
Shawn Tarver; Chino Valley Fire District
Meridith Van Winkle; Hopi Tribe EMS
Donna Ward; Timberline-Fernwood Fire Department
Robert Young; Camp Verde Ambulance
Field Test Sites

Big Horn EMS James Upchurch, MD
Gwinnett Technical Institute Bill Harris
Steve Moyers
McKennan Hospital EMS Education Don Jones
University of South Alabama - EMS Ed Carlson
University of Virginia Emergency Medicine Donna Burn, RN

Children’s Hospital of Pittsburgh Mercy Hospital Westmoreland Regional Hospital
Horizon Health Systems UPMC Health Systems
Lee Hospital West Penn Hospital
Paul M. Paris, MD, FACEP; Chief Medical Director

Donald F. Goodman, MBA, CPA; Chief Operating Officer, Chief Financial Officer
Walt A. Stoy, PhD, EMT-P; Director of Educational Programs
Gregg S. Margolis, MS, NREMT-P; Associate Director of Education
Thomas E. Platt, M.Ed., NREMT-P; Assistant Director of Education
Debra A. Lejeune, BS, NREMT-P; Publishing Coordinator
John Dougherty, EMT-P; Clinical Coordinator
Albert Boland, NREMT-P; Coordinator of Continuing Education
Bonnie Rolison, NREMT; Student Services Specialist
Pamela M. Westfall; Administrative Assistant
Colleen M. O’Hara, M.Ed.; Administrative Assistant
Kimberle A. Stokes, NREMT; Administrative Assistant
Jacqueline Jones Lynch; UPMC Department of Radiology
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UPMC Health System Printing Services

Pete Vizzoca, Supervisor Kevin Shaw Glenn Grimm
Ray Jones Kevin Sloan
Webmaster
Charles P. Kollar
Editor
Mary Kay Margolis, BS, EMT; University of Pittsburgh, Department of Emergency Medicine
Thanks to the hundreds of peer reviewers who provided diverse knowledge and skills from
across the country. They contributed to the content and shared their ideas and visions
about the new curriculum.
This project would not have been possible without the extraordinary support of The Maternal
and Child Health Bureau. NHTSA would like to extend a special thanks to Mark Nehring
and Jean Athey, Ph.D. for their leadership and commitment to EMS.
xii
EMT-INTERMEDIATE CURRICULUM - COURSE TOPICS

WASHINGTON STATE AMENDED EDITION
Lesson Lesson Topic

Section 1 Preparatory
Lesson 1-1 Roles and Responsibilities of the EMT-Intermediate
Lesson 1-2 Medical/Legal Issues/ Ethics
Lesson 1-3 Documentation
Section 2 -Essentials
Lesson 2-1 Overview of Human Systems
Lesson 2-2 Patient Assessment
Lesson 2-3 Clinical Decision Making
Lesson 2-4 Airway Management and Ventilation - ILS Technicians only
Lesson 2-5 Airway Management and Ventilation - AW or ILS/AW Technicians only
Lesson 2-6 Assessment and Management of Shock
Lesson 2-7 Intravenous & Intraosseous Line Placement and Infusion
Section 3 -Pharmacology and Emergency Care

Lesson 3-1 Pharmacology of Emergency ILS Medications/Medication administration
Lesson 3-2 Cardiology
Lesson 3-3 Medical
Section 4 - Special Considerations

Lesson 4-1 Pediatrics
Lesson 4-2 Geriatrics
xiii
Required Initial Instruction for the Intravenous Therapy Certification

IV Therapy Technician Training Course Prerequisites
The applicant must be certified as an EMT for at least 1 year and have completed the
following training:
• AED Training
• Trauma training in an approved EMT-B or trauma course
• EMT-B, or EMT-B Orientation Training
• Current in required CME/OTEP
Required Lessons
Section 1 – Preparatory
Lesson 1-1: EMT-I Roles & Responsibilities.
Lesson 1-2: Med./Legal/ Ethics
Lesson 1-3: Documentation
Section 2 – Essentials
Lesson 2-1: Human Systems
Lesson 2-2: Patient Assessment
Lesson 2-3: Clinical Decision Making
Lesson 2-6: Assessment and Management of Shock
Lesson 2-7: IV & IO Infusion
Clinical/Field Internships
Clinical Internship Requirements 10 IV insertions on Humans. . At

the option of the MPD, 5 may be
NOTE: It is recommended that some IV insertions performed on training aids.
be accomplished during the field internship.
Competency for all skills is determined by the Lab skill proficiency required in:
County Medical Program Director. • IO line placement
Field internship Competency Determined By the

County Medical Program Director
Evaluations/Examinations
• Practical Skill Evaluations during the course AND Individual Comprehensive End of
Course Practical Skill Evaluations as identified in the Appendices
• Washington State Written Certification Examination for the appropriate certification level
xiv
Required Initial Instruction for Airway Certification

Airway Technician Training Course Prerequisites
following training:
• AED Training
Required Lessons
Lesson 2-5: Airway Management & Ventilation – AW or ILS/Airway Only
Clinical Internship Requirements 10 ET intubations on Humans. .

At the option of the MPD, 5 may
NOTE: It is recommended that some ET be performed on training aids.
intubations be accomplished during the field
internship. Competency for all skills is • Lab skill proficiency required
determined by the County Medical Program in: ML-AWs
Director.

xv
Required Initial Instruction for IV/Airway Certification

IV/Airway Technician Training Course Prerequisites
following training:
• AED Training
Required Lessons
Clinical Internship Requirements 10 IV insertions on Humans. At
the option of the MPD, 5 may be
NOTE: It is recommended that some IV insertions performed on training aids.
and ET intubations be accomplished during the
field internship. Competency for all skills is 10 ET intubations on Humans. At
determined by the County Medical Program the option of the MPD, 5 may be
Director. performed on training aids.
Lab skill proficiency required in:

• IO line placement
• ML-AWs
xvi
Required Initial Instruction for ILS Certification

Intermediate Life Support (ILS) Technician Training Course Prerequisites
following training:
• AED Training
Required Lessons
Lesson 2-4: Airway Management and Ventilation - ILS Techs only
Section 3 - Pharmacology and Emergency Care
Lesson 3-1: Pharmacology and Medication Administration
Lesson 3-2: Cardiology
Lesson 3-3: Medical
Lesson 4-1: Pediatrics
Lesson 4-2: Geriatrics
Clinical Internship Requirements 10 IV insertions on Humans. At the
NOTE: It is recommended that some IV insertions option of the MPD, 5 may be
be accomplished during the field internship. performed on training aids.
Competency for all skills is determined by the • Lab skill proficiency required in:
County Medical Program Director. • IO placement
• ML-AWs
• Medication Administration
xvii
Required Initial Instruction for ILS/Airway Certification

Intermediate Life Support/Airway (ILS/AW) Technician Training Course Prerequisites
following training:
• AED Training
Required Lessons
Lesson 3-1: Pharmacology and Medication Administration
Lesson 3-3: Medical
Clinical Internship Requirements 10 IV insertions on Humans. At the
NOTE: It is recommended that some IV insertions and/or ET option of the MPD, 5 may be
intubations be accomplished during the field internship. performed on training aids.
Competency for all skills is determined by the County Medical 10 ET intubations on Humans. At the
Program Director. option of the MPD, 5 may be
performed on training aids.
• Lab skill proficiency required in:
• IO placement
• ML-AWs
• Practical Skill Evaluations during the course AND Individual Comprehensive End of Course Practical Skill
Evaluations as identified in the Appendices
xviii
Required Instruction to Upgrade from The Old 1985 DOT Module Training &
Certification to the New 2000 ILS or ILS/Airway Certification Level
Old IV Technician to New Old Airway Technician to Old IV/Airway Tech to
Lesson ILS or ILS/AW New ILS or ILS/AW New ILS or ILS/AW
Certification Level Certification Level Certification Level
Lesson 1-1: EMT-I Roles & Resp. Required Required Required
Lesson 1-2: Med./Legal/ Ethics Required Required Required
Lesson 1-3: Documentation Required Required Required
Lesson 2-1: Human Systems Required Required Required
Lesson 2-2: Patient Assessment Required Required Required
Lesson 2-3: Clinical Decision Making Required Required Required
Lesson 2-4: Airway Management and Lesson 2-4 Required if ILS Lesson 2-4 Required if ILS Lesson 2-4 Required if ILS
Ventilation - ILS Techs only Certification is desired Certification is desired Certification is desired
OR OR OR
Lesson 2-5: Airway Management and Lesson 2-5 Required if Lesson 2-5 Required if Lesson 2-5 Required if
Ventilation - AW Technicians or ILS/AW Certification is ILS/AW Certification is ILS/AW Certification is
ILS/AW Technicians only desired desired desired
Lesson 2-6: Assessment and Required Required Required
Management of Shock
Lesson 2-7: IV & IO Infusion Required Required Required
Lesson 3-1: Pharmacology and Required Required Required
Medication Administration
Lesson 3-2: Cardiology Required Required Required
Lesson 3-3: Medical Required Required Required
Lesson 4-1: Pediatrics Required Required Required
Lesson 4-2: Geriatrics Required Required Required
Optional - 10 ET 10 IV Insertions on
Clinical Internship Requirements Intubations on Humans if Humans. At the option
NOTE: It is recommended that AW or ILS/AW certification of the MPD, 5 may be
some IV insertions and/or ET desired. . At the option of performed on training aids.
intubations be accomplished the MPD, 5 may be
performed on training aids. Lab skill proficiency
during the field internship. Lab skill proficiency required in:
Competency for all skills is Lab skill proficiency
required in: • IO line placement
determined by the County Medical required in:
• IO line placement • ML-AW
Program Director. • IO line placement
• ML-AW • Medication
• ML-AW
• Medication administration administration
• Medication administration
Field internship Competency Determined By the County Medical Program Director
• Practical Skill Evaluations during the course AND Individual Comprehensive End of Course Practical Skill Evaluations as
identified in the Appendices
xix
Required Instruction to Upgrade from 2000 IV, AW or IV/AW Training & Certification
Levels to the New 2000 ILS or ILS/Airway Certification Level
New IV Technician to New Airway Tech to New New IV/Airway Tech to
Lesson New ILS or ILS/AW ILS or ILS/AW New ILS or ILS/AW
Lesson 1-1: EMT-I Roles & Resp. N/A N/A N/A
Lesson 1-2: Med./Legal/ Ethics N/A N/A N/A
Lesson 1-3: Documentation N/A N/A N/A
Lesson 2-1: Human Systems N/A N/A N/A
Lesson 2-2: Patient Assessment N/A N/A N/A
Lesson 2-3: Clinical Decision Making N/A N/A N/A
Lesson 2-4: Airway Management and Lesson 2-4 Required if ILS
Ventilation - ILS Techs only Certification is desired N/A N/A
OR
Lesson 2-5: Airway Management and Lesson 2-5 Required if
Ventilation - AW Technicians or ILS/AW Certification is N/A N/A
ILS/AW Technicians only desired
Lesson 2-6: Assessment and N/A Required N/A
Management of Shock
Lesson 2-7: IV & IO Infusion N/A Required N/A
Lesson 3-1: Pharmacology and Required Required Required
Medication Administration
Lesson 3-2: Cardiology Required Required Required
Lesson 3-3: Medical Required Required Required
Lesson 4-1: Pediatrics Required Required Required
Lesson 4-2: Geriatrics Required Required Required
Optional - 10 ET 10 IV Insertions on
Clinical Internship. At the option of Intubations on Humans if Humans. At the option of
the MPD, 5 may be performed on AW or ILS/AW certification the MPD, 5 may be
training aids. desired. At the option of performed on training aids.
NOTE: It is recommended that the MPD, 5 may be
some IV insertions and/or ET performed on training aids. Lab skill proficiency
intubations be accomplished Lab skill proficiency required in: Lab skill proficiency
required in: required in:
during the field internship. • IO line placement
Competency for all skills is • ML-AW • Medication administration
• ML-AW
determined by the County Medical • Medication administration
Program Director. • Medication administration
• Practical Skill Evaluations during the course AND Individual Comprehensive End of Course Practical Skill Evaluations as
identified in the Appendices
xx
Required Instruction to Transition from OLD 1985 IV, AW or IV/AW Training &
Certification Levels to the New 2000 IV, AW or IV/AW Training & Certification Levels
OLD IV OLD Airway Tech OLD IV/Airway
Lesson Technician to to New Airway Tech to New
New IV Technician IV/Airway Tech
Lesson 1-1: EMT-I Roles & Resp. *N/A *N/A *N/A
Lesson 1-2: Med./Legal/ Ethics *N/A *N/A *N/A
Lesson 1-3: Documentation *N/A *N/A *N/A
Lesson 2-1: Human Systems *N/A *N/A *N/A
Lesson 2-2: Patient Assessment *N/A *N/A *N/A
Lesson 2-3: Clinical Decision Required Required Required
Making
Lesson 2-5: Airway Management N/A *Training in Multi- *Training in Multi-
and Ventilation - AW Technicians or Lumen airway if not lumen airway if not
ILS/AW Technicians only previously trained previously trained
Lesson 2-6: Assessment and *N/A N/A N/A
Management of Shock
Lesson 2-7: IV & IO Infusion *Training in IO N/A *Training in IO
infusion and saline infusion and saline
locks if not locks if not
previously trained previously trained
Clinical Internship Requirements Lab skill Lab skill Lab skill

proficiency proficiency proficiency
required in: required in: required in:
• IO line placement • ML-AW • IO line placement
• ML-AW
• Practical Skill Evaluations during the course AND Individual Comprehensive End of Course
Practical Skill Evaluations as identified in the Appendices for those skills in which the student was
updated
*Although lessons may indicate minimal training or not applicable (N/A) for transition training
purposes, the objectives for required lessons and lessons marked with an asterisk (*) will be
included in the written recertification examination.
xxi
NOTES:
xxii
THE EMT-INTERMEDIATE: NATIONAL STANDARD CURRICULUM
History
The last revision of the EMT-Intermediate: National Standard Curriculum occurred in the
early 1980s with a completed curriculum published in 1985. This current revision came
about as a result of the National Highway Traffic Safety Administration's (NHTSA) January
1990 Consensus Workshop on Emergency Medical Services Training Programs.
Participants discussed the national training curricula needs of Emergency Medical Service
(EMS) providers. Using a nominal group process, the participants identified the top priority
needs for EMS training in the United States.
The top priorities identified at that meeting led to revision of the EMT-Basic: National
Standard Curriculum in 1994 and the First Responder: National Standard Curriculum in
1995. Upon the completion of these curricula, NHTSA funded a project to revise the
EMT-Paramedic: National Standard Curriculum, EMT-Intermediate: National Standard
Curriculum, and Associated Refresher programs. This curriculum is a result of that contract.
As stated in the contract, this curriculum is specifically designed to address the educational
needs of the traditional EMT-Intermediate. It is not intended to expand the scope of practice
of the EMT-Intermediate. It is designed to provide a solid foundation for professional
practice and additional education with a heavy emphasis on clinical problems solving and
decision making.
The development utilized a variety of resources to help in curricular decision making. They
included, but were not limited to: National Emergency Medical Services Education and
Practice Blueprint, ASTM F1489-93, A Standard Guide for Performance of Patient
Assessment by the EMT-Intermediate, Institute of Medicine’s Report - Emergency Medical
Services for Children, The EMS Agenda for the Future, The EMT and EMT-Intermediate
Practice Analysis. These resources provided invaluable insight and assistance throughout
the curriculum development.
The Curriculum Development Process

Because of the size of this project, many individuals were brought together to develop the
curriculum. These extraordinarily talented individuals were organized into groups and
teams. The Administrative Team’s primary responsibility was to assure that the project was
proceeding according to plan and to serve as a “hub” for the various groups and individuals
involved in the many aspects of curriculum development.
The content of this curriculum was developed by writing teams that were each assigned a
unit of the curriculum. Each writing team consisted of at least one author, one subject
matter expert, and up to eight adjunct writers. These writing teams consisted of some of the
most experienced educators and clinicians in emergency medicine. The authors were
responsible for coordinating the writing group and actually developing the materials. The
subject matter experts were responsible for the accuracy of each section. The subject
matter experts were nationally recognized content experts. For all medical areas, the
subject matter expert was a physician. The adjunct writers contributed to the development
and review of the material.

The peer reviewers of the curriculum represented professionals from around the country
who expressed an interest in participating in the curriculum development process. They had
the opportunity to submit comments about each draft of the curriculum to the writing team
for consideration. The National Review Team consisted of representatives from national
EMS organizations. The National Review team received every draft of the curriculum, and
had the opportunity to register organizational opinions. Additionally, the National Review
Team had two face-to-face meetings. These meetings were instrumental in developing
consensus opinions on controversial issues.
The National Association of State EMS Directors and the National Council of State EMS
Training Coordinators made extraordinary contributions to the overall design, development,
and content of the curriculum throughout the project. More importantly, these organizations
will assume the responsibility for implementing the curriculum in the coming years.
One pilot of the EMT-Intermediate curriculum was conducted at the Maricopa Community
College in Prescott, Arizona by Flagstaff Medical Center. As part of their in-kind service to
the project, the Joint Review Committee of Educational Programs for the EMT-Intermediate
selected sites from around the country to serve as field test. These sites were asked to
implement a draft of the curriculum and provide feedback to the administrative team. Both
the pilot test and the field test sites were an important component of the curriculum
development. The project team gained valuable insight into the implementation of this
curriculum.
The National Registry of EMTs’ support of this project was extraordinary. The National
Registry contributed to the design and development of the examinations and final evaluation
tools that were used in the pilot program, as well as the tabulation and evaluation of scores.
They contributed significantly to the design and development of the skill sheets that are
contained within this curriculum. The National Registry provided financial support for
meetings of the group leaders.
The Joint Review Committee on Educational Programs for the EMT-Paramedic conducted
surveys that were used to establish the clinical requirements. They also developed the
affective evaluation tools.
Curriculum Goal and Approach

A curriculum is only one component of the educational process. Alone, it cannot assure
competence. The goal of this curriculum is to be part of an educational system that
produces a competent entry level EMT-Intermediate. For the purpose of this project,
competence was defined relative to the Description of the Profession.
2
Description of the Profession

The first step in the curriculum design phase of the project was to define the profession in
terms of general competencies and expectations. The Description of the Profession was
drafted and underwent extensive community and peer review. It was designed to be both
practical and visionary, so as to not limit the growth and evolution of the profession.
Ultimately it served as the guiding document for the curriculum development. The
Description of the Profession also provided the philosophical justification of the depth and
breadth of coverage of material. The Description of the Profession for the EMT-
Intermediate is attached as Appendix A.
Educational Model
From the Description of the Profession, an Educational Model was developed to achieve the
goals of the course. This Educational Model also went thought extensive community and
peer review. This is a graphical representation of the major components of the curriculum.
The EMT-Intermediate Educational Model was designed to be consistent with, and build
upon, the Educational Model for the EMT-Basic. The Educational Model is not intended to
imply a rigid order or sequence of the material. Course planners and educators should
adapt and modify the order of the material to best meet their needs and those of their
students.
Much of the material in the preparatory section sets the stage for the rest of the course.
Although there is no requirement to adhere to the order of the model, most educators agreed
that this information should be presented early in the course. Additionally, Airway and
Ventilation and Patient Assessment are fundamental skills and knowledge areas and should
be presented toward the beginning of the course of study. In the Educational Model, the
Medical and Trauma modules appear on either side Patient Assessment. In general, it is
assumed that most programs will cover this material after the Preparatory, Airway, and
Patient Assessment material.
The Model is also designed to emphasize the role of professional education as part of life
long learning (fig. 1).
Continuum of Life Long Learning
Basic Education ÎCompetencies/Prerequisites Î Professional Education Î

Continuing Education
The EMT-Intermediate: National Standard Curriculum Diagram of Educational Model

Washington State Amended edition is attached as Appendix B.
3
Competencies
EMT-Intermediate program directors often comment that poor basic skills become
problematic when attempting to teach many parts of the EMT-Intermediate course.
Deficiencies in basic skills are difficult to overcome throughout the course, but are most
evident when teaching communication skills, documentation, and pharmacology math skills.
It is not the intent of professional education to teach basic skills, but rather build on an
existing base of academic competencies. The EMT-Intermediate curriculum assumes
competence in English and math prior to beginning the course.
Documentation skills rely far more heavily on spelling, grammar, vocabulary and syntax than
on the mastery of the specialized form of report writing that is found in health care. If, through
program evaluation, a program identifies less than satisfactory results in documentation skills,
it should raise the prerequisite level of English competence.
Similarly, if a program has difficulty with the student’s pharmacology math skills, it is
suggested that the prerequisite level of math competence be increased, rather than
attempting to remediate these basic skills in the context of EMT-Intermediate education.
Because of the variability in the roles and responsibilities of EMT-Intermediates throughout

the country, no Functional Job Analysis was conducted. It is, however, suggested that
programs assess applicant’s basic skills prior to entry into training. If the competence of the
applicant is low, the student should be encouraged to remediate the deficiency prior to
pursuing EMT-Intermediate certification. If the program chooses to enroll students with low
basic skills levels, it is the program’s responsibility to provide individual tutoring, increase
course time, provide remedial education, or require co-requisite course work to improve the
candidates basic skills prior to graduation.
Course Length
Basic academic skills play a very important role in course length and attrition rate. Attrition
rate is a function of the groups’ basic academic skills and the length of the course. If course
length remains constant, and the basic skills of the applicants’ decreases, the attrition rate
will rise. Correspondingly, if a program seeks to decrease its attrition rate or increase
examination performance, it may do so by increasing the basic academic skills of its
students, increasing course length, or both. This information should be taken into account
in course planning.
The emphasis of EMT-Intermediate education should be competence of the graduate, not

the amount of education that they receive. The time involved in educating an EMT-
Intermediate to an acceptable level of competence depends on many variables. Based on
the experience in the pilot and field testing of this curriculum, it is expected that the average
program, with average students, will achieve average results in approximately 300-400 total
hours of instruction. The Washington State Amended curriculum average course hours
were approximately 103 hours for full ILS/Airway instruction.
4
The length of this course will vary according to a number of factors, including, but not limited
to:
-student’s basic academic skills competence
-faculty to student ratio
-student motivation
-the student’s prior emergency/health care experience
-prior academic achievements
-clinical and academic resources available
-quality of the overall educational program
Appendix C is a summary of the average time needed to cover a draft of the Washington
State Amended curriculum. These times are meant only as a guide to help in program
planning. Training institutes MUST adjust these times based on their individual needs,
goals and objectives. These times are only recommendations, and should NOT be
interpreted as minimums or maximums. Those agencies responsible for program oversight
are cautioned against using these hours as a measure of program quality or having satisfied
minimum standards. Competence of the graduate, not adherence to arbitrary time frames,
is the only measure of program quality.
Prerequisites as Identified for the Washington State Amended curriculum

following training:
• AED Training
EMT-Basic
It has been a long held tradition to use EMT-Basic certification as a prerequisite for more
advanced EMS education, and this curriculum continues that tradition. It is important to
note that some educators have questioned the practice of using EMT-Basic as a required
certification prior to enrollment in EMT-Intermediate education. In fact, no studies have
been able to verify EMT-Basic certification or experience as a predictor of success in EMT-
Intermediate education. Of course, EMT-Intermediates are required to be competent in all
of the skills and knowledge of an EMT-Basic, and this knowledge base and skills
competence should be verified during EMT-Intermediate education.
Although this curriculum identifies EMT-Basic as a prerequisite, we have done so in the

absence of empirical data suggesting that this is appropriate. We encourage flexibility in
approaching the issue of EMT-Basic as a prerequisite to EMT-Intermediate education. We
also recognize that it may be possible to incorporate all of the material of an EMT-Basic
class into an EMT-Intermediate program, eliminating the need for it as a prerequisite.
Clearly, more research is needed.
5
Life Long Learning/Continuing Education

Continuing education is an integral component of any professional education process and
the EMT-Intermediate must be committed to life-long learning. The EMT-Intermediate
curriculum must fit within the context of a continuing educational system. This is necessary
due to the continually changing dynamics and evolution of medical knowledge.
This curriculum is designed to provide the student with the essentials to serve as an entry
level EMT-Intermediate. We recognize that enrichment and continuing education will be
needed in some cases to bring the student to full competency. We strongly urge employers
and service chiefs to integrate new graduates into specific orientation training programs.
It is important to recognize that this curriculum does not provide students with extensive
knowledge in hazardous materials, blood-borne pathogens, emergency vehicle operations
or rescue practices in unusual environments. These areas are not core elements of
education and practice as identified in the National EMS Education and Practice Blueprint.
Identified areas of competency not specifically designed within the EMT-Intermediate:
National Standard Curriculum should be taught in conjunction with this program as a local or
state option.
EMT-INTERMEDIATE EDUCATION
Society is becoming more demanding in all areas in education. The current trend in
professional education is to demonstrate, in quantitative ways, the value and quality of the
program. Simply adhering to standards is no longer adequate to convince the stakeholders
that educational programs are satisfying the needs of its constituency. Government,
society, and the profession are demanding that educational programs are held accountable
for the product that they are producing. This section of the curriculum briefly describes
critical components, along with adherence to the EMT-Intermediate: National Standard
Curriculum, Washington State Amended Edition that will enable programs to objectively
demonstrate their value and quality.
Sponsorship
EMT-Intermediate education should take place in an academic environment. An academic
environment has services such as a library, student counseling (education, academic,
psychological, career, crisis intervention), admissions, financial aid, learning skills centers,
student health services, etc. Additionally, an academic environment offers such advantages
as admissions screening, standardized student selection criteria, registrar, record keeping,
bursar, student activities, collegial environment, formal academic credit, medial resources,
and vast institutional resources.
The financial resources should be adequate for the continued operation of the educational
program to ensure each class of students is funded to complete the course. The budget
should reflect sound educational priorities including those related to the improvement of the
educational process.
6
Admissions of students should be made in accordance with clearly defined and published
practices of the instruction. Specific academic, health related, and/or technical
requirements for admission shall be clearly defined and published. The standards and /or
prerequisites must be made know to all potential applicants.
The program should be responsible for establishing a procedure for determining that the
applicants or students’ health will permit them to meet the written technical standards of the
program. Students should be informed of and have access to health services. The health
and safety of students, faculty, and patients associated with educational activities must be
adequately safeguarded.
Accurate information regarding program requirements, tuition and fees, institutional and
programmatic policies, procedures, and supportive services shall be available to all
prospective students and provided to all enrolled students. There should be a descriptive
synopsis of the current curriculum on file and available to candidates and enrolled students.
There should be a statement of course objectives, copies of course outlines, class and
laboratory schedules, clinical and field internship experience schedules, and teaching plans
on file and available.
Student and faculty recruitment and student admission and faculty employment practices
shall be non-discriminatory with respect to race, color, creed, sex, age, disabling conditions,
and national origin. The program and sponsoring institution should have a defined and
published policy and procedure for processing student and faculty grievances.
Policies and processes for student withdrawal and for refunds of tuition and fees shall be
published and made known to all applicants. Polices by which student may perform service
work while enrolled in the program must be published and made known to all concerned in
order to avoid practices in which students are substituted for regular staff.
Student records shall be maintained for student admissions, attendance, academic

counseling and evaluation. Grades and credits for courses shall be recorded and
permanently maintained by the sponsoring institution.
Program Planning/Communities of Interest

As with all professional education, it is critically important that EMT-Intermediate education
programs are planned, executed and evaluated in a continuous quality improvement model.
Only through a thorough assessment of the needs of the community, the establishment of
goals to meet those needs, and program evaluation relative to those needs, will a program
be able to demonstrate its quality and value.
Every professional education program is designed and conducted to serve a number of

communities of interest. It is incumbent on the program director to identify whom the
program is serving, and adapt the program to best meet those needs. The program’s goal
statement should help to clarify the communities that the program serves.
Although students are the consumer of the educational program, they are not the customers
of the product. Ultimately, the program serves the employers of graduates, not students.
7
Typically, the communities of interest include directors, managers, and medical directors
who hire or supervise graduates. Other communities of interest might include: colleagues,
government officials, hospital administrators, insurance companies, patients, and the public.
As part of the planning process, the program should regularly assess the communities of
interest, and establish objectives to best serve them. One way to survey the communities of
interest is to establish an advisory board consisting of representatives from various
communities of interest and regularly question them as to their expectations of entry level
EMT-Intermediates. The program would use this information for program planning.
Specifically, the program should use this information to clarify how to achieve their program
goals and objectives.
Program Goal
Each EMT-Intermediate program should have a program goal. The program goal is a
statement of the desired outcome of the program, and typically references graduating
competent entry-level providers. By design, program goals are broad based, but establish
the parameters by which the effectiveness of the program will be evaluated. A program
may have multiple goals, but most use one for clarity. For example, a typical program goals
statement might read:
The goal of the ABC EMT-Intermediate Education program is to produce

competent, entry level EMT-Intermediates to serve in career and volunteer
positions in XYZ County.
If the program provided additional training that is clearly not within the definition of the entry
level practitioner, then additional information should be included in the goal. Education
planning should be based on the program goal, the mission of the sponsoring institution,
and the expectations of the health care community. The goal should be made know to all
members of the communities of interest, especially the students and faculty. The goal will
be used to select appropriate curricular materials, clinical experiences, and many other
aspects of program planning.
Program Objectives
Objectives are more specific statements of the outcomes of the program, and are derived
from the program goal in conjunction with the communities of interest. The program can
establish as many objectives as they see fit to accurately reflect the program goal. Often,
programs find it useful to establish objective along the three domains of learning. Examples
might include:
Program Cognitive Objective:

At the completion of the program, the graduate of the ABC EMT-Intermediate
Education Program will demonstrate the ability to comprehend, apply, and
evaluate the clinical information relative to his role as an entry level EMT-
Intermediate in XYZ County.
8
Program Psychomotor Objective:

At the completion of the program, the student will demonstrate technical
proficiency in all skills necessary to fulfill the role of entry level EMT-
Intermediate in XYZ County
Program Affective Objective:
At the completion of the program, the student will demonstrate personal
behaviors consistent with professional and employer expectations for the entry
level EMT-Intermediate in XYZ County.
Goals and objectives must be consistent with the needs of the communities of interest, e.g.
the program sponsors, employers, students, medical community, and profession. There
may be some goals that are important institutional goals that are not useful program goals.
The only goals that are considered program goals are those that relate specifically to the
competencies attained in the program.
Use of the Goals and Objectives in Program Evaluation

Program goals and objectives form the basis for program assessment. Once the goals and
objectives are established, they serve as a mechanism to evaluate the effectiveness of the
program. By utilizing a variety of evaluation methodologies (performance of graduates on
certification exams, graduate surveys, employer surveys, medical director surveys, patient
surveys) the program can evaluate their effectiveness at achieving each objective. For
example, if graduates consistently perform poorly on the cardiac section of certification
exams, and graduates, employers, and medical directors all state that students are weak in
cardiology; the program should critically evaluate this section of their curriculum.
Programs are encouraged to evaluate each objective in as many ways as possible. For
example, graduate cognitive skills could be evaluated by performance on standardized
tests, certification exams, graduate surveys, employer surveys, and medical director
surveys. This provides much more information than using one source of data.
Course Design
The EMT-Intermediate program should consist of four components of instruction: didactic
instruction, skills laboratory, clinical education, and field internship. The first three typically
occur concurrently, and the field internship serves as a verification that the student is
serving as a competent, entry level practitioner.
Didactic Instruction
The didactic instruction represents the delivery of primarily cognitive material. Although this
is often delivered as lecture material, instructors are strongly encouraged to utilize alternate
delivery methods (video, discussion, demonstration, simulation, etc.) as an adjunct to
traditional classroom instruction. The continued development and increased sophistication
of computer aided instruction offers many options for the creative instructor. It is not the
responsibility of the instructor to cover all of the material in a purely didactic format, but it is
the responsibility of the program director to assure that all students are competent over the
material identified by the declarative section.
9
Skills Laboratory
The skills laboratory is the section of the curriculum that provides the student with the
opportunity to develop the psychomotor skills of the EMT-Intermediate. The skills laboratory
should be integrated into the curriculum in such a way as to present skills in a sequential,
building fashion. Initially, the skills are typically taught in isolation, and then integrated into
simulated patient care situations. Toward the latter part of the program, the skills lab should
be used to present instructional scenarios to emphasize the application and integration of
didactic and skills into patient management.
Clinical Education
Clinical education represents the most important component of EMT-Intermediate education
since this is where the student learns to synthesize cognitive and psychomotor skills. To be
effective, clinical education should integrate and reinforce the didactic and skills laboratory
components of the program. Clinical instruction should follow sound educational principles,
be logically sequenced to proceed from simple to complex tasks, have specific objectives,
and be closely supervised and evaluated. Students should not be simply sent to clinical
environments with poorly planned activities and be expected to benefit from the experience.
The ability to serve in the capacity of an entry level EMT-Intermediate requires experience
with actual patients. This process enables the student to build a database of patient
experiences that serves to help in clinical decision making and pattern recognition. A skilled
clinical educator must point out pertinent findings and focus the beginner’s attention.
Program directors should be cautioned against using time as a criterion to determine the
quantity of clinical education. More than any other phase of EMT-Intermediate education,
minimum amounts of patient contacts and frequency of skills performed must be established
for clinical education. It is acceptable to use a time based system to help in program
planning, but a system must be used to assure that every student satisfies each and every
clinical objective.
Typically, clinical education for the EMT-Intermediate takes place in both the hospital and
field environments:
Hospital Clinical
Because of the unpredictable nature of emergency medicine, the hospital environment
offers two advantages in EMT-Intermediate education: volume and specificity. In the
hospital setting, the EMT-Intermediate student can see many more patients than is possible
in the field. This is a very important component in building up a “library” of patient care
experiences to draw upon in clinical decision making.
The use of multiple departments within the hospital enables the student to see an adequate
distribution of patient situations. In addition to emergency departments, which most closely
approximate the types of patients that EMT-Intermediates should see, clinical education
should take advantage of critical care units, OB/GYN, operating rooms/anesthesia,
recovery, pediatrics, psychiatric, etc.
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This will help assure a variety of patient presentations and complaints. These also provide
a more holistic view of health care and an appreciation for the care that their patients will
undergo throughout their recovery. This places emergency care within context.
EMT-Intermediate programs throughout the country have created clinical learning

experiences in many environments. There is application to emergency medical care in
almost any patient care setting. When a particular location lacks access to some patient
populations, educational programs have created innovative solutions. Programs are
encouraged to be creative and seek out clinical learning experiences in many settings.
Examples include: morgues, hospices, nursing homes, primary care settings, doctor’s
offices, clinics, laboratories, pharmacies, day care centers, well baby clinics, and community
and public health centers.
Field Clinical
It is unreasonable to expect students to derive benefit from being placed into a field
environment and performing. Field clinical represents the phase of instruction where the
student learns how to apply cognitive knowledge and the skills developed in skills laboratory
and hospital clinical to the field environment. In most cases, field clinical should be held
concurrently with didactic and hospital clinical instruction.
Field instruction, as well as hospital clinical, should follow a logical progression. In general,
students should progress from observer to participant to team leader. The amount of time
that a student will have to spend in each phase will be variable and depend on many
individual factors. One of the largest factors will be the amount and quality of previous
emergency care experience. With the trend toward less and less EMT experience prior to
EMT-Intermediate education, program directors must adjust the amount of field experience
to the experience of the students.
Clinical affiliations shall be established and confirmed in written affiliation agreements with
institutions and agencies that provide clinical experience under appropriate medical
direction and clinical supervision. Copies of these agreements must be included with
your course application when submitting a course to the Washington State
Department of Health for approval. Students should have access to patients who present
common problems encourage in the delivery of advanced emergency distributed by age and
sex. Supervision should be provided by instructors or preceptors appointed by the program.
The clinical site should be periodically evaluated with respect to its continued
appropriateness and efficacy in meeting the expectations of the programs. Clinical affiliates
should be accredited by the Joint Commission on Accreditation of Healthcare Organizations.
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Field Internship
The final ability to integrate all of the didactic, psychomotor skills, and clinical instruction into
the ability to serve as an entry level EMT-Intermediate is conducted during the field
internship phase of the program. The field internship in not an instructional, but rather an
evaluative, phase of the program. The field internship should occur toward the end of the
program, with enough coming after the completion of all other instruction to assure that the
student is able to serve as an entry level EMT-Intermediate. During the field internship the
student should be under the close supervision of an evaluator.
Field internship must occur within an emergency medical service, which demonstrates
medical accountability. Medical accountability exists when there is good evidence that the
EMS providers is not operating as an independent practitioner, and when field personnel are
under direct medical control of on-line physicians or in a system utilizing standing orders
where timely medical audit and review provide quality improvement.
Quality improvement is also a required component of EMS training. The role of medical
direction is paramount in assuring the provision of highest quality out-of-hospital care.
Medical Directors should work with individuals and systems to review out-of-hospital cases
and strive to achieve a sound method of continuous quality improvement.
Washington State Clinical/Field Internship Rotation Requirements

In addition to the hours of instruction and practical skill evaluations, this course requires that
the student successfully complete patient interactions in a clinical setting. The training course
may utilize emergency departments, clinics or physician offices. The program director or
medical director must establish appropriate relationships with various clinical sites to assure
adequate contact with patients and initiate written agreements with each clinical/field site.
The student should interview and assess a minimum of the clinical/field experiences listed
below. In addition, the student should record the patient history and assessment on a
prehospital care report; i.e., Washington State Medical Incident Report (MIR), just as if
interacting with this patient in a field setting. The prehospital care report should then be
reviewed by the Primary Instructor to assure competent documentation practices in
accordance with minimum data requirements. The training course must establish a
feedback system to assure that students have acted safely and professionally during their
training. Students should receive a written report of their performance by clinical or
ambulance staff.
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Clinical/Field Internship Requirements

Internship Type IV Techs AW Techs ILS Techs only ILS/AW Techs only
10 IV insertions 10 ET 10 IV insertions on 10 IV insertions on
Clinical Internship Requirements on Humans. At intubations on Humans. At the Humans. At the option of
the option of the Humans. At option of the MPD, the MPD, 5 may be
NOTE: It is recommended that MPD, 5 may be the option of 5 may be performed on training aids.
some IV insertions and/or ET performed on the MPD, 5 performed on 10 ET intubations on
intubations are accomplished training aids. may be training aids. Humans. At the option of
during the field internship. performed on the MPD, 5 may be
Competency for all skills is Lab skill training aids. performed on training aids.
determined by the County Medical proficiency Lab skill Lab skill proficiency
Program Director. required in: Lab skill proficiency required in:
• IO line proficiency required in: • IO placement
placement required in: • IO placement • ML-AWs
• ML-AWs • ML-AWs • Medication
Administration
Note: Students must complete clinical/field rotations prior to entrance to the Individual
Comprehensive End of Course Evaluation.
Students who have been reported to have difficulty in the clinical or field setting must
receive remediation and redirection. Students should be required to repeat clinical or field
setting experiences until they are deemed competent within the goals established by the
County Medical Program Director.
Washington State Training Course Forms

Course Approval Forms: - You may complete these forms through the Internet at
www.doh.wa.gov/hsqa/emtp, or request copies from the Education, Training and Regional
Support Section.
Training Course Application:

This form must be completed and received by the Education, Training and
Regional Support Section at least two weeks prior to the start of the course.
Course Schedule:
This form must be completed and submitted with the Training Course
Application.
Clinical and Field internship agreements:

Copies of the required clinical and field internship agreements must be
submitted with your course application and course schedule.
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Course Completion Forms:
BLS/ALS Course Completion Roster:

This form must be completed by indicating all students enrolled in the class
(whether they successfully completed or not). - You may complete these forms
through the Internet at www.doh.wa.gov/hsqa/emtp, or request copies from
the Education, Training and Regional Support Section.
Certificate of Course Completion:

The Lead Instructor must issue a Certificate of Course Completion attesting to
student competency for the student to be eligible to take the Washington State
written certification examination. Prior to issuing the certificate, Lead
Instructor must verify the student’s:
• Comprehensive cognitive, affective and psychomotor abilities.
• Successful completion of the clinical/field rotation following the
procedures identified in Appendix H.
The Certificate of Course Completion:

• Is provided by the Lead Instructor and issued to students who
successfully complete the EMT-Intermediate Course.
• Must include the course approval number, course location,
Student’s name, Lead Instructor’s name and signature, and course
completion date.
Student Assessment
Any educational program must include several methods for assessing student achievement.
As mentioned before, quizzes of the cognitive and psychomotor domains should be provided
regularly and frequently enough to provide the students and the faculty with valid and timely
indicators of the student’s progress toward and the achievement of the competencies and
objectives stated in the curriculum. Ultimately, the program director is responsible for the
design, development, administration and grading of all written and practical examinations.
This task is often delegated to others. Some programs use outside agency developed or
professionally published evaluation instruments. This does not alleviate the program’s
responsibility to assure the appropriateness of these exam materials. All examinations used
within the program must have demonstrated validity and reliability and conform to
psychometric standards. Programs are encouraged to use outside sources to validate
examinations and/or as a source of classroom examination items.
The primary purpose of this course is to meet the entry-level job expectations as indicated in
the job description. Each student, therefore, must demonstrate attainment of knowledge,
attitude, and skills in each area taught in the course. It is the responsibility of the
educational institution, program director, medical director, and faculty to assure that
students obtain proficiency in all content areas. If after counseling and remediation a
student fails to demonstrate the ability to learn specific knowledge, attitudes and skills, the
program director should not hesitate to dismiss the student. The level of knowledge,
attitudes and skills attained by a student in the program will be reflected in his performance
on the job as an EMT-Intermediate.
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This is ultimately a reflection on the program director, primary instructor, medical director
and educational institution. It is not the responsibility of the certifying examination to assure
competency over successful completion of the course. Program directors should only
recommend qualified candidates for certification.
Requirements for successful completion of the course are as follows:
Cognitive - Students must demonstrate competency of all content areas. This

is most often done using quizzes, regular topical exams, and some
combination of comprehensive exams (mid terms and finals). Cognitive
evaluations must be reliable and viable. Programs should incorporate
psychometric principles whenever possible. For example, item analysis should
be utilized to assure discrimination on achievement tests. Scores on tests of
known validity and reliability should be correlated to teacher made
examinations. Medical director should take examinations and provide content
validity input. Examinations should be balanced to areas within the course.
Pass/fail scores should be established with an understanding of standard
setting. Decisions regarding the continuation of students in class need to be
made following a pattern of performance. One test failure should not result in
failure from the program. Grading practices should be standardized to prevent
bias by instructional staff. Essay and open ended questions should be clearly
written and acceptable answers should be known before the examination is
administered. Tests should be kept secure and reviewed by students during
class time. Programs should investigate methods to Special remedial sessions
may be utilized to assist in the completion of a unit or module of instruction.
Scoring should be in accordance with accepted practices.
Affective - Students must demonstrate professionalism, conscientiousness

and interest in learning. The affective evaluation instruments contained within
this curriculum were developed using a valid process and their use is strongly
recommended. Just as with cognitive material, the program cannot hold a
student responsible for professional behaviors that were not clearly taught.
The professional attributes evaluated using this instrument references the
material in the Roles and Responsibilities of the EMT-Intermediate section of
the curriculum. The instruments can be incorporated into all four components
of the program: didactic, practical laboratory, clinical and field internship.
Students who fail to do so should be counseled while the course is in progress
in order to provide them the opportunity to develop and exhibit the proper
attitude expected of an EMT-Intermediate. See Appendix D.
Psychomotor - Students must demonstrate proficiency in all skills. A

complete list of skill competencies expected to be completed within the
program should be available to each student. Students should know pass/fail
score of any instrument utilized within an educational program. Whenever
possible multiple evaluators recording performance of a student should be
made.
15
Scenarios should be medically accurate and flow, as they would in a typical

EMS call. In clinical and field internships, all instructional staff must be familiar
with psychomotor instruments and expectations. Inter-rater reliability between
various instructional staff must be monitored by the program. Clinical and field
instructional staff orientations may help resolve issues of inter-rater reliability.
Course ending skills examinations should be administered. Special remedial
sessions may be utilized to assist in the completion of a unit or module of
instruction. Pass/fail scores should be in accordance with accepted practices.
It is strongly recommended that program utilize the skills evaluation
instruments provided in this curriculum. See Appendix H.
Students should be evaluated in all three domains in didactic, practical laboratory, clinical
and field internship. For example, the student’s cognitive knowledge can be evaluated in
the clinical setting by direct questioning or discussions. Secondly, if an IV is started on a
patient, the psychomotor skill should be evaluated. Finally, the affective domain, their
professional attributes can be measured. This example also applies to skills laboratories.
In the skills laboratory, the cognitive domain can be measured by asking questions about
the skill, and the affective domain can be measured by their attitude in learning and
practicing the skills.
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FLOW CHART OF THE EMT-INTERMEDIATE LIFE SUPPORT COURSE

PRACTICAL SKILL EVALUATION PROCESS
Step # 1
EMT-I Students must demonstrate proficiency on practical skills identified for each
lesson using practical evaluation skill sheets identified on page H-6. Some skill sheets
are used multiple times throughout the course. (EVALUATION LESSONS MAY BE
COMBINED WITH PRACTICAL SKILL LABS TO MEET THIS REQUIREMENT).
Students must achieve the required score for each skill listed on page H-35, and receive
NO check marks in the Critical Criteria section.
MPD-approved Evaluators must complete all evaluations.

Step # 2
EMT-I Students must complete clinical/field rotations prior to entrance to the
comprehensive end of course evaluation. Information regarding clinical and field
rotations is located on pages H-3 and H-4.
Step # 3
EMT-I Students must complete the INDIVIDUAL COMPREHENSIVE END OF
COURSE PRACTICAL SKILLS EVALUATION using the role play model identified on H-
5, and skill sheets on pages H-29 and H-31. MPD-approved Evaluators must complete
all evaluations.
Step # 4
EMT-I Students: Instructors must issue a CERTIFICATE of COURSE COMPLETION
attesting to student competency for the student to be eligible to take the Washington
State written certification examination. Prior to issuing the certificate, Instructors must
verify the student’s:
1. Comprehensive cognitive, affective and psychomotor abilities.

2. Successful completion of the clinical/field rotation following the procedures identified
on pages H-3 and H-4.
Step # 5
EMT-I Students: Following receipt of an Instructor-issued Certificate of Course
Completion, the student is eligible to take the Washington State written certification
examination.
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NARRATIVE OF THE EMT-INTERMEDIATE COURSE

Step # 1 - PRACTICAL SKILL EVALUATIONS
The practical skill evaluation sheets provided in this appendix are to be used in conjunction
with the core curriculum and are organized in the order of the corresponding lessons. They
should be copied and provided to each student at the beginning of the training course and
are to be used to document the performance of required skills evaluations throughout the
training course and during the Comprehensive End of Course Evaluation.
Required Practical skill Evaluations
Students must demonstrate proficiency on practical skills identified for each “evaluation lesson”
using the required practical skill evaluation sheets specified for that lesson on page H-6. Some
skill sheets are used multiple times throughout the course. (EVALUATION LESSONS MAY BE
COMBINED WITH PRACTICAL SKILL LABS TO MEET THIS REQUIREMENT). MPD-
approved Evaluators must complete all evaluations.
Individual Practical skill Evaluation Sheets

The individual practical skill evaluation sheets located on pages H-7 through H-27 are to be
used to document the performance of students during course practical skill evaluations. MPD-
approved Evaluators must complete all evaluations. Evaluator names and signatures must
appear on each evaluation. All practical skill evaluations must be successfully completed
before participating in the Comprehensive End of Course Evaluation. Students must achieve
the required score for each skill listed on page H-35, and receive NO check marks in the
Critical Criteria section.
Individual Comprehensive End of Course Evaluation Skill Sheets

The Comprehensive End of Course Evaluation skill sheets located on pages H-29 and H-31
are to be used to document the performance of each student during the Individual
Comprehensive End of Course Evaluation. MPD-approved Evaluators must complete all
evaluations.
EMT-I Course Practical Skills Evaluation & Individual Comprehensive Course

Evaluation Summary Sheet
The Practical Skills Evaluation and Individual Comprehensive Course Evaluation Summary
Sheet located on page H-33 is to be used to document the final results of each student’s
performance following individual practical skill evaluations and the Comprehensive End of
Course Evaluation. The instructor or MPD signature is required on the Practical skill
Evaluation and Comprehensive End Of Course Evaluation Summary Sheet.
Step # 2 - CLINICAL/FIELD ROTATIONS
In addition to the hours of instruction and practical skill evaluations, this course requires that
the student successfully complete patient interactions in a clinical setting. The training
course may utilize emergency departments, clinics or physician offices.
18
The program director or medical director must establish appropriate relationships with
various clinical sites to assure adequate contact with patients and initiate written
agreements with each clinical/field site.
ambulance staff.
Clinical/Field Internship Requirements

Internship Type IV Techs AW Techs ILS Techs only ILS/AW Techs only
10 IV insertions 10 ET 10 IV insertions on 10 IV insertions on Humans.
Clinical Internship Requirements on Humans. At intubations on Humans. At the At the option of the MPD, 5
NOTE: It is recommended that the option of Humans. At option of the MPD, may be performed on
some IV insertions and/or ET the MPD, 5 the option of 5 may be training aids.
intubations are accomplished may be the MPD, 5 performed on 10 ET intubations on
during the field internship. performed on may be training aids. Humans. At the option of
Competency for all skills is training aids. performed on the MPD, 5 may be
determined by the County training aids. Lab skill performed on training aids.
Medical Program Director. Lab skill proficiency Lab skill proficiency
proficiency Lab skill required in: required in:
required in: proficiency • IO placement • IO placement
• IO line required in: • ML-AWs • ML-AWs
placement • ML-AWs • Medication • Medication Administration
Administration
Step # 3 - INDIVIDUAL COMPREHENSIVE END OF COURSE EVALUATION

The purpose of the Comprehensive End of Course Evaluation is to combine cognitive
knowledge and practical skills learned during the course to provide emergency care as if
responding to a real field situation. This evaluation is intended to be general rather than specific
in nature to determine if the team has the basic knowledge and skill necessary to perform
adequately during an EMS emergency.
19
The EMT-I Individual Comprehensive End of Course Evaluation is conducted in an individual

evaluation format using a BLS assistant as necessary to provide emergency care to the patient.
• Only the individual student will be evaluated, not the BLS assistant. The assistant is
provided to assist the EMT-I with BLS procedures as if they were part of the response team.
• The Comprehensive End of Course Evaluation should be designed to be a realistic

experience for the students. The instructor is responsible for developing specific medical
and trauma scenarios to be used by the students during the Individual Comprehensive End
of Course Evaluation.
• The scenarios developed will not include any prescribed medications that could be
administered by EMT-Basic assistants. The student and their assistant must perform
appropriate patient care.
• If appropriate care is not provided, remediation and repeat of a station will be necessary.
ROLE PLAY MODEL

Role Play is practical skill performance evaluations from written scenarios. Students may have
the use of an EMT-Basic assistant. Only the individual student will be evaluated, not the EMT-B
assistant. The assistant is provided to assist the EMT-I with BLS procedures as if they were
part of the response team. This method must be used for the Individual Comprehensive End of
Course Evaluation. Role Play is also appropriate for end of lesson evaluations and practical
skill evaluations
SCENARIO DEVELOPMENT
It is the instructor’s responsibility to develop scenarios used in Role Play evaluation. During the
scenario development, skill combinations are encouraged. For example: for the Trauma
evaluation, oxygen, splinting, PASG stabilization, fluid replacement and immobilization could be
combined. For the Medical evaluation, pharmacology elements could be introduced to include
indications, contraindication, dosages, side effects, etc. Scenarios for EMT-Intermediate
evaluations must not include prescribed medications the EMT-B assistant might assist
the patient in administering.
Step # 4 - CERTIFICATE OF COURSE COMPLETION

Instructors must issue a CERTIFICATE OF COURSE COMPLETION attesting to student
competency for the student to be eligible to take the Washington State written certification
examination. Prior to issuing the certificate, Instructors must verify the student’s:
2. Successful completion on the clinical/field rotation following the procedures identified on
pages H-3 and H-4.
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The CERTIFICATE OF COURSE COMPLETION MUST include:

• Course approval number (Issued by DOH – Emergency Medical and Trauma Prevention)
• Course location
• Student’s name
• Instructor’s name and signature
• Course completion date
Step # 5 - WASHINGTON STATE WRITTEN CERTIFICATION EXAMINATION

Following receipt of an Instructor issued Certificate of Course Completion; the student is eligible
to take the Washington State written certification examination.
Program Personnel
There are typically many individuals involved in the planning and execution of an EMT-
Intermediate program. For clarity, the following terms are defined, as they will be used
throughout this document.
These identified roles and responsibilities are a necessary part of each EMT-Intermediate
program. The individuals carrying them out may vary from program to program and from
locality to locality as the exact roles interface and overlap. In fact, one person, if qualified,
may serve in multiple roles.
Program Director/Course Coordinator

The Program Director is the individual responsible for course planning, organization,
administration, periodic review, program evaluation, continued development, and
effectiveness. The program should have a full-time Program Director while the program is
in progress, whose primary responsibility is to the educational program. The program
Director should contribute an adequate amount of time to assure the success of the
program. The program director shall actively solicit and require the cooperative involvement
of the medical director of the program.
The program director must have appropriate training and experience to fulfill the role. They
should have at least equivalent academic training and preparation and hold all credentials
for which the students are being prepared, or hold comparable credentials, which
demonstrate at least equivalent training and experience.
The program director should have training and education in education and evaluation and
be knowledgeable in administration of education and related legislative issues for EMT-
Intermediate education. The program director should assume ultimate responsibility for the
administration of the didactic, clinical, and field internship phases of the program. It is the
program directors responsibility to monitor all phases of the program and assure that they
are appropriate and successful.
21
Washington State requires one of the following for the Program Director/Course
Coordinator:
1. An approved Senior EMT Instructor (SEI), OR
2. A Medical Program Director & Department of Health approved, non-SEI with appropriate
training and experience.
Program Faculty/Instructors
The depth and breadth of EMT-Intermediate education has evolved through the years and
expanded considerably from the early days of emergency medicine. It is no longer
reasonable to assume that one individual possesses the required depth of knowledge to be
able to teach the entire program. As a result the Program Director and/or Course
Coordinator should use content area experts extensively through the program.
Washington State requires the following for the instructional personnel:

1. Medical Program Director and Department of Health approval
2. The lead instructor must be a certified paramedic
3. Content experts may be used to instruct, however, the paramedic lead instructor is
responsible for all instruction provided.
4. The lead paramedic instructor may also be the program director/course coordinator if
they meet the requirements listed under Program Director/Course Coordinator listed
above.
Course Medical Director

Medical direction of the EMT-Intermediate is an essential component of out-of-hospital
training. Physician involvement should be in place for all aspects of EMS education. The
Course Medical Director of the EMT-Intermediate program should be a local physician with
emergency medical experience who will act as the ultimate medical authority regarding
course content, procedures, and protocols. All of the program faculty should work closely
together in the preparation and presentation of the program.
The Course Medical Director can assist in recruiting physicians to present materials in class,
settling questions of medical protocol and acting as a liaison between the course and the
medical community. During the program the Medical Director will be responsible for
reviewing the quality of care rendered by the EMT-Intermediate student in the clinical and
field setting. The Course Medical Director should review all course content material and
examinations. The medical director should periodically observe lectures and practical
laboratories, field and clinical internships. The medical director should participate in clinical
instruction, student counseling, psychomotor and oral testing, and summative evaluation.
22
Most importantly, the Course Medical Director is responsible to verify student competence in
the cognitive, affective and psychomotor domains. Students should not be awarded course
completion certificates unless the medical director and program director can assure through
documentation of completion of terminal competencies that each student has completed the
full complement of education. Documentation of completion of course competencies should
be affixed to the student file with signatures of the medical director and program director at
the completion of the course.
Licensure, Certification and Registration

The Washington State Department of Health requires specific evaluation of cognitive and
psychomotor performance prior to course completion to obtain official certification as an
EMT-Intermediate. These evaluations are conducted throughout the course and as a final
course comprehensive practical evaluation, prior to course completion. The National
Registry of EMTs is a recognized agency that provides examinations for some states,
however, National Registration as an EMT Intermediate is not required by Washington
State. The program director should contact the State Office of Emergency Medical and
Trauma Prevention for certification information.
Program Evaluation
On-going evaluation must be initiated to identify instructional or organizational deficiencies,
which affect student performance. The evaluation process should include both objective
and subjective methods. Main methods of objective evaluation generally used are: 1)
Graduates’ performance on standardized examinations, and 2) Graduates’ performance in
practice in accordance with established standards of care. Group and individual
deficiencies may indicate problems in conducting the education program.
Subjective evaluation should be conducted at regular intervals by providing students with

written questions on their opinions of the program's strengths and weaknesses. Students
should be given the opportunity to comment on the instruction, presentation style and
effectiveness. Students should also be asked to comment on the program's compliance
with the specified course of instruction, the quality and quantity of psychomotor skills labs,
clinical rotations, and the validity of the examinations.
The purpose of this evaluation process is to strengthen future educational efforts. All
information obtained, as part of the subjective evaluation should be reviewed for legitimacy
and possible incorporation into the course. Due to the important nature of this educational
program, every effort should be made to ensure the highest quality instruction.
Facilities
The physical environment for the provision of the EMT-Intermediate program is a critical
component for the success of the overall program. The facility should sufficient space for
seating all students. Abundant space should be made available for demonstration during
the presentation of the course material. Additional rooms or adequate space should be
available to serve as a practice area. The facility should be well lit for adequate viewing of
various types of visual aids and demonstrations. Heating and ventilation should assure
student and instructor comfort and the seats should be comfortable with availability of desk
23
tops or tables for taking notes. There should be an adequate number of tables for display of
equipment, medical supplies, and training aids. A chalkboard (flip chart, grease board)
should be in the main hall. A projection screen and appropriate audiovisual equipment
should be located in the presentation facility. Practice areas should be carpeted and large
enough to accommodate six students, one instructor, and the necessary equipment and
medical supplies. Tables should be available for practice areas, with appropriate and
sufficient equipment and medical supplies.
Equipment and Supplies

Sufficient supplies and equipment to be used in the provision of instruction shall be available
and consistent with the needs of the curriculum and adequate for the students enrolled.
The equipment must be in proper working order and sufficient to demonstrate skills of
patients in various age groups. It is recommended that all the required equipment for the
program be stored at the facility to assure availability for its use. A list of minimal
essential supplies and equipment is provided in Appendix F.
24
HOW TO USE THE CURRICULUM
There are four modules of instruction in the ILS technician core content. There are 14
lessons within the four modules. Each section has the following components:
Unit Terminal Objective

The unit terminal objective represents the desired outcome of completion of the block of
instruction. In most cases it is a very high level objective, which can make it difficult to
evaluate. This global objective represents the desired competency following completion of
the section. Although this objective may be viewed as the aggregate of lower level
objectives, in many cases, the whole is greater than the sum of the parts.
Objectives
These are the individual objectives of the curriculum. Mastery of each of these objectives
provides the foundation for the higher order learning that is expected of the entry level
provider. The instructor and student should strive to understand the complex
interrelationships between the objectives. These objectives are not discrete, disconnected
bits of knowledge, but rather fit together in a mosaic that is inherently interdependent. The
objectives are divided into three categories: Cognitive, Affective, and Psychomotor.
Cognitive Affective Psychomotor

mental process-- emotional process-- physical process--
perception feelings muscular activity
reasoning
intuition
To assist with the design and development of a specific unit, each objective has a numerical
value, e.g., 3-2.1. The first number is the module of instruction, followed by a hyphen and
the number of the specific unit. For example, 3-2.1 is:
Module 3: Patient Assessment

Unit 3-2: Techniques of Physical Examination
Objective 3-2.2 Describe the techniques of inspection, palpation, percussion,
and auscultation. (C-1)
At the end of each objective is a letter for the type of objective: C = Cognitive; A = Affective;
and P = Psychomotor. (The example above is cognitive). The number following the type of
objective represents the level of objective: 1 = Knowledge; 2 = Application; and 3 =
Problem Solving. (The example above is knowledge).
25
Declarative
This material is designed to provide program directors and faculty with clarification on the
depth and breadth of material expected of the entry level EMT-Intermediate. The
declarative material is not all-inclusive. The declarative sections of the curriculum
lack much of the specific information that must be added by the instructor. The
declarative information represents the bare minimum that should be covered, but the
instructor must elaborate on the material listed. Every attempt has been made in
development of the declarative material to avoid specific treatment protocols, drug dosages
or other material that changes over time and has regional variations. It is the responsibility
of the instructors to provide this information.
Specifically, the declarative material is used to help instructors develop lesson plans and
instructional strategies. It is also designed to assist examination and publishers in
developing appropriate evaluation materials and instructional support materials. It is of
utmost importance to note that the declarative material is not designed to be used as
a lesson plan, but rather it should be used by instructors to help develop their own
lesson plans.
Clinical Rotations
The clinical rotations that appear in the EMT-Intermediate: National Standard Curriculum
represent a stark departure from previous clinical education recommendations. In the past,
clinical competence was determined simply by the number of hours spent in various clinical
environments. As there is no assurance that time produced an adequate number of clinical
exposures resulting in entry level clinical competence, a different approach was taken with
this curriculum. In-kind services were provided by the Joint Review Committee for EMT-
Intermediate Program Accreditation (JRC).
The JRC survey all existing accredited paramedic programs and asked them to identify the
number of psychomotor skills, patient age groups, pathologies, patient complaints and team
leader skills they were currently utilizing in order to identify competent entry level
paramedics. The results of the survey were then presented to the JRC sponsoring
organization committee members who possess expertise in cardiology, pediatrics,
anesthesia, surgery, emergency medicine and EMT-Intermediate education. Using both
subject matter expertise and the results of the surveys of accredited programs; the JRC
established the clinical rotation goals presented in this curriculum. Items presented in bold
are essentials and must be completed by each student within the program. Items in italics
are recommendations to achieve the essential.
Although these patient exposures cover a wide domain of skills, pathologies, complaints and
ages, they can be achieved in either the clinical or field internship. For example, a student
may demonstrate the ability to perform a comprehensive assessment, formulate and
implement an treatment plan for patients with chest pain in either a hospital critical care unit
or during an encounter in the field. If the patient in this example was not experiencing chest
pain at the time of the student evaluation, but had experienced chest pain which resulted in
admission to the critical care unit. This interaction would suffice for meeting the clinical
26
rotation for one encounter with a chest pain patient. During this experience the student
should complete an evaluated physical examination, a history based upon the initial and
present condition of the patient and formulate a treatment plan for the patient based upon
initial field or admission findings. This same principle of encountering patients who have
identified pathologies or complaints within the past 48 hours will suffice for meeting the
clinical rotation requirement.
Some categories can be counted more than once. For example if a student in the field
internship encounter a patient with chest pain who was 68 years old and start an IV, the
student would obtain credit for a complaint, an age and a skill. The established IV and chest
pain assessment, and treatment and implementation plan must be evaluated and the patient
age group credit must be recorded. Encounters without evaluation and recording should not
be awarded credit.
Obviously during the education the best experience would occur in the field setting, which
most approximates the function of the job. Recognizing the extended field time that would
be necessary to see the recommend variety of patient conditions and skills would be
infeasible, the curriculum permits students to obtain these experiences in either hospital
clinical or field. The team leaders skills cannot be met during hospital rotations. The JRC
recommends that a student will obtain credit for one patient for each encounter. For
example if a patient has both chest pain and a syncope episode, the student can utilize this
experience for either a chest pain patient or a syncope patient, but not for both. The
program must develop a clinical rotation patient tracking system in order to assure that each
student encounters the recommended number of skills, ages, pathologies, complaints and
team leader skills.
The clinical rotations contained within this curriculum are being accomplished by EMT-
Intermediate education programs at the time of the curriculum revision. These rotations do
not represent an increase in clinical requirements. The program director along with the
community of interest should use feedback loops that are part of the program evaluation
process to either increase or decrease the number of patient exposures based upon valid
measurement instruments utilized in graduate surveys. If employers or graduates indicate
the need for increased patient encounters in order to bring current graduates to the level of
competency then the program should increase the number of encounters to correspond to
this need. Likewise if graduates and employers indicate some rotations provided more than
competent experience the program may reduce the number of patient encounters within the
recognized category.
Although the categories were researched by the JRC, a program director, medical director
or community of interest may add different encounters in order to meet community needs.
For example if a program is located in an area with a large geriatric population, the program
may increase the number of encounters with geriatric patients to correspond to community
needs.
27
EDUCATING PROFESSIONALS
It has long been recognized that EMT-Intermediates, as an integral part of the health care
team, are health care professionals. As such, the education of EMT-Intermediates should
follow a professional, rather than purely technical, model of instruction. Employers and
patients are significantly increasing their expectations of EMT-Intermediates, and EMS
education will need to respond.
In Responsive Professional Education, Stark, Lowther, and Hagerty (1986), propose that
professional preparation is a combination of developing both professional competence and
professional attitudes.
Historically, most EMS education has focused primarily on technical competence. Technical
competence is only one component of professional competence. Professional competence
includes six subcategories:
Conceptual competence - Understanding the theoretical foundations of the

profession
Technical competence - Ability to perform tasks required of the profession
Interpersonal competence - Ability to use written and oral communications
effectively
Contextual competence - Understanding the societal context (environment) in
which the profession is practiced
Integrative competence - Ability to meld theory and technical skills in actual
practice
Adaptive competence - Ability to anticipate and accommodate changes (e.g.
technological changes) important to the profession.
The main areas of focus of the National Standard Curriculum are on conceptual and
technical competence. This revision of the EMT-Intermediate curriculum is the first to
address the strategies of interpersonal and therapeutic communication. Unfortunately,
conceptual, technical, and interpersonal competencies are only part of the competencies
required for reflective practice.
It is incumbent on the program to keep contextual, integrative and adaptive competence in

mind through the entire program. These are not discreet topic areas and do not easily lend
themselves to behavioral objectives. Programs and faculty members must constantly
weave these issues into the conceptual and technical components of the course.
Contextual competence is an appreciation for how the professional’s practice fits into larger
pictures. Professional practice in not conducted in a vacuum, but impacts, and is impacted
upon, by many forces. Of course, entry level EMT-Intermediates understand how their
practice affects individual patients. In addition, they must appreciate how their actions
impact the EMS system where the work, the overall EMS system, the profession, the health
care system, and society in general.
28
Teaching to improve contextual competence requires constant reinforcement of the

interdependent nature of professional practice. Faculty must have a clear understanding of
the relationship that EMS has with the health care system, the environment and society in
general. Faculty must strive to repeatedly emphasize the “big picture” and not to fall into the
trap of considering the individual practitioner, or the EMS profession, as a separate entity.
Integrative competence is generally built by having a strong mastery of the theoretical base
of the content material. Students can often memorize treatment protocols (practice) without
having a grasp of the underlying pathophysiology. In the short term, this enables them to
pass the test, but results in poor ability to integrate the material. Eventually, this shortfall
manifests itself as poor decision making and problem solving skills. Medical education must
balance theory and practice and constantly emphasize the relationship between the two.
Theory and practice are not discreet, mutually exclusive concepts, but rather the flip sides of
the same coin.
Another way to improve integrative competence is to broaden the base of educational
exposures of the student. It has been repeatedly demonstrated that a broad distribution of
course work, typical in liberal studies educational approach, increases integrative
competence. Although not always possible, programs which are not satisfied with their
graduates’ ability to integrate theory and practice may find that adding additional courses
from other disciplines will improve the students higher level cognitive skills.
It is effectively impossible for a centrally developed curriculum to identify specific objective

and declarative material for contextual, integrative and adaptive competence, but their
importance cannot be overstated. Individual instructors and programs must keep these
competencies in mind as they are developing instruction strategies to build entry level
competence. These competencies are often the result of leadership, mentoring, role
modeling, a focus on high level cognition, motivation and the other teaching skills of the
faculty.
Professional attitudes, in large part, represent the affective objectives of the program.
Unfortunately the development of true professional attitudes is much more than the
aggregate sum of the individual objectives. These attitudes represent the social climate,
moral and ethical identity of the individual and the profession. These attitudes are
influenced and shaped, through role modeling, mentoring, and leading by example. It is very
difficulty to “teach” in a didactic sense and this is often interpreted by students as preaching.
Generally, professional attitudes are best nurtured through leadership and mentoring.
Faculty are encouraged to provide a positive role model for the development of professional
attitudes in all interactions with students. EMT-Intermediate programs should take seriously
their responsibility to develop the following professional attitudes:
Professional identity - The degree to which a graduate internalized the norms
of a professional
Ethical standards - The degree to which a graduate internalizes the ethics of a
profession
Scholarly concern for improvement - The degree to which a graduate
recognizes the need to increase knowledge in the profession through research
29
Motivation for continued learning - The degree to which a graduate desires to

continue to update knowledge and skills.
Career marketability - The degree to which a graduate becomes marketable
as a result of acquired training
Emergency medicine, like all professions, has a professional culture, personality, behaviors
and attitudes that we consider acceptable. The opinion that others have about our
profession are profoundly influenced by the professional identity of each of our members. It
is very important that we shape our identity consciously, or run the risk of being
misunderstood by others. The degree to which new graduates adopt the behaviors and
attitudes that the profession considers to be acceptable is a measure of our success in
shaping each student’s professional identity.
Ethical behavior is one of the cornerstones of professional attitudes. Ethics involves the
critical evaluation of complex problems and decision making that takes into account the
ambiguity that is most often present in professional decisions. Ethical behavior and decision
making involves the ability to consider the greater social ramifications of your actions.
It is becoming increasingly important to have empirical data to validate clinical decisions.
This fact is significantly increasing the role of research in medicine. Every medical
professional must understand and appreciate the role of research in the future of health
care. Of course, not all health care providers will be conducting research, but everyone
must be committed to the concept of research as the foundation for decision making.
Primary professional education is just the beginning of a life long journey. The art and
science of medicine changes over time. This requires that the professional adopt, from the
beginning of practice, a sincere commitment to personal growth and continual improvement.
The last professional attitude is really a function of all that we have discussed. An
individual’s career marketability is a function of his ability to integrate professional
competencies and professional attitudes into his own practice and work habits. Not only will
this affect the ability to gain initial employment, but also significantly impact his promotion
potential. It is a very real and practical responsibility of education to prepare professionals
for the work place and position them to be able to progressively be promoted. This keeps
quality individuals intellectually stimulated, professionally challenged, and financially
satisfied so they will not feel a need to leave the profession.
Professional education is a journey, not a destination. It is impossible, and fruitless, to

dissect professionalism into increasingly smaller objectives. Mastery of hundreds or
thousands of individual objectives does not assure that the graduate will integrate these
objectives into professional behaviors. Like Humpty Dumpty, all of the parts may not be
able to be assembled into a meaningful whole. There are many people who have mastered
various parts of professional competence, but are not able to integrate and synthesize the
skills into effective practice. This is the art of medicine, and is not taught specifically, but
nurtured and allowed to grow through the creation of a supportive and positive environment.
NOTES:
30
31
NOTES:
32
Instructor Lesson Plans
Section 1 - Preparatory
Lesson 1-1: Roles and Responsibilities of the EMT-Intermediate

Lesson 1-1: Roles and Responsibilities of the EMT Intermediate
OBJECTIVES LEGEND
C=Cognitive P=Psychomotor A=Application
1=Knowledge
2=Application
3=Problem Solving Level
TERMINAL INSTRUCTIONAL OBJECTIVE

1. At the completion of this lesson, the EMT-Intermediate will understand his or her
roles and responsibilities within an EMS system, and how these roles and
responsibilities differ from other levels of providers.
2. Integrate the principles of the Washington State Trauma Triage Procedures into
trauma response situations.
COGNITIVE OBJECTIVES
At the completion of this lesson, the EMT-Intermediate student will be able to:
1. Define the following terms: (C-1)
• Medical direction
• Medical Control
• Protocols
• Patient Care Procedures
• Trauma Triage Tool
2. Describe the recognized levels of EMS training/education, leading to
licensure/certification in his or her state. (C-1)
3. Explain EMT-Intermediate recertification requirements in Washington State [Provide
Student Handout on recertification in Washington State (SEE Appendix K)]. (C-1)
4. Review examples of local protocols. (C-1)
5. Discuss prehospital care as an extension of the physician. (C-1)
6. Describe the relationship between ALS on the scene, the EMT-Intermediate on the
scene, and the EMS physician providing on-line medical direction/control (C-1)
7. Discuss the Washington State Trauma Triage Tool and how it is used to direct
trauma patient. (C-1)
8. Understand the purpose of the Washington State Trauma Triage Tool. (C-1)
9. Understand who developed and approved the Washington State Trauma Triage Tool. (C-1)
10. Understand the components of the Washington State Trauma Triage Tool. (C-1)
11. Understand regional patient care procedures. (C-1)
12. Understand how to use the Washington State Trauma Triage Tool according to the
regional approved Patient Care Procedures. (C-1)
13. Understand the difference between Regional Patient Care Procedures and Medical
Program Director approved Patient Care Protocols. (C-1)
14. Understand the purpose of trauma wristbands. (C-1)
Section 1: Page 2
AFFECTIVE OBJECTIVES
There are no affective objectives in this lesson.
PSYCHOMOTOR OBJECTIVES
There are no psychomotor objectives in this lesson.
PREPARATION
Motivation:
EMT-Intermediates need to understand their roles and responsibilities within an
EMS system, and how these responsibilities differ from other levels of providers.
The EMT-Intermediate must also know how to provide optimal care utilizing the
Washington State Trauma Triage Tool. It is the intent of this lesson to provide the
EMS provider with an overview of these areas.
Prerequisite Skills:
Students must meet the prerequisites for the IV, AW or ILS course.
MATERIALS
AV Equipment:
Utilize various audio-visual materials relating to the lesson topic. The continuous
design and development of new audio-visual materials relating to EMS requires
careful review to determine which best meet the needs of the program. Materials
should be edited to assure meeting the objectives of the curriculum.
EMS Equipment:
Trauma triage tags
Trauma wristbands
PERSONNEL
Primary Instructor:
One instructor knowledgeable in Medical Incident Command and Washington State
Trauma Triage Procedures.
Assistant Instructor:
Not required.
Recommended Minimum Time to Complete:
Three hours
Section 1: Page 3
Presentation
DECLARATIVE
I. Introduction
A. EMS Provider levels
1. First responder
2. EMT-Basic
3. EMT-Intermediate levels
a) Intravenous Therapy Technician
b) Airway Management Technician
c) IV and Airway Management Technician
d) ILS Technician
e) ILS and Airway Technician (ILS/Airway)
4. Paramedic
B. EMT-Intermediate Education
1. Initial Education
a) National Standard Curriculum as amended and approved by the
Washington State Department of Health
(1) Prerequisites
(2) Provides standardized minimum training
(3) Includes all cognitive, psychomotor, affective objectives
(4) Clinical requirements
(5) Length
(a) Minimum hours Commitment
b) Educational Resources
(1) Facilities
(2) Instructors
(3) Equipment
(4) Clinical experiences
2. Enhancement
a) Meeting additional state or local needs
b) Needs to change to reflect current practice
3. Recertification Requirements [Provide Student Handout on
recertification in Washington State (SEE Appendix K)].
II. Primary Responsibilities
A. Preparation
1. Physical, mental, emotional
a) Positive health practices
2. Appropriate equipment and supplies
3. Adequate knowledge and skill maintenance
Section 1: Page 4
B. Response
1. Safety
2. Timeliness
C. Scene assessment
1. Safety
2. Mechanism
D. Patient assessment
E. Recognition of injury or illness
1. Prioritization
F. Management
1. Following protocols
2. Interacting with medical direction/control physician, as needed
G. Appropriate disposition
1. Treat and transport
a) Ground
b) Air
2. Selection of the proper receiving facility
H. Patient Transfer
1. Acting as patient advocate
2. Briefing hospital staff
I. Documentation
1. Thorough, accurate patient care reports
2. Completed in timely manner
J. Returning to service
1. Preparation of equipment and supplies
2. Preparing crew
a) Debriefing
III. Interacting with Medical direction/control
A. Many services provided by EMT-Intermediates are derived from medical
practices
B. EMT-Intermediates operate as “physician extension”
C. Physicians regarded as the authorities on issues of medical care.
D. Physicians, properly educated and motivated, are a vital component to EMS
E. Role of the EMS physician in providing Medical Direction/Control
1. Education and training of personnel
2. Participation in personnel selection process
3. Participation in equipment selection
4. Development of patient care procedures, in cooperation with regional EMS
councils
5. Development of clinical protocols, in cooperation with expert EMS
personnel
Section 1: Page 5
6. Participation in quality improvement and problem resolution

7. Provide direct input into patient care
8. Interface between EMS systems and other health care agencies
9. Advocacy within the medical community
10. Serve as the “medical conscience” of the EMS system
a) Advocate for quality patient care.
11. Types of medical direction/control
a) On-line/Direct
b) Off-line/Indirect
F. Benefits of medical direction/control
1. On-line
a) Immediate and patient specific care
b) Telemetry
c) Continuous quality improvement
2. Off-line
a) Prospective
(1) Development of protocols/standing orders, training
(2) Selection of equipment and supplies
b) Retrospective
(1) Patient care report review, Quality Improvement (QI)
G. Interacting with a ALS on the scene
IV. State of Washington - Prehospital Trauma Triage Destination Procedures
more commonly known as the Trauma Triage Tool
A. Purpose:
1. To ensure that major trauma patients are transported to the most
appropriate facility.
2. To ensure that the “Right patient is transported to the Right facility in
the Right amount of time,”
3. To help EMT-B’s decide whether or not the patient they are treating is in
fact a major trauma patient.
4. If patient is a major trauma patient, that patient(s) must be taken to the
highest-level trauma facility within 30 minutes transport time, by either
ground or air.
5. “30 minute transport time” begins the moment the patient is packaged and
ready for either ground or air transport.
Section 1: Page 6
B. Trauma Triage Tool Components (See page following lesson. Student

handout located in APPENDIX I)
1. Step 1 or Step 2 patients require prehospital personnel to notify medical
control
2. Step 1 patients are determined by Assessment of Vital Signs & Level of
Consciousness
a) If patient meets any of the criteria found in Step 1 then they are a major
trauma patient and require transportation to the highest level trauma
center within 30 minutes transport time via ground or air.
3. Step 2 patients are determined by Assessment of the Anatomy of the
Patient’s Injury
a) If patient meets any of the criteria found in Step 2 then they are a major
trauma patient and require transportation to the highest level trauma
center within 30 minutes transport time via ground or air.
4. Step 3 patients are assessed using Biomechanics of Injury and other Risk
Factors.
a) Step 3 patients require contact of medical control to determine patient
destination.
C. Regional Patient Care Procedures (PCPs)
1. What are Regional Patient Care Procedures?
a) A blueprint which identifies the EMS & Trauma Systems response to
patients.
b) A process which assures the correct agency provides the appropriate
personnel to the right patient and transports that patient to the
appropriate facility in an acceptable amount of time
2. Developed by a cooperative effort among Regional Councils, local councils,
MPDs, EMS provider agencies, hospitals, emergency communications
centers, interested citizens and the Washington State Department of
Health’s Office of Emergency Medical and Trauma Prevention
3. Approved by the Washington State Department of Health’s Office of
Emergency Medical and Trauma Prevention
4. Regional Patient Care Procedures Identify:
a) Level of personnel dispatched
b) Procedures for Triage
c) Facility to first receive and transfer patients
5. Patient Care Protocols are not the same as Patient Care Procedures. They
are:
a) MPD-developed and approved
b) Written treatment guidelines for patient care
Section 1: Page 7
c) On-line Protocols
(1) EMS personnel talk with base station or medical control regarding
patient care in accordance with patient care protocols
d) Off-line Protocols
(1) EMS personnel follow patient care protocols without direct
consultation with the base station or medical control
D. Relationship Between the Regional Patient Care Procedures and the
Trauma Triage Tool
1. Trauma Triage Tool (TTT)
a) Operationalizes the Regional Patient Care Procedures (PCPs)
b) TTT is a field evaluation tool to help ensure PCPs are put into effect
correctly
E. Trauma Wrist Bands
1. Purpose of Trauma Wrist Bands
a) Patient Tracking Mechanism
b) Only state in the country gathering this type of data
c) Track the major trauma patient from the field to hospital, rehabilitation
and discharge
d) Data gathered from the major trauma patient will be used for quality
improvement of the EMS system
2. How to use Trauma Wrist Bands
a) Orange Trauma Wrist Bands are attached to ALL Major Trauma
Patients
b) Wristbands should be applied to all major trauma patients. If in doubt,
Band the patient
3. EMS personnel should accurately record the number from the Wrist Band
on to each medical incident report form
Section 1: Page 8
STATE OF WASHINGTON
PREHOSPITAL TRAUMA TRIAGE (DESTINATION) PROCEDURE
Purpose
The purpose of the Triage Procedure is to ensure that major trauma patients are transported to the most appropriate
hospital facility. This procedure has been developed by the Prehospital Technical Advisory Committee (TAC), endorsed by
the Governor's EMS and Trauma Care Steering Committee, and in accordance with RCW 70.168 and WAC 246-976 adopted
by the Department of Health (DOH).
The procedure is described in the schematic with narrative. Its purpose is to provide the prehospital provider with quick
identification of a major trauma victim. If the patient is a major trauma patient, that patient or patients must be taken to the
highest level trauma facility within 30 minutes transport time, by either ground or air. To determine whether an injury is major
trauma, the prehospital provider shall conduct the patient assessment process according to the trauma triage procedures.
Explanation of Process
A. Any certified EMS and Trauma person can identify a major trauma patient and activate the trauma system.
This may include requesting more advanced prehospital services or aero-medical evacuation.
B. The first step (1) is to assess the vital signs and level of consciousness. The words "Altered mental status"
mean anyone with an altered neurologic exam ranging from completely unconscious, to someone who responds to
painful stimuli only, or a verbal response which is confused, or an abnormal motor response.
The "and/or" conditions in Step 1 mean that any one of the entities listed in Step 1 can activate the trauma system.
Also, the asterisk (*) means that if the airway is in jeopardy and the on-scene person cannot effectively manage the airway,
the patient should be taken to the nearest medical facility or consider meeting up with an ALS unit. These factors
are true regardless of the assessment of other vital signs and level of consciousness.
C. The second step (2) is to assess the anatomy of injury. The specific injuries noted require activation of the
trauma system. Even in the assessment of normal vital signs or normal levels of consciousness, the presence of
any of the specific anatomical injuries does require activation of the trauma system.
Please note that steps 1 and 2 also require notifying Medical Control.
D. The third step (3) for the prehospital provider is to assess the biomechanics of the injury and address other
risk factors. The conditions identified are reasons for the provider to contact and consult with Medical Control
regarding the need to activate the system. They do not automatically require system activation by the prehospital
provider.
Other risk factors, coupled with a "gut feeling" of severe injury, means that Medical Control should be consulted and
consideration given to transporting the patient to the nearest trauma facility.
Please note that certain burn patients (in addition to those listed in Step 2) should be considered for immediate transport or
referral to a burn center/unit.
Patient Care Procedures

To the right of the attached schematic you will find the words "according to DOH-approved regional patient care procedures."
These procedures are developed by the regional EMS and Trauma council in conjunction with local councils. They are
intended to further define how the system is to operate. They identify the level of medical care personnel who participate in
the system, their roles in the system, and participation of hospital facilities in the system. They also address the issue of inter-
hospital transfer, by transfer agreements for identification, and transfer of critical care patients.
In summary, the Prehospital Trauma Triage Procedure and the Regional Patient Care Procedures are intended to work in a
"hand in glove" fashion to effectively address EMS and Trauma patient care needs. By functioning in this manner, these two
instruments can effectively reduce morbidity and mortality.
If you have any questions on the use of either instrument, you should bring them to the attention of your local or regional EMS
and Trauma council or contact 1-800-458-5281.
1994/Disc 1/triage.exp
Section 1: Page 9
STATE OF WASHINGTON
PREHOSPITAL TRAUMA TRIAGE (DESTINATION) PROCEDURES
EFFECTIVE DATE 1/95
• Prehospital triage is based on the following 3 steps: Steps 1 and 2 require prehospital EMS personnel to notify medical
control and activate the Trauma System. Activation of the Trauma System in Step 3 is determined by medical control**
STEP 1
ASSESS VITAL SIGNS & LEVEL OF CONSCIOUSNESS
• Systolic BP <90*
• HR >120*
* for pediatric (<15y) pts. use BP <90 or capillary refill >2 sec.
* for pediatric (<15y) pts. use HR <60 or >120 1. Take patient to the
Any of the above vital signs associated with signs and symptoms of shock highest level
and/or YES trauma center
• Respiratory Rate <10 >29 associated with evidence of distress within 30 minutes
and/or transport time via
• Altered mental status ground or air
transport
according to DOH
**If prehospital personnel are unable to effectively manage airway, consider approved regional
rendezvous with ALS, or intermediate stop at nearest facility capable of patient care
immediate definitive airway management. procedures.
NO
2. Apply "Trauma ID
STEP 2 Band" to patient.
YES
ASSESS ANATOMY OF INJURY
• Penetrating injury of head, neck, torso, groin; OR
• Combination of burns > 20% or involving face or airway; OR
• Amputation above wrist or ankle; OR
• Spinal cord injury; OR
• Flail chest; OR
• Two or more obvious proximal long bone fractures.
NO
STEP 3 1. Take patient to the

ASSESS BIOMECHANICS OF INJURY AND highest level trauma
OTHER RISK FACTORS center within 30
• Death of same car occupant; OR minutes transport
• Ejection of patient from enclosed vehicle; OR time via ground or
• Falls > 20 feet; OR CONTACT air transport
• Pedestrian hit at > 20 mph or thrown 15 feet according to DOH
MEDICAL approved regional
• High energy transfer situation
Rollover YES CONTROL YES patient care
procedures.
Motorcycle, ATV, bicycle accident FOR
Extrication time of > 20 minutes
• Extremes of age <15 >60 DESTINATION 2. Apply "Trauma ID
Band" to patient
• Hostile environment (extremes of heat or cold) DECISION
• Medical illness (such as COPD, CHF, renal failure, etc.)
• Second/third trimester pregnancy
• Gut feeling of medic
NO
NO
TRANSPORT PATIENT PER REGIONAL PATIENT CARE PROCEDURES
Section 1: Page 10
APPLICATION
Procedural (How)
Demonstrate Washington State Triage procedures.
Contextual (When, Where, Why)

The process for determining appropriate trauma care is important. It should begin upon
arrival at scene, following determination that the scene is safe.
STUDENT ACTIVITIES
Auditory (Hear)
None identified for this lesson.
Visual (See)
1. Students should see a trauma wristband.
2. Students should the Washington State Trauma Triage Tool.
Kinesthetic (Do)
1. Students should practice utilizing the Washington State Trauma Triage Tools and
apply a trauma wristband.
INSTRUCTOR ACTIVITIES
Supervise student practice.
Reinforce student progress in cognitive, affective, and psychomotor domains.
Redirect students having difficulty with content (complete remediation forms).
EVALUATION
Written:
Develop evaluation instruments, e.g., quizzes, verbal reviews, handouts, to
determine if the students have met the cognitive and affective objectives of this
lesson.
Practical:
Evaluate the actions of the students during role-play, practice or other skill stations
to determine their compliance with the cognitive and affective objectives and their
mastery of the psychomotor objectives of this lesson.
Section 1: Page 11
REMEDIATION
Identify students or groups of students who are having difficulty with this subject
content. Complete remediation sheet from the instructor's course guide.
ENRICHMENT
What is unique in the local area concerning this topic? Complete enrichment sheets
from the instructor's course guide and attach with lesson plan.
Section 1: Page 12
Lesson 1-2: Medical/Legal Issues

Section 1 - Preparatory/Lesson 1-2: Medical/Legal Issues and Ethics
OBJECTIVES LEGEND
1=Knowledge
2=Application

At the completion of this lesson, the EMT-Intermediate will understand the legal and
ethical issues that impact the decisions made in the out-of-hospital environment
MEDICAL LEGAL
1. Differentiate between the scope of practice and the standard of care for EMT-
Intermediate practice (C-3)
2. Define and describe what constitutes abandonment. (C-1)
3. Define and describe what constitutes Assault. (C-1)
4. Define and describe what constitutes Battery. (C-1)
5. Define and describe what constitutes Abandonment, i.e., when ILS Technician turns
a patient’s care over to an IV Technician. (C-1)
6. Given a scenario, describe appropriate patient management and care techniques in
a refusal of care situation. (C-3)
7. Identify the legal issues involved in the decision not to transport a patient, or to
reduce the level of care being provided during transportation. (C-1)
8. Discuss the responsibilities of the EMT-Intermediate relative to advanced
directives/EMS No-CPR, and withholding or stopping resuscitation efforts (Refer to
existing local protocols). (C-1)
9. Describe the actions that the EMT-Intermediate should take to preserve evidence at
a crime or accident scene. (C-1)
10. Describe the importance of providing accurate documentation (oral and written) in
substantiating an incident. (C-1)
11. Describe the characteristics of a prehospital care report required to make it an
effective patient care record. (C-1)
Section 1: Page 14
Presentation
DECLARATIVE
I. Scope of Practice Vs. Standard of Care
A. Scope of practice
1. Range of duties and skills an EMT-Intermediate is allowed and expected to
perform when necessary.
2. Usually set by state law or regulation and by local medical direction/control.
B. Standard of Care
1. Exercising the degree of care, skill, and judgment, which would be expected
under like or similar circumstances by a similarly trained, reasonable EMT-
Intermediate in the location involved.
2. Standard of care is established by court testimony and referenced to
published codes, standards, criteria and guidelines applicable to the
situation.
II. Legal complications related to consent
A. Abandonment
1. Terminating care when it is still needed and desired by the patient, and
without assuring that appropriate care continues to be provided by another
qualified provider.
2. May occur in the field, i.e., when an EMS provider releases the care of a
patient to another EMS provider who is certified at a lower level of skill
performance or when a patient is delivered to the emergency department
and left unattended, without a formal transfer to ER staff.
3. Exist When: NOTE: THE INSTRUCTOR SHOULD PROVIDE THE
STUDENT HANDOUT LOCATED IN APPENDIX J.
a) A paramedic releases the care of a patient to an ILS Technician when
paramedic level skills are needed to maintain the continuum of care
b) An ILS/Airway Technician releases the care of a patient to an ILS
Technician when endotracheal intubation skills are required to maintain
the continuum of care
c) An ILS Technician releases the care of a patient to an IV/Airway
Technician when drug administration is required
d) An IV/Airway Technician releases the care of a patient to an ILS
Technician when endotracheal intubation skills are required to maintain
e) An Airway Technician releases the care of a patient to an IV Technician
or an ILS Technician when endotracheal intubation skills are required to
maintain the continuum of care
f) An IV Technician releases the care of a patient to an EMT or a First
Responder when IV skills are required to maintain the continuum of
care
g) An EMT-B trained provider releases care to an EMT-A trained provider
when EMT-B skills, (i.e. multi-lumen airway) are required to maintain
Section 1: Page 15
h) An EMT-B or EMT-A releases the care of a patient to a First Responder

INSTRUCTOR NOTE: An example of h) above would be a fire district with First
Responder personnel, providing an aid response to an industrial site that has
certified EMTs attending the patient
B. Assault
1. Threatening, attempting or causing fear of offensive physical contact with a
patient or other individual (for example, threatening to restrain a patient
unless he or she quiets down).
2. May be a civil or criminal violation
C. Battery
1. Unlawful touching of another person without consent (for example, drawing
a patient's blood without permission)
2. May be a civil or criminal violation
III. Refusal of care or transport
1. Patient must be conscious and able to make a reasonable decision.
2. Make multiple attempts to convince the patient to accept care.
3. Enlist the help of others to convince the patient.
4. Assure that the patient is informed about the implication of the decision and
potential for harm
5. Consult medical direction/control.
6. Request patient and a disinterested witness to sign a "release from liability"
form.
7. Advise the patient that he or she may call again for help if needed.
8. Attempt to get family or friends to stay with the patient.
9. Document situation and actions thoroughly on prehospital care report.
IV. Resuscitation Issues
A. Withholding or Stopping Resuscitation
1. Procedure should be established by local protocols
2. Role of medical direction/control should be clearly delineated
B. Advance Directives/EMS No-CPR
1. Status depends on state laws and local protocols
2. Written patient statements of preference for future medical treatment.
a) Living will
b) Durable power of attorney for health care
c) Do not resuscitate (DNR) orders/EMS No-CPR
3. Authority granted in part by the Patient Self-Determination Act of 1990
Section 1: Page 16
4. Medical direction/control must establish and implement policies for dealing

with advance directives
a) Policy should specify EMT-Intermediate care for the patient with an
advance directive
b) Must provide for reasonable measures of comfort to the patient and
emotional support to family and loved ones
V. Crime and Accident Scene Responsibilities
A. Crime Scene
1. Protect self and other EMS personnel
2. Care for the patient(s) as necessary
3. Notify law enforcement if not already involved
4. Observe and document any items moved or anything unusual at the scene
5. Protect potential evidence
a) Leave holes in clothing from bullet or stab wounds intact, if possible
b) Do not touch or move items at scene unless necessary in delivery of
care
B. Accident Scene
1. Protect self and other EMS personnel
2. Care for the patient(s) as necessary
3. Summon additional personnel if needed
VI. Documentation
A. Importance
1. If it is not written down, it was not done.
2. Memory is fallible -- claims may not be filed until years after an event
B. Characteristics of an Effective Patient Care Record (PCR)
1. Completed promptly
a) A record made "in the course of business", not long after the event.
b) Prompt completion essential to the PCR becoming part of the hospital
record.
2. Completed thoroughly
a) Coverage of assessment, treatment and other relevant facts.
b) Should paint a complete, clear picture of patient condition and care.
3. Completed objectively
a) Observations rather than assumptions or conclusions.
b) Avoid use of emotionally and value-loaded words or phrases.
4. Completed accurately
a) Descriptions should be as precise as possible.
b) Avoid using abbreviations or jargon not commonly understood.
Section 1: Page 17
5. Confidentiality maintained
a) Should have a standard policy on release of information.
b) Whenever possible, patient consent should be obtained prior to release
of information.
C. Copy to become part of patient's hospital record
D. Maintained at least for extent of statute of limitations
NOTES:
Section 1: Page 18

Section 1 - Preparatory/Lesson 1-3: Documentation
OBJECTIVES LEGEND
1=Knowledge
2=Application
Objectives
In order to properly document, the EMT-Intermediate shall:
1. Identify and use medical terminology correctly. (C-1)
2. Recite appropriate and accurate medical abbreviations and acronyms. (C-1)
3. Record all pertinent administrative information. (C-1)
4. Describe the information pertinent to agency reimbursement. (C-1)
5. Analyze the documentation for accuracy and completeness, including spelling. (C-3)
6. Identify and eliminate extraneous or nonprofessional information. (C-1)
7. Describe the differences between subjective and objective elements of
documentation. (C-1)
8. Evaluate a finished document for errors and omissions. (C-3)
9. Evaluate a finished document for proper use and spelling of abbreviations and
acronyms. (C-3)
10. Advocate the confidential nature of an EMS report. (C-1)
11. Describe the potential consequences of poor documentation. (C-1)
12. Describe the special considerations concerning patient refusal of transport. (C-1)
13. Describe the special considerations concerning mass casualty incident
14. Apply the principles of documentation to computer charting, as this technology
becomes available. (C-3)
15. Identify the pertinent, reportable clinical data of each patient interaction. (C-1)
16. Record the pertinent reportable clinical data appropriately. (C-1)
17. Note and record “pertinent negative” clinical findings. (C-1)
Affective Objectives
18. Assume responsibility for self-assessment of all documentation.
19. Advocate among peers, the relevance and importance of properly completed
documentation.
20. Correct errors and omissions, using proper procedures as defined under local
protocol.
21. Revise documents, when necessary, using locally approved procedures.
22. Resolve the common negative attitudes toward the “task” of documentation.
Section 1: Page 20
Psychomotor Objectives
23. Demonstrate the potential consequences of poor documentation. (P-2, P-3)
24. Write legibly. (P-1)
25. Demonstrate consistency in thoroughly attending to each area of the report form. (P-1)
26. Demonstrate consistent narrative format (P-1)
27. Illustrate pertinent patient comments, such as suicide threats, by writing accurate
direct quotes, using quotation marks.(P-1)
Section 1: Page 21
Presentation
DECLARATIVE
I. Introduction
A. Importance of Documentation
1. Written record of incident
a) May be the only source of information for persons subsequently
interested in the event.
2. Legal record of incident
a) May be used in court proceedings.
b) May be the EMT-Intermediate’s sole source of reference to a case.
3. Professionalism
a) As a link to subsequent professional care, documentation may be the
only means for EMT-Intermediates to represent themselves to certain
other health professionals.
B. Other uses of documentation
1. Medical audit
a) May be used in run review conferences or other educational forums
2. Quality improvement
a) May be used to tally the individual’s performance of patient care
procedures and to review individual performance
3. Billing
a) May be used for acquiring the billing data necessary for economic
survival of many EMS services.
4. Data collection
a) May be used for research purposes.
II. General considerations
A. Medical abbreviations
1. Be familiar with commonly accepted medical abbreviations and their correct
spelling.
B. Medical acronyms
1. Be familiar with common industry acronyms.
C. Incident times
1. Understand the legal purposes of accurate recording of the following
incident times:
a) Time of call
b) Time of dispatch
c) Time of arrival at the scene
d) Time of departure from the scene
e) Time of arrival at the medical facility (when transporting a patient)
f) Time back in service
Section 1: Page 22
D. Medical control interaction

1. Accurately note in the document narrative (and elsewhere, when
applicable) medical control advice and orders, and the results of
implementing that advice and those orders.
E. "Pertinent negatives"
1. Record “pertinent negative” findings, that is, findings that warrant no
medical care or intervention, but which, by seeking them, show evidence of
the thoroughness of the EMT-Intermediate’s examination and history of the
event.
F. Pertinent oral statements made by patient and other on-scene people
1. Record statements made which may have an impact on subsequent patient
care or resolution of the situation, including reports of:
a) Mechanism of injury
b) Patient’s behavior
c) First aid interventions attempted prior to the arrival of EMS personnel
d) Safety-related information, including disposition of weapons
e) Information of interest to crime scene investigators
f) Disposition of personal property items (e.g. Watches, wallets)
G. Use of quotations
1. The EMT-Intermediate should put into quotation marks any statements by
patients or others, which relate to possible criminal activity or admissions of
suicidal intention.
III. Elements of a properly-written EMS document
A. Accurate
1. Document accuracy depends on all information provided, both narrative and
check box, being:
a) Precise
b) Comprehensive
2. All check box sections of a document must show that the EMT-Intermediate
attended to them, even if a given section was unused on a call.
B. Legible
1. Legibility means that others can read handwriting, especially in the narrative
portion of the document, without difficulty.
2. Check box marking should be clear and consistent from the top page of the
document to all underlying pages.
C. Timely
1. Documentation should be completed ideally before the EMT-Intermediate
handles tasks subsequent to the patient interaction.
Section 1: Page 23
D. Unaltered
1. While writing the document, should the EMT-Intermediate make an error, a
single line should be drawn through the error, and the area initialed and
dated.
2. Should alterations to a document be required after the document has been
submitted, see “document revision/correction”, below.
E. Free of non-professional/extraneous information
1. Jargon
2. Slang
3. Bias
4. Libel/slander
5. Opinion/impression
IV. Systems of narrative writing
A. Head to toe approach
1. The narrative uses a comprehensive, consistent physical approach from
head to toe.
B. Body systems approach
1. The narrative uses a review of the primary body systems in a
comprehensive manner
C. Call incident approach
D. Patient management approach
E. Other formats
V. Special considerations of documentation
A. Documentation of patient's refusal of care and/or transport
1. When a patient refuses medical care, the EMT-Intermediate must show in
the report the process undergone to come to that conclusion, including
a) The EMT-Intermediate’s advice to the patient
b) The advice rendered by medical control by telephone or radio
c) Signatures of witness(es) to the event, according to local protocol
d) Complete narrative, including quotations or statements by others
B. Documentation in mass casualty situations
1. In unusual circumstances, comprehensive documentation has to wait until
after mass casualties are triaged and transported. The EMT-Intermediate
should know and follow local procedures for documentation of mass
casualty situations.
VI. Document revision/correction
A. How done
1. Write revisions to documents on separate report forms
2. Note the purpose of the revision, and why the information did not appear on
the original document
3. Note the date and time
Section 1: Page 24
B. By whom
1. Revisions should be made by the original author of a document
C. When done
1. When the need for revision is realized, it should be done as soon as
possible
D. Acceptable method(s)
1. Corrections
a) Written narrative is appropriate, on a new report form which is then
attached to the original
2. Deletions and Additions
a) Should not be done on the original report form. These should only be
done on a new report form.
3. Supplemental narratives
a) If more information comes to the EMT-Intermediate’s attention, a
supplemental narrative can be written on a separate report form and
attached to the original.
E. How to properly make changes/additions
VII. Consequences of inappropriate documentation
A. Implications to medical care
1. An incomplete, inaccurate, or illegible report may cause subsequent
caregivers to provide inappropriate care to a patient.
B. Legal implications
1. A lawyer considering the merits of an impending lawsuit can be dissuaded
from a case when documentation is done correctly. The converse is true if
documentation is anything less.
VIII.Summary
A. The EMT-Intermediate shall assume responsibility for self-assessment of all
documentation
B. Peer advocacy of proper appreciation and the importance of properly completed
documentation.
1. Documentation is a maligned task in EMS, but one of utmost importance for
a variety of reasons.
2. A professional EMS provider appreciates this and strives to set a good
example to others regarding the completion of the documentation tasks.
C. Respect the confidential nature of an EMS report
D. Principals of documentation are to remain valid regarding computer charting, as
that technology becomes available
Section 1: Page 25
NOTES:
Section 1: Page 26
Section 2 - Essentials
Lesson 2-1: Overview of Human Systems

Section 2 - Essentials/Lesson 2-1: Overview of Human Systems
LESSON TERMINAL INSTRUCTIONAL OBJECTIVE
At the end of this lesson the EMT-Intermediate student will be able to explain how the
anatomy and physiology of each body system relates provides the foundation for the clinical
practice of out of hospital emergency medicine.
OBJECTIVES LEGEND
1=Knowledge
2=Application
At the completion of this lesson, the EMT Intermediate student will be able to use the
principles of anatomy and physiology as a foundation for the clinical practice of out of
hospital emergency medicine.
Organization and General Plan of the Body

1. Review the definition of anatomy & physiology. (C-1)
2. Define homeostasis, and use an example to explain. (C-1)
3. Review and state the anatomical terms for the parts of the body. (C-1)
4. Use proper terminology to describe the location of body parts with respect to one
another. (C-1)
5. Name the body cavities, their membranes, and some organs within each cavity. (C-1)
6. Explain how and why the abdomen is divided into smaller areas. Be able to name
organs in these areas. (C-1)
Tissues and Membranes

7. Describe the general characteristics of each of the four major categories of tissues. (C-1)
8. Describe the functions of the types of epithelial tissues with respect to the organs in
which they are found. (C-1)
9. Describe the functions of the connective tissues, and relate them to the functioning of
the body or a specific organ system. (C-1)
10. Explain the differences, in terms of location and function, among skeletal muscle,
smooth muscle, and cardiac muscle. (C-1)
11. Name some membranes made of connective tissue. (C-1)
The Integumentary System
12. Name the two major layers of the skin and the tissue of which each is made. (C-1)
13. Describe how the arterioles in the dermis respond to heat, cold, and stress. (C-1)
14. Name the tissues that make up the subcutaneous tissue, and describe their functions.
(C-1)
The Skeletal System
15. Describe the functions of the skeleton
Section 2: Page 2
16. Explain how bones are classified, and give an example of each type. (C-1)
17. Name the major bones of the human skeleton (Be able to point to each on diagrams,
skeleton models, or yourself). (C-1)
18. Describe the functions of the skull, vertebral column, rib cage, scapula, and pelvic bone.
(C-1)
19. Explain how joints are classified. For each type, give an example, and describe the
movement possible. (C-1)
The Muscular System

20. Describe muscle structure in terms of muscle cells, tendons, and bones. (C-1)
21. Describe the structure and function of the muscle system and identify three types of
muscle. (C-1)
22. Learn the major muscles of the body and their functions. (C-1)
The Nervous System

23. Name the divisions of the nervous system and the parts of each, and state the general
functions of the nervous system. (C-1)
24. State the functions of the parts of the brain; be able to locate each part on a diagram.
(C-1)
25. Name the meninges and describe their locations. (C-1)
26. State the locations and functions of cerebrospinal fluid. (C-1)
27. Explain how the sympathetic division of the autonomic nervous system enables the
body to adapt to a stress situation. (C-1)
28. Explain how the parasympathetic division of the autonomic nervous system promotes
normal body functioning in relaxed situations. (C-1)
The Senses
29. Explain the general purpose of sensations. (C-1)
30. Describe the characteristics of sensations. (C-1)
31. Explain referred pain and its importance. (C-1)
32. Explain the importance of baroreceptor. (C-1)
Blood
33. Describe the composition and explain the functions of blood plasma. (C-1)
34. State the function of red blood cells, including the protein and the mineral involved. (C-1)
35. State what platelets are, and explain how they are involved in hemostasis. (C-1)
Section 2: Page 3
The Heart
36. Describe the location of the heart and the pericardial membranes. (C-1)
37. Name the chambers of the heart and the vessels that enter or leave each. (C-1)
38. Name the valves of the heart, and explain their functions. (C-1)
39. Describe coronary circulation, and explain its purpose. (C-1)
40. Describe the cardiac cycle. (C-1)
41. Explain stroke volume, cardiac output. (C-3)
The Vascular System

42. Describe the structure of arteries and veins, and relate their structure to function. (C-1)
43. Describe the structure of capillaries, and explain the exchange processes that take
place in capillaries. (C-1)
44. Describe the pathway and purpose of pulmonary circulation. (C-1)
45. Name the branches of the aorta and their distributions. (C-1)
46. Name the major systemic veins, and the parts of the body they drain of blood. (C-1)
47. Describe the modifications of fetal circulation, and explain the purpose of each. (C-1)
48. Define blood pressure. (C-1)
49. Explain how the heart and kidneys are involved in the regulation of blood pressure. (C-3)
The Respiratory System

50. State the general function of the respiratory system. (C-1)
51. Describe the structure and functions of the nasal cavities and pharynx. (C-1)
52. Describe the structure of the larynx and explain the speaking mechanism. (C-1)
53. Describe the structure and functions of the trachea and bronchial tree. (C-1)
54. State the locations of the pleural membranes, and explain the functions of serous fluid.
(C-1)
55. Describe the structure of the alveoli and pulmonary capillaries, and explain the
importance of surfactant. (C-1)
56. Name and describe the important air pressures involved in breathing. (C-1)
57. Describe normal inhalation and exhalation and forced exhalation. (C-1)
58. Explain the diffusion of gases in external respiration and internal respiration. (C-1)
59. Describe how oxygen and carbon dioxide are transported in the blood. (C-1)
60. Name the pulmonary volumes and define each. (C-1)
The Digestive System

61. Describe the general functions of the digestive system, and name its major divisions.
(C-1)
62. Describe the structure and functions of the teeth and tongue. (C-1)
63. Describe the location and function of the pharynx and esophagus. (C-1)
64. Describe the location, structure, and function of the stomach, liver, gallbladder,
pancreas, and small intestine. (C-1)
65. Describe the location and functions of the large intestine. (C-1)
66. Describe the functions of the liver. (C-1)
Section 2: Page 4
The Urinary System

67. Describe the location and general function of each organ of the urinary system. (C-1)
68. State the general function of the urinary system. (C-1)
Fluid-Electrolyte and Acid-Base Balance

69. Describe the water compartments and the name for the water in each. (C-1)
70. Explain how water moves between compartments. (C-1)
71. Explain the regulation of the intake and output of water. (C-1)
72. Describe the effects of acidosis and alkalosis. (C-1)
None defined
None defined
Section 2: Page 5
Presentation
DECLARATIVE
I. Introduction
A. Anatomy and Physiology
1. Anatomy is the study of an organism’s structure and parts
2. Physiology is the study of an organism’s body functions
3. Tissues
a) Epithelial tissue
b) Connective tissue
c) Muscle groups
d) Nerve tissue
4. Organs
5. Organ systems
a) Integumentary system
b) Skeletal system
c) Muscular system
d) Nervous system
e) Respiratory system
f) Circulatory system
g) Lymphatic system
h) Digestive system
i) Urinary system
j) Endocrine system
k) Pancreas
l) Reproductive system
(1) Male
(2) Female
6. Anatomical terminology
a) Descriptive terms for body parts and areas
b) The anatomical position
c) Body cavities
(1) Cranial cavity
(2) Spinal cavity
(3) Thoracic cavity
(4) Abdominal cavity
(5) Pelvic cavity
d) Body planes
e) Frontal/coronal plane
f) Sagittal plane
g) Transverse plane
h) Abdominal quadrants
Section 2: Page 6
II. Tissues
A. Epithelial tissue and glands
B. Connective tissue
1. Blood
a) Plasma
b) Blood cells
(1) Red blood cells
(2) White blood cells
(3) Platelet
2. Adipose tissue
3. Fibrous and elastic connective tissue
4. Bone
5. Cartilage
C. Muscle tissue
1. Skeletal muscles
a) Voluntary muscle
2. Smooth muscles
a) Involuntary muscle
3. Cardiac muscles
a) Involuntary muscle
D. Nerve tissue
III. Integumentary system
A. Function of the skin
B. The epidermis
C. The dermis
1. Receptors
2. Glands
3. Blood vessels
D. Subcutaneous tissue
IV. Skeletal system
A. Functions of the skeleton
B. Classifications of bones
1. Long bones
2. Short bones
3. Flat bones
4. Irregular bones
C. The skeleton
1. Skull
2. Vertebral column
3. Rib cage
4. The shoulder and arm
5. The hip and leg
Section 2: Page 7
D. Joints
1. Immovable joints
2. Slightly movable joints
3. Freely movable
V. The muscular system
A. Muscle structure
1. Composed of contractile tissues
2. Responsible for movement
B. Major muscles
1. 350 skeletal muscles example:
a) Biceps, triceps, etc.
2. Smooth muscle example:
a) Intestinal wall muscle
3. Cardiac heart muscle
VI. The nervous system
A. Nervous system divisions
1. Central nervous system
2. Peripheral nervous system
B. The central nervous system
1. Nerve cells
a) Neuron
(1) Cell body, contains nucleus
(2) Dendrites, carry impulse to the cell body
(3) Axons, carry impulse away from the cell body
b) Gray matter - collection of cell bodies
c) White mater - contains myelinated axons
d) Types
(1) sensory or afferent
(2) Motor or efferent
(3) Connector neurons or interneurons
e) Impulse transmission
(1) Electrical - synapses
(2) Chemical - neurotransmitter
2. Brain
a) Skull or cranium, protective bonny covering
b) Suspension - ligaments
c) Meninges
(1) Dura mater
(2) Arachnoind mater
(3) Pia mater
d) Potential spaces formed by meninges
(1) Epidural space
Section 2: Page 8
(2) Subdural space

(3) Subarachnoid
e) Cerebrospinal fluid, appearance and function
f) Circulation
(1) Vertebrals
(a) Basilar artery
(b) Posterior cerebral arteries
(c) Circle of Willis
(2) Internal carotids
(a) Ophthalmic artery
(b) 3 major branches
(3) Venous drainage
(a) Venous sinuses
(b) Internal jugular veins
g) Areas of specialization
(1) Temporal lobe - speech center
(2) Occipital cortex in the cerebellum - vision
(3) Frontal lobe - personality
(4) Cerebellum - balance and coordination
(5) Parietal lobe - sensory
(6) Cross over of tracts
h) Parts including location and function
(1) Cerebrum
(2) Cerebellum
(3) Brain stem
(a) Medulla
(b) Pons
(c) Midbrain
i) Ventricles
j) Hypothalamus
k) Thalamus
3. The spinal cord
a) Functions
(1) Reflex center
(2) Pathway for conducting impulses
b) Length 17-18 inches long, average
c) Diameter - 10 mm vs. 15 mm of spinal canal
d) Covered by meninges as is the brain
e) Boney covering - vertebrae
(1) Vertebral body
(2) Pedicle
(3) spinous process
Section 2: Page 9
(4) Transverse process

(5) Articular facets
f) Connections of joint and ligament
g) Divisions of spinal column
(1) Cervical
(2) Thoracic
(3) Lumbar
(4) Sacral
(5) Coccygeal
h) Functions of the spinal cord
(1) Afferent impulses
(2) Efferent impulses
i) Divisions of the spinal cord
(1) Cervical
(2) Thoracic
(3) Lumbar
j) Series of 31 segments give rise to paired spinal nerves
(1) Dorsal root contains afferent fibers
(2) Ventral root contains efferent fibers
(3) Dermatomes
k) Level of injury or disease of spinal cord
(1) More serious the closer to the brain stem they occur
(2) Dynamics of neurogenic shock
l) Nerve root control
(1) Cervical (shoulder girdle C5)
(2) Thoracic
(a) Sensation at nipple level (T4)
(b) Sensation at the umbilicus level (T10)
(3) Lumbar
(4) Sacral
C. The peripheral nervous system
1. Cranial nerves - origins in the brain and innervate structures outside the brain
2. Peripheral Nerves
a) Categories
(1) Somatic sensory
(a) Pain
(b) Temperature
(c) Touch
(d) Pressure
(e) Position or muscle sense
(2) Somatic motor
Section 2: Page 10
(3) Visceral sensory - from glands and structures composed of somatic or

cardiac muscle
(4) Visceral motor
b) Brachial plexus
(1) collection of nerves at the posterior triangle of the neck
(2) May be injured at birth, or in injuries causing permanent disability
(3) Major nerves
c) Lumbar-sacral plexus - formed by union of lumbar, sacral and coccygeal
nerves
D. The autonomic nervous system
1. Function - beyond conscious control
2. Division and effects of each
a) Sympathetic division
(1) More widespread effects
(2) Stimulation causes increased heart rate, increased BP, rise in blood
sugar, bronchodilation
(3) “Fight or flight
b) Parasympathetic division
(1) Effects more apparent in quiet state
(2) Body conservation processes, i.e., digestion and storage of materials
for well-being
(3) Complementary effects
VII. The senses
A. Sense of taste - mouth and tongue
B. Sense of smell - nose and sinuses
C. Sight - the eyes
D. Hearing - the ears
E. Touch - skin
VIII.Blood
A. Characteristics of blood
1. Amount
2. Color
3. pH
4. Viscosity
B. Plasma
C. Blood cells
1. Red blood cells
a) Function
b) Production and maturation
c) Blood types
2. White blood cells
a) Functions
Section 2: Page 11
3. Platelet
a) Function
4. Blood clotting
IX. The heart
A. Pericardial membranes
1. Mediastinum
2. Pericardial membranes
3. Fibrous membranes
4. Fibrous pericardium
5. Parietal pericardium
6. Visceral pericardium/epicardium
7. Serous fluid
B. Chambers, vessels, and valves
1. Right atrium
a) Vena cava
(1) Superior vena cava
(2) Inferior vena cava
b) Tricuspid valve
2. Left atrium
a) Pulmonary veins
b) Mitral valves/bicuspid
3. Right ventricle
a) Pulmonary artery
b) Pulmonary semilunar valve
4. Left ventricle
a) Aorta
b) Aortic semilunar valve
5. Coronary vessels
C. The cardiac cycle
1. Systole
2. Diastole
D. Cardiac output
1. Heart rate
a) Baroreceptor - sensory nerve endings that adjust blood pressure as a result
of vasodilation or vasoconstriction
2. Stroke volume
a) The amount of blood pumped into the cardiovascular system as a result of
one contraction
X. The vascular system
A. Layers of blood vessels
1. Tunica intima/endothelium
2. Tunica media
Section 2: Page 12
3. Tunica externa
B. Arteries
C. Veins
1. Valves
D. Capillaries
E. Exchange in the capillaries
1. Gas exchange
2. Fluid exchange
F. Blood pressure
XI. Respiratory system
A. Anatomy
1. Nose and nasal cavities
2. Pharynx
3. Larynx
4. Trachea and bronchial tree
5. Lungs and pleural membranes
6. Alveoli
B. The mechanics of breathing
1. Inhalation
2. Exhalation
C. Exchange of gases
1. Diffusion of gasses
D. Transportation of gases in the blood
E. Pulmonary volumes
1. Tidal volume
2. Minute respiratory volume
3. Inspiratory reserve
4. Expiratory reserve
5. Vital capacity
6. Residual air
F. Regulation of respiration
1. Nervous control
2. Chemical control
G. Acid base balance
1. Respiratory acidosis
2. Respiratory alkalosis
3. Respiratory compensation
XII. The digestive system
A. The oral cavity
1. Teeth
2. Tongue
3. Salivary glands
Section 2: Page 13
B. Pharynx
C. Esophagus
D. Stomach
E. Small intestine
F. Liver
G. Gall bladder
H. Pancreas
I. Large intestine
XIII.The urinary system
A. Kidneys
1. Internal structure
B. General function
1. Excrete body wastes
2. Regulate the body’s fluid balance
3. Regulate the blood pressure
C. Elimination of urine
1. Ureters
2. Urinary bladder
3. Urethra
D. Acid-base balance
1. Buffer systems
a) Bicarbonate buffer system
b) Phosphate buffer system
c) Protein buffer system
2. Respiratory compensation
a) Respiratory acidosis
b) Respiratory alkalosis
c) Respiratory compensation for metabolic changes
3. Renal compensation
4. Effects of pH changes
a) Acidosis
b) Alkalosis
E. Acid - base balances
1. Hydrogen ion and pH
2. Buffer systems
a) Carbonic acid-bicarbonate buffering
b) Protein buffering
c) Renal buffering
d) Other buffers
3. Acid-base imbalances
a) Metabolic acidosis
(1) Pathophysiology
(2) Clinical presentation
(3) Evaluation and treatment
Section 2: Page 14
b) Metabolic alkalosis (rare)

(1) Pathophysiology
c) Respiratory acidosis
(1) Pathophysiology
d) Respiratory alkalosis
(1) Pathophysiology
Section 2: Page 15
NOTES:
Section 2: Page 16

Section 2 - Essentials/Lesson 2-2: Patient Assessment
OBJECTIVES LEGEND
1=Knowledge
2=Application
Topic - History Taking

At the completion of this topic, the EMT-Intermediate student will be able to:
1. Describe the techniques of history taking. (C-1)
2. Describe techniques of establishing a rapport with the patient. (C-1)
3. Describe the importance of using good listening skills during the interview process. (C-1)
4. Describe the use of body language and touch for a means of communication. (C-1)
5. Describe methods to manage communication barriers. (C-1)
6. Describe open-ended questions. (C-1)
7. Describe direct questions. (C-1)
8. Differentiate between the use of open-ended and direct questions in patient
interviewing. (C-3)
9. Describe the components of a S.A.M.P.L.E. patient history. (C-1)
10. Describe history-taking techniques when dealing with sensitive topics. (C-1)
11. Describe special challenges to history taking. (C-1)
• Silence
• Over talkative patients
• Patients with multiple symptoms
• Anxious patients
• Reassurance
• Anger and hostility
• Intoxication
• Crying
• Depression
• Sexually attractive or seductive patients
• Confusing Behaviors or Histories
• Limited communication skills
• Talking with family and friends
12. Describe why patience and repetition may be necessary while taking a patient
S.A.M.P.L.E. history. (C-1)
13. Describe the importance of empathy when obtaining a health history.
14. Describe the importance of confidentiality when obtaining a health history.
Section 2: Page 18
15. Obtain a S.A.M.P.L.E. history from a simulated patient suffering from an acute illness
or injury.
16. Use the techniques of history taking to collect a complete patient history.
17. Use methods to manage communication barriers in a simulated patient interview.
18. Document the patient history.
19. Interpret the findings of the patient history.
Topic - Techniques of Physical Examination

TOPIC TERMINAL OBJECTIVE
At the end of this topic, the EMT-Intermediate student will be able to explain the clinical
significance of physical exam findings.
1. Define the following terms: inspection, palpation, and auscultation. (C-1)
2. Describe the techniques of inspection, palpation, percussion, and auscultation. (C-1)
3. Evaluate the importance of a general survey. (C-3)
4. Describe the examination of skin (C-1)
5. Differentiate normal and abnormal findings of the skin assessment. (C-3)
6. Distinguish the importance of abnormal findings of the skin assessment. (C-3)
7. Describe the examination of the head and neck. (C-1)
8. Describe the normal assessment findings of the skull. (C-1)
9. Describe the assessment of temperature. (C-1)
10. Describe the examination of the eyes. (C-1)
11. Distinguish between normal and abnormal assessment findings of the eyes. (C-3)
12. Describe the examination of the ears. (C-1)
13. Describe the examination of the nose. (C-1)
14. Describe the examination of the mouth. (C-1)
15. Describe the examination of the neck. (C-1)
16. Describe the survey of the chest. (C-1)
17. Describe the examination of the posterior chest. (C-1)
18. Differentiate the characteristics of breath sounds. (C-3)
19. Describe the examination of the anterior chest. (C-1)
20. Differentiate normal and abnormal assessment findings of the chest examination. (C-3)
21. Describe the examination of the arterial pulse including rate and rhythm. (C-1)
22. Distinguish normal and abnormal findings of arterial pulse. (C-3)
23. Describe the assessment of the jugular veins. (C-1)
24. Describe special examination techniques of the cardiovascular examination. (C-1)
25. Describe the examination of the abdomen. (C-1)
26. Describe the examination of the extremities. (C-1)
27. Describe the proper sequence of physical examination. (C-1)
Section 2: Page 19
28. Describe the general guidelines of recording examination information. (C-1)

29. Organize the findings of a patient examination. (C-1)
30. Discuss the considerations of examination of an infant or child. (C-1)
31. Discuss the considerations of examination of a patient with special needs. (C-1)
32. Demonstrate a caring attitude when performing physical examination skills. (A-3)
33. Discuss the importance of a professional appearance and demeanor when performing
physical examination skills. (A-1)
34. Appreciate the limitations of conducting a physical exam in the prehospital
environment. (A-2)
35. Demonstrate the techniques of inspection, palpation, and auscultation. (P-1, 2)
36. Demonstrate the examination of skin(P-1, P-2)
37. Demonstrate the examination of the head and neck. (P-1, 2)
38. Demonstrate the normal assessment findings of the skull. (P-1, 2)
39. Demonstrate the assessment of temperature. (P-1, 2)
40. Demonstrate the examination of the eyes. (P-1, 2)
41. Demonstrate the examination of the ears. (P-1, 2)
42. Demonstrate the examination of the nose. (P-1, 2)
43. Demonstrate the examination of the mouth. (P-1, 2)
44. Demonstrate the examination of the neck. (P-1, 2)
45. Demonstrate the survey of the chest. (P-1, 2)
46. Demonstrate the examination of the posterior chest. (P-1, 2)
47. Demonstrate the examination of the anterior chest. (P-1, 2)
48. Demonstrate the examination of the arterial pulse including rate and rhythm(P-1,2)
49. Demonstrate the assessment of the jugular veins. (P-1, 2)
50. Demonstrate special examination techniques of the cardiovascular examination. (P-1, 2)
51. Demonstrate the examination of the abdomen. (P-1, 2)
52. Demonstrate the examination of the extremities. (P-1, 2)
53. Demonstrate the proper sequence of physical examination. (P-1, 2)
54. Demonstrate the general guidelines of recording examination information. (P-1, 2)
55. Organize the findings of a patient examination. (P-1, 2)
56. Discuss the considerations of examination of an infant or child. (P-1, 2)
57. Discuss the considerations of examination of a patient with special needs. (P-1, 2)
58. Demonstrate the sequence of physical examination. (P-1,2)
59. Demonstrate the guidelines of recording examination information. (P-1,2)
Section 2: Page 20
Topic - Patient Assessment

At the end of this topic, the EMT-Intermediate student will be able to integrate the principles
of history taking and techniques of physical exam to perform a scene size-up, initial
assessment, focused history and physical exam, detailed physical exam and an
ongoing assessment.
60. Recognize hazards/potential hazards.(C-1)
61. Describe common hazards found at the scene of a trauma and a medical patient. (C-1)
62. Determine hazards found at the scene of a medical or trauma patient. (C-2)
63. Differentiate safe from unsafe scenes.(C-3)
64. Describe methods to making an unsafe scene safe. (C-1)
65. Discuss common mechanisms of injury/nature of illness.(C-1)
66. Predict patterns of injury based on mechanism of injury.(C-2)
67. Compare data regarding mechanism of injury to actual scenes. (C-3)
68. Discuss the reason for identifying the total number of patients at the scene.(C-1)
69. Organize the management of a scene following size-up.(C-3)
70. Explain the reason for identifying the need for additional help or assistance.(C-1)
71. Summarize the reasons for forming a general impression of the patient during the
initial assessment.(C-1)
72. Discuss methods of assessing mental status.(C-1)
73. Differentiate levels of consciousness in the adult, infant and child. (C-3)
74. Differentiate between assessing the altered mental status in the adult, child and infant
patient.(C-3)
75. Discuss methods of assessing the airway in the adult, child and infant patient.(C-1)
76. State reasons for management of the cervical spine once the patient has been
determined to be a trauma patient.(C-1)
77. Analyze a scene to determine if spinal precautions are required. (C-3)
78. Describe methods used for assessing if a patient is breathing.(C-1)
79. Differentiate between a patient with adequate and inadequate minute ventilation. (C-3)
80. Distinguish between methods of assessing breathing in the adult, child and infant
patient.(C-3)
81. Compare the methods of providing airway care to the adult, child and infant patient.(C-
3)
82. Describe the methods used to obtain a pulse.(C-1)
83. Differentiate between obtaining a pulse in an adult, child and infant patient.(C-3)
84. Discuss the need for assessing the patient for external bleeding.(C-1)
85. Describe normal and abnormal findings when assessing skin color.(C-1)
86. Describe normal and abnormal findings when assessing skin temperature.(C-1)
87. Describe normal and abnormal findings when assessing skin condition.(C-1)
Section 2: Page 21
88. Describe normal and abnormal findings when assessing skin capillary refill in the infant
and child patient.(C-1)
89. Explain the reason for prioritizing a patient for care and transport.(C-1)
90. Differentiate patients requiring immediate transport versus those not requiring
immediate transport. (C-3)
91. Describe the evaluation of patient’s perfusion status based on findings in the initial
assessment. (C-1)
92. Determine a patient’s pulse pressure and relate it to the patient’s perfusion status. (C-1)
93. Describe orthostatic vital signs and evaluate their usefulness in assessing a patient in
shock. (C-1)
94. Compare and contrast the relative advantages and disadvantages of capillary refill. (C-3)
95. Apply the techniques of physical examination to the medical patient. (C-1)
96. Describe the unique needs for assessing an individual with a specific chief complaint
with no known prior history.(C-1)
97. Differentiate between the history and physical exam that is performed for responsive
patients with no known prior history and patients responsive with a known prior
history.(C-3)
98. Describe the unique needs for assessing an individual who is unresponsive or has an
altered mental status.(C-1)
99. Differentiate between the assessment that is performed for a patient who is
unresponsive or has an altered mental status and other medical patients requiring
assessment.(C-3)
100. Discuss the reasons for reconsidering the mechanism of injury.(C-1)
101. Define and state the reasons for performing a rapid trauma assessment.(C-1)
102. Recite examples and explain why patients should receive a rapid trauma
assessment.(C-1)
103. Apply the techniques of physical examination to the trauma patient. (C-1)
104. Describe the areas included in the rapid trauma assessment and discuss what should
be evaluated.(C-1)
105. Differentiate cases when the rapid assessment may be altered in order to provide
patient care.(C-3)
106. Discuss the reason for performing a focused history and physical exam.(C-1)
107. Describe when and why a detailed physical examination is necessary. (C-1)
108. Discuss the components of the detailed physical exam in relation, to the techniques of
examination.(C-1)
109. State the areas of the body that are evaluated during the detailed physical exam.(C-1)
110. Explain what additional care should be provided while performing the detailed physical
exam.(C-1)
111. Distinguish between the detailed physical exam that is performed on a trauma patient
and that of the medical patient.(C-3)
112. Differentiate patients requiring a detailed physical exam from those who do not. (C-3)
113. Discuss the reasons for repeating the initial assessment as part of the on-going
assessment.(C-1)
114. Describe the components of the on-going assessment.(C-1)
Section 2: Page 22
115. Describe trending of assessment components.(C-1)
116. Explain the rationale for crew members to evaluate scene safety prior to entering.(A-2)
117. Serve as a model for others explaining how patient situations affect your evaluation of
mechanism of injury or illness.(A-3)
118. Explain the importance of forming a general impression of the patient.(A-1)
119. Explain the value of performing an initial assessment.(A-2)
120. Demonstrate a caring attitude when performing an initial assessment. (A-3)
121. Attend to the feelings that patients with medical conditions might be experiencing.(A-1)
122. Value the need for maintaining a professional caring attitude when performing a
focused history and physical examination. (A-3)
123. Recognize and respect the feelings that patients might experience during
assessment.(A-1)
125. Explain the rationale for the feelings these patients might be experiencing.(A-3)
126. Demonstrate a caring attitude when performing a detailed physical examination. (A-3)
127. Explain the value of performing an on-going assessment.(A-2)
128. Explain the value of reassessing a patient after interventions. (A-2)
assessment.(A-1)
130. Explain the value of trending assessment components to other health professionals
who assume care of the patient.(A-2)
At the completion of this topic, the EMT-Intermediate will be able to:
131. Observe various scenarios and identify potential hazards. (P-1)
132. Demonstrate the scene-size-up. (P-2)
133. Demonstrate the techniques for assessing mental status.(P-1,2)
134. Demonstrate the techniques for assessing the airway.(P-1,2)
135. Demonstrate the techniques for assessing if the patient is breathing.(P-1,2)
136. Demonstrate the techniques for assessing if the patient has a pulse.(P-1,2)
137. Demonstrate the techniques for assessing the patient for external bleeding.(P-1,2)
138. Demonstrate the techniques for assessing the patient's skin color, temperature,
condition and capillary
139. Demonstrate the ability to prioritize patients.(P-1,2)
140. Using the techniques of examination, demonstrate the assessment of a medical
patient. (P-1,2)
141. Demonstrate the patient care skills that should be used to assist with a patient who is
responsive with no known history.(P-1,2)
Section 2: Page 23
142. Demonstrate the patient care skills that should be used to assist with a patient who is
unresponsive or has an altered metal status.(P-1,2)
143. Perform a rapid medical assessment. (P-1,2)
144. Perform a focused history and physical exam of the medical patient. (P-1,2)
145. Using the techniques of physical examination demonstrate the assessment of a
trauma patient. (P-1,2)
146. Demonstrate the rapid trauma assessment that should be used to assess a patient
based on mechanism of injury.(P-1,2)
147. Perform a focused history and physical exam on a non-critically injured patient. (P-1,2)
148. Perform a focused history and physical exam on a patient with life-threatening injuries.
(P-1,2)
149. Demonstrate the skills involved in performing the detailed physical exam.(P-1,2)
150. Perform a detailed physical examination. (P-1,2)
151. Demonstrate the skills involved in performing the on-going assessment.(P-1,2)
Section 2: Page 24
Presentation
DECLARATIVE
I. History Taking
A. Purpose
1. Develop a database of information
2. Guide physical examination
B. Source of History
1. Who provided it
a) Patient
b) Family
c) Friends
d) Police
2. Bias
3. Value
C. Reliability of history
1. Variable
a) Memory
b) Trust
c) Motivation
2. Made at the end of the evaluation, not the beginning
D. Communication principles
1. Establishing rapport
2. Practice good listening skills
3. Communicate through body language and touch
4. Manage communication barriers
a) Avoid use of confusing medical terminology
b) Non-English speaking patient
c) Cultural considerations
d) Sensorially handicapped
(1) Deaf patient
(2) Blind patient
E. Techniques of History Taking
1. Setting the stage
a) The environment
(1) Proper environment enhances communication
(2) Place for you and the patient to sit
(3) Be cautious of power relationship
(4) Personal space
b) Your demeanor and appearance
(1) Just as you are watching the patient, the patient will be watching you
(2) Messages of body language
(3) Clean, neat, professional appearance
Section 2: Page 25
c) Note taking
(1) Difficult to remember all details
(2) Patient care is priority
2. Learning about the present illness
a) Greeting the patient
(1) Greet by name
(2) Avoid the use of unfamiliar or demeaning terms such as Granny or Hon,
etc.
b) Opening questions
(1) Find out why the patient is seeking emergency medical care
(2) Use a general, open-ended question
(3) Following the patients leads
(a) Facilitation
(i) Your posture, actions or words should encourage the patient to
say more
(ii) Making eye contact or saying phrases such as “Go-on” or “I'm
listening may help the patient to continue
(b) Reflection
(i) Repetition of the patient’s words that encourage additional
responses
(ii) Typically does not bias the story or interrupt the patient’s train
of thought
(c) Clarification
(i) Used to clarify ambiguous statements or words
(d) Sympathetic Responses
(i) Use techniques of therapeutic communication to interpret
feelings and your response
(e) Confrontation
(i) Some issues or response may require you to confront patients
about their feelings.
(f) Interpretation
(i) Goes beyond confrontation, requires you to make an inference
(g) Asking about feelings
c) Getting more information
(1) Attributes of a symptom
(a) Location
(i) Where is it
(ii) Does it radiate
(b) Its quality
(i) What is it like
(c) Its quantity or severity
(i) How bad is it
(d) Its timing
Section 2: Page 26
(i) When did it start

(ii) How long does it last
(e) The setting in which it occurs
(i) Emotional response
(ii) Environmental factors
(f) Factors that make it better or worse
(g) Associated manifestations
3. Clinical reasoning
a) Results of questioning may allow you to think about associated problems
and body systems
F. Types of questions
1. Direct questions
a) To gather additional information, direct questions may be required
b) Should not be leading questions
c) Ask one question at a time
d) Use language that is appropriate
2. Open-ended questions
a) Allows patient to tell story in own words
b) Response are more accurate and complete
c) Obtain larger amount of information with fewer questions
d) Requires more time
G. Components of a S.A.M.P.L.E. Patient History
1. Signs/Symptoms (Assess history of present illness)
a) Sign - any medical or trauma condition displayed by the patient and
identifiable by the EMT-Basic, e.g., Hearing = respiratory distress, Seeing =
bleeding, Feeling = skin temperature.
b) Symptom - any condition described by the patient, e.g., shortness of breath.
c) Chief complaint
(1) Main part of the health history
(2) The one or more symptoms that the patient is seeking medical care for
(3) Record in patient's own words
d) History of Present illness
(1) Elaboration and clarification of chief complaint
(2) Determine chronology, nature, and severity of current illness or injury
(3) Components of present illness
(a) Location
(b) Quality
(c) Intensity
(d) Quantity
(e) Chronology of complaints
(f) Setting
(g) Scenario of first symptom
Section 2: Page 27
(h) Aggravation and alleviation

(i) Associated complaints
(j) Modification of symptoms related to complaint
e) Current health status
(1) Environmental conditions
(2) Personal habits
(a) Current Medications
(b) Allergies
(c) Tobacco use
(d) Alcohol, Drugs and Related substances
(e) Diet
(f) Sleep patterns
(g) Exercise and leisure activities
(h) Environmental hazards
(i) Use of safety measures
(j) Home situation and significant other
2. Allergies
a) Medications
b) Food
c) Environmental allergies
d) Consider medical identification tag
3. Medications
a) Prescription
(1) Current
(2) Recent
(3) Birth control pills
b) Non-prescription
(1) Current
(2) Recent
c) Consider medical identification tag
4. Pertinent Past Medical History
a) General state of health
b) Medical Illnesses
c) Psychiatric illnesses
d) Accidents and injuries
e) Surgeries
f) Hospitalizations
g) Consider medical identification tag
Section 2: Page 28
5. Last oral intake: Solid or liquid

a) Time
b) Quantity
6. Events leading to the injury or illness
a) Chest pain with exertion
b) Chest pain while at rest
H. Taking a history on sensitive topics
a) Alcohol and Drugs
b) Physical abuse or violence
c) Sexual history
I. Special challenges
1. Silence
a) Silence is often uncomfortable
b) Silence has meaning and many uses
(1) Patient’s may use this to collect their thoughts, remember details or
decide whether or not they trust you
(2) Be alert for non-verbal clues of distress
c) Silence may be a result of the interviewer’s lack of sensitivity
2. Over talkative patients
a) Faced with a limited amount of time interviewers may become impatient
b) Although there are no perfect solutions, several techniques may be helpful
(1) Lower your goals, accept a less comprehensive history
(2) Give the patient free reign for the first several minutes
(3) Summarize frequently
3. Patients with multiple symptoms
4. Anxious patients
a) Anxiety is natural
b) Be sensitive to non-verbal clues
5. Reassurance
a) It is tempting to be overly reassuring
b) Premature reassurance blocks communication
6. Anger and hostility
a) Understand that anger and hostility are natural
b) Often the anger is displaced toward the clinician
c) Do not get angry in return
7. Intoxication
a) Be accepting not challenging
b) Do not attempt to have the patient lower their voice or stop cursing. This
may aggravate them
c) Avoid trapping them in small areas
8. Crying
Section 2: Page 29
a) Crying, like anger and hostility may provide valuable insight

b) Be empathetic
9. Depression
a) Be alert for signs of depression
b) Be sure you know how bad it is
10. Sexually attractive or seductive patients
a) Clinicians and patients may be sexually attracted to each other
b) Accept these as normal feelings, but prevent them from affecting your
behavior
c) If a patient becomes seductive or makes sexually advances, frankly but
firmly make clear that your relationship is professional not personal.
11. Confusing Behaviors or Histories
a) Be prepared for the confusion and frustration of behaviors and histories
b) Be alert for mental illness, delirium or dementia
12. Limited intelligence
a) Do not overlook the ability of these patients to provide you with adequate
information
b) Be alert for omissions
c) Severe mental retardation may require you to get information from family or
friends
13. Talking with family and friends
a) Some patients may not be able to provide you with all information
b) Try to find a third party who can help you get the whole story
14. Patience during history taking
a) Due to limited communication skills, non-English speaking patients or
confusion, the EMT-Intermediate must:
(1) Be patient while obtaining the patient history
(2) Repeat questions a different way as necessary to allow the patient to
understand.
II. Techniques of Physical Examination
A. Physical Examination: Approach and Overview
1. Examination Techniques and equipment
a) Examination Techniques
(1) Inspection
(2) Palpation
(3) Auscultation
b) Measurement of vitals
(1) Pulse
(2) Respirations
(3) Blood pressure
(4) Temperature
Section 2: Page 30
c) Instrumentation
(1) Stethoscope
(2) Thermometer
(3) BP cuff
2. General Approach
a) Examine the patient systematically
b) Place special emphasis on areas suggested by the present illness and chief
complaint
c) Keep in mind that most patients view a physical exam with apprehension
and anxiety
d) They feel vulnerable and exposed
3. The physical exam should include
a) Mental Status
b) General Survey
c) Vital Signs
d) Skin
e) Head (Eyes, ears, noes, mouth)
f) Neck
g) Chest
h) Abdomen
i) Pelvis
j) Posterior body
k) Extremities
B. Mental Status
1. Appearance and behavior
a) Assess for level of consciousness
(1) Alertness
(2) Response to verbal stimuli
(3) Response to touch or shake of shoulder (tactile)
(4) Response to painful stimuli
(5) Unresponsive
b) Possible findings:
(1) Normal
(2) Drowsiness
(3) Obtundation
(a) Insensitive to unpleasant or painful stimuli by reducing level of
consciousness by an anesthetic or analgesic
(4) Stupor
(a) State of lethargy and unresponsiveness
(b) Person seems unaware of surroundings
(5) Coma
(a) State of profound unconsciousness
Section 2: Page 31
(b) Absence of spontaneous eye movements

(c) No response to verbal or painful stimuli
(d) Patient can not be aroused by any stimuli
(6) Posture and motor behavior
c) Facial expression
(1) Anxiety
(2) Depression
(3) Elation
(4) Anger
(5) Response to imaginary people or objects
(6) Withdrawal
d) Manner, affect, and relation to person and things
2. Memory
a) Assess orientation:
(1) Time
(2) Place
(3) Person
b) Possible findings:
(1) Disorientation
3. Assess remote memory (i.e. Birthdays)
4. Assess recent memory (i.e. Events of the day)
C. General Survey
1. Level of Consciousness
a) Awake
b) Alert
c) Responsive
d) Unresponsive
2. Signs of Distress
a) Assess for signs of distress
b) Examples (not inclusive)
(1) Cardiorespiratory insufficiency
(a) Labored breathing
(b) Wheezing
(c) Cough
(2) Pain
(a) Wincing
(b) Sweating
(c) Protecting a painful part
(3) Anxiety
(a) Anxious face
(b) Fidgety movement
(c) Cold moist palms
Section 2: Page 32
3. Apparent state of health

4. Skin color and obvious lesions
a) Pallor
b) Cyanosis
c) Jaundice
d) Rashes
e) Bruises - ecchymosis
f) Scars
g) Discoloration
5. Posture, gait and motor activity
a) Preferred posture
(1) Tripodal
(2) Paralysis
(3) Limpness
(4) Restless or quiet
(5) Involuntary motor activity
6. Odors of breath or body
a) Breath odors may indicate underlying conditions
(1) Alcohol/Alcoholic beverage
(2) Acetone
(3) Infections
(4) Liver failure
7. Facial expression
a) Observe expression
b) At rest, during conversation and during the examination
8. Vital Signs
a) Blood Pressure
b) Respiratory rate
c) Pulse
d) Temperature
D. Anatomical regions
1. The Skin
a) Anatomy and Physiology Review
(1) Changes with Age
b) Techniques of Exam
(1) Inspect and palpate the skin
(2) Note the following characteristics
(a) Color
(i) The red color of oxyhemoglobin and pallor due to lack of
oxygen are best seen where the epidermis is thinnest
(ii) The fingernails and lips and the mucous membranes of the
mouth and palpebral conjunctiva
Section 2: Page 33
(iii) In dark skinned persons, the palms and the soles may also be
useful
(b) Moisture
(c) Temperature
(d) Texture
(e) Mobility and turgor
(f) Lesions
2. Head, ears, eyes, and nose
(1) The head
(2) The ears
(3) The nose
(4) The mouth
(5) The neck
(6) Changes with age
b) Techniques of Examination
(1) The head
(a) The scalp
(i) Part the hair in several places
(ii) Look for scaliness, lumps or other lesions
(b) The skull
(i) Observe the general size and contour of the skull.
(ii) Palpate and inspect note any tenderness, deformities or lumps
(c) The face
(i) Note the facial expression and contours
(ii) Observe for asymmetry, involuntary movements, masses and
edema
(d) The skin
(i) Observe the skin
(ii) Note color, pigmentation, texture, thickness, hair distribution
and any lesions
(2) The eyes
(a) Pupils
(i) Inspect the size, shape and symmetry of the pupils
(ii) Test the pupillary reactions to light
(a) Look for
(i) Direct reaction
(ii) Consensual reaction
(b) Accommodation
(i) Ask the patient to focus on a distant object
Section 2: Page 34
(ii) Then have the person shift the gaze to a near object
(a) Normal response
(i) Pupil constriction
(ii) Convergence of the axes of the light
(3) The ears
(a) The auricle
(i) Inspect each auricle and surrounding tissue for deformities,
lumps and skin lesions, drainage, tenderness, erythema
(4) The nose
(a) Inspect the anterior and inferior surface of the nose
(i) Asymmetry
(ii) Deformity
(iii) Foreign bodies
(b) Palpate for tenderness
(5) The mouth
(a) Inspect the lips, observe color, moisture, note any lumps, ulcers,
cracking or scaliness
(b) Look into the patient’s mouth with a good light and a tongue blade,
inspect the oral mucosa
(c) Note the color of the gums and teeth
(d) Inspect the teeth
(e) Inspect the tongue
(6) The neck
(a) Inspect the neck, noting its symmetry and any masses or scars
(b) Inspect and palpate the trachea for any deviation
(c) Inspect for jugular venous distention (JVD)
(7) Head and cervical spine
(a) The cervical spine
(i) Inspection
(ii) Palpation
(a) Tenderness
(b) Deformities
3. Chest
a) Anatomy and Physiology
b) Techniques of Examination
(1) General Approach
(a) Have the patient expose their chest so that you can see the entire
chest
(b) Proceed in an orderly fashion
(i) Inspect
(ii) Palpate
(iii) Auscultate
(iv) Compare side to side
Section 2: Page 35
(c) Try to visualize the underlying lobes of the lungs

(2) Examination of the thorax and ventilation
(a) Observe rate, rhythm, depth and effort of breathing
(b) Check the patient for cyanosis
(c) Listen to the patient’s breathing
(d) Observe the shape of the chest
(3) Examination of the posterior chest
(a) Inspect, noting
(i) Any deformities or asymmetry
(a) Barrel Chest
(b) Traumatic flail chest
(ii) Abnormal retractions
(iii) Impairment of respiratory movement
(b) Palpate, noting
(i) Any tender areas
(ii) Assessment of observed abnormalities
(iii) Further assessment of respiratory expansion
(c) Auscultate breath sounds
(i) Normal
(a) Vesicular
(b) Bronchovesicular
(c) Bronchial
(d) Tracheal
(ii) Added sounds (Adventitious Lung Sounds)
(a) Discontinuous Sounds (Crackles)
(i) Fine Crackles
(ii) Course Crackles
(b) Continuous Sounds
(i) Wheezes
(ii) Rhonchi
(c) Pleural friction rub
(iii) Diminished or absent
(a) Effusion
(b) Consolidation
(4) Examination of the anterior chest
(a) Inspect, noting
(i) Any deformities or asymmetry
(ii) Abnormal retractions
(iii) Impairment of respiratory movement
(b) Palpate, noting
(i) Any tender areas
(ii) Assessment of observed abnormalities
Section 2: Page 36
(iii) Further assessment of respiratory expansion

(c) Auscultate
(i) Breath sounds
(ii) Added sounds
4. Abdomen
b) Techniques of examination
(1) General approach
(a) Ideally, the patient should not have a full bladder
(b) Make the patient comfortable in a supine position
(c) Before palpation ask the patient to point out any Areas of pain -
examine these areas last
(d) Have warm hands, a warm stethoscope and short nails
(e) Approach slowly and avoid quick, unexpected movements
(f) Distract the patient as needed with conversation
(g) Visualize each organ as you examine each in the region as you are
examining
(h) Proceed in an orderly manner
(i) Inspection - all four quadrants
(ii) Palpation - all four quadrants
(2) Inspection of the abdomen, including the flanks, noting
(a) Skin
(i) Scars
(ii) Striae
(iii) Dilated veins
(iv) Rashes and lesions
(v) Discoloration
(vi) Ascites
(vii) Herniation
(b) The Umbilicus
(i) Contour
(ii) Location
(iii) Signs of inflammation or hernia
(c) The contour of the abdomen
(i) Bulges
(a) Flat
(b) Rounded
(c) Protuberant
(d) Scaphoid
(e) Bulges at the flanks
(f) Hernias
Section 2: Page 37
(ii) Symmetry
(d) Peristalsis
(e) Pulsations
(f) Ascites
(3) Palpation
(a) Muscle guarding
(b) Rigidity
(c) Large Masses
(d) Tenderness
5. Extremities
a) Anatomy and Physiology
(1) Structure and Function of Joints
(2) Specific Joints
b) Techniques of examination
(1) General Approach
(a) Direct your attention to function as well as structure
(b) Assess general appearance, bodily proportions and ease of
movement.
(c) Note particularly
(i) Limitation in the range of motion
(ii) Unusual Increase in the mobility of a joint
(d) In general, note:
(i) Signs of inflammation
(a) Swelling
(b) Tenderness
(c) Increased heat
(d) Redness
(ii) Crepitus
(iii) Deformities
(iv) Muscular Strength
(v) Symmetry
(2) Patient Sitting Up
(a) Hands and Wrist
(i) Range of motion
(a) Make a fist with each hand
(b) Extend and spread the fingers
(c) Flex and extend the wrists
(d) With palms down move the hands lateral and medially
(ii) Inspection
(a) Swelling
(b) Redness
Section 2: Page 38
(c) Nodules
(d) Deformities
(e) Muscular atrophy
(iii) Palpation
(a) Note:
(i) Swelling
(ii) Tenderness
(iii) Bogginess
(b) Elbows
(i) Range of motion
(a) Ask the patient to bend and straighten the elbows
(b) Keep the arms at the sides with elbows flexed
(c) Supination - turn palms up
(d) Pronation - turn palms down
(ii) Inspection
(a) Support the patient's forearms with your opposite hand so
that the elbow is flexed to about 70 degrees
(b) Examine the elbow
(iii) Palpation
(a) Noting:
(i) Tenderness
(ii) Swelling
(iii) Thickening
(c) Shoulders and related structures
(i) Range of Motion
(a) Ask the patient to
(i) Raise both arms to a vertical position at the sides of the
head
(ii) External rotation and abduction - Place both hands
behind the neck with elbows to the side
(iii) Internal rotation - Place both hands behind the small of
the back
(b) Cup your hands over the shoulders and note any crepitus
(ii) Palpation
(a) Note:
(i) Tenderness
(ii) Swelling
(d) Ankles and feet
(i) Inspection
(a) Observe all surfaces of the ankle and feet
(b) Note:
(i) Deformities
(ii) Nodules
Section 2: Page 39
(iii) Swelling
(iv) Calluses
(v) Corns
(ii) Palpation
(a) Note
(i) Tenderness
(ii) Bogginess
(iii) Swelling
(iii) Range of Motion
(a) The ankle joint
(i) Dorsiflex
(ii) Plantar flex
(b) The traverse tarsal joint
(i) Inversion
(ii) Eversion
(c) The Metatarsophalangeal Joints
(i) Flexion of the toes
(e) Knees and hips
(i) Inspection of the knees
(a) Note alignment and deformity
(b) Observe atrophy of the quadriceps
(ii) Palpation of the knees
(a) Palpate, note:
(i) Thickening
(ii) Swelling
(iii) Range of motion
(a) Ask the patient to bend each knee in turn up to the chest
(b) Note the flexion of the hip and knee
(c) Assess for rotation of the hips
(d) Assess abduction of the hips
(iv) Palpation of the hips
(a) Palpate the hip joint
E. Posterior body
1. The Spine
a) Inspection
(1) From the side note the cervical, thoracic and lumbar curves
(2) Note curvatures
(a) Lordosis
(b) Kyphosis
(c) Scoliosis
(3) Look for differences in the height of the shoulders
(4) Look for differences in the height of the iliac crest
Section 2: Page 40
b) Range of motion
(1) Flexion - ask the patient to bend forward and touch the toes
(a) Note:
(i) Smoothness of movement
(ii) Symmetry of movement
(iii) Range of motion
(iv) Curve in the lumbar area
(2) Lateral bending - bend sideways
(3) Extension - back backwards toward you
(4) Rotation - twist the shoulders one way and then the other
c) Palpation
(1) Palpate the spinous process with your thumb
(a) Identify tenderness
(2) Palpate in the area costovertebral angle
(a) Identify tenderness
d) Abnormal findings
F. The Physical Examination of Infants and Children
1. Approach to the Patient
2. Techniques of Examination
G. Recording examination findings
III. Patient Assessment
A. Scene Size-up/Assessment
1. Body substance isolation review
a) Eye protection if necessary
b) Gloves if necessary
c) Gown if necessary
d) Mask if necessary
2. Scene safety
a) Definition - an assessment to assure the well-being of the EMT-
Intermediate.
b) Personal protection - Is it safe to approach the patient?
(1) Crash/rescue scenes
(2) Toxic substances - low oxygen areas
(3) Crime scenes - potential for violence
(4) Unstable surfaces: slope, ice, water
c) Protection of the patient - environmental considerations
d) Protection of bystanders - if appropriate, help the bystander avoid becoming
a patient.
e) Do not enter unsafe scenes
f) Scenes may be dangerous even if they appear to be safe
3. Definition - an assessment of the scene and surroundings that will provide
valuable information to the EMT-Intermediate.
Section 2: Page 41
4. Mechanism of injury/ nature of illness

a) Medical
(1) Nature of illness - determine from the patient, family or bystanders why
EMS was activated.
(2) Determine the total number of patients. If there are more patients than
the responding unit can effectively handle, initiate a mass casualty plan.
(a) Obtain additional help prior to contact with patients, such as law
enforcement, fire, rescue, ALS, utilities. EMT-Intermediate is less
likely to call for help if involved in patient care.
(b) Begin triage.
b) Trauma
(1) Mechanism of injury - determine from the patient, family or bystanders
and inspection of the scene what is the mechanism of injury.
(2) Determine the total number of patients.
(a) If there are more patients than the responding unit can effectively
handle, initiate a mass casualty plan.
(i) Obtain additional help prior to contact with patients. EMT-
Intermediate is less likely to call for help when involved in
patient care.
(ii) Begin triage.
(iii) If the responding crew can manage the situation, consider
spinal precautions and continue care.
B. Initial Assessment
1. General Impression of the Patient
a) Definition
(1) The general impression is formed to determine priority of care and is
based on the EMT-Intermediate's immediate assessment of the
environment and the patient's chief complaint.
(2) Determine if ill, i.e., medical or injured (trauma). If injured, identify
mechanism of injury; if ill, identify nature of illness
(3) Age
(4) Sex
(5) Race
2. Assess patient and determine if the patient has a life threatening condition.
a) If a life threatening condition is found, treat immediately.
b) Assess nature of illness or mechanism of injury.
3. Assess Patient's Mental Status. Maintain Spinal Immobilization if Needed.
a) Levels of mental status (AVPU)
(1) Alert
(2) Responds to Verbal stimuli.
(3) Responds to Painful stimuli.
(4) Unresponsive - no gag or cough
4. Assess the Patient's Airway Status.
a) Patent
b) Obstructed
(1) Suction
(2) Positioning
(3) Airway Adjuncts
Section 2: Page 42
(4) Invasive Techniques

(a) Endotracheal Intubation
(b) Multi-lumen airways
5. Assess the Patient's Breathing.
a) Adequate
b) Inadequate
6. Assess the Patient's Circulation.
a) Assess the patient's pulse.
b) Assess if major bleeding is present. If bleeding is present, control bleeding.
c) Assess the patient's perfusion by evaluating skin color and temperature.
7. Identify Priority Patients.
a) Consider:
(1) Poor general impression
(2) Unresponsive patients - no gag or cough
(3) Responsive, not following commands
(4) Difficulty breathing
(5) Shock (hypoperfusion)
(6) Complicated childbirth
(7) Chest pain with BP <100 systolic
(8) Uncontrolled bleeding
(9) Severe pain anywhere
(10)Multiple injuries
b) Expedite transport of the patient.
8. Proceed to the appropriate focused history and physical examination.
C. Focused History and Physical Exam
1. Responsive Medical Patients
a) Assess patient history
(1) Chief complaint
(2) History of Present Illness
(3) Past medical history
(4) Current health status
b) Perform physical examination
(1) Utilize the techniques of patient assessment previously identified:
(a) Assess the head as necessary.
(b) Assess the neck as necessary.
(c) Assess the chest as necessary.
(d) Assess the abdomen as necessary.
(e) Assess the pelvis as necessary.
(f) Assess the extremities as necessary.
(g) Assess the posterior body as necessary.
c) Assess baseline vital signs.
d) Provide emergency medical care based on signs and symptoms in
consultation with medical direction/control.
2. Unresponsive Medical Patients
a) Perform rapid assessment.
b) Utilize the techniques of patient assessment previously identified:
(1) Position patient to protect airway.
(2) Assess the head.
Section 2: Page 43
(3) Assess the neck.

(4) Assess the chest.
(5) Assess the abdomen.
(6) Assess the pelvis.
(7) Assess the extremities.
(8) Assess the posterior aspect of the body.
c) Assess baseline vital signs.
d) Obtain patient history from bystander, family, friends
(1) Chief Complaint
(a) Attributes of a symptom
(i) Location
(a) Where is it
(b) Does it radiate
(ii) Its quality - what is it like
(iii) Its quantity or severity - how bad is it
(iv) Its timing
(a) When did it start
(b) How long does it last
(v) The setting in which it occurs
(a) Emotional response
(b) Environmental factors
(vi) Factors that make it better or worse
(vii) Associated manifestations
D. Focused History and Physical Exam - Trauma Patients
1. Re-consider Mechanism of Injury
a) Helps to Identify Priority Patients
b) Helps to guide the assessment
c) Significant mechanism of injury
(1) Ejection from vehicle
(2) Death in same passenger compartment
(3) Falls > 20 feet
(4) Roll-over of vehicle
(5) High-speed vehicle collision
(6) Vehicle-pedestrian collision
(7) Motorcycle crash
(8) Unresponsive or altered mental status
(9) Penetrations of the head, chest, or abdomen
(10)Hidden injuries
(a) Seat belts
(i) If buckled, may have produced injuries.
(ii) If patient had seat belt on, it does not mean they do not have
injuries.
(b) Airbags
(i) May not be effective without seat belt.
(ii) Patient can hit wheel after deflation.
Section 2: Page 44
(iii) Lift the deployed airbag and look at the steering wheel for
deformation.
(a) "Lift and look" under the bag after the patient has been
removed.
(b) Any visible deformation of the steering wheel should be
regarded as an indicator of potentially serious internal
injury, and appropriate action should be taken.
(c) Child safety seats
(i) injury patterns with airbags
(ii) proper use in vehicles with airbags
(d) Infant and child considerations
(i) Falls >10 feet
(ii) Bicycle collision
(iii) Vehicle in medium speed collision
2. Perform rapid trauma physical examination on patients with significant
mechanism of injury to determine life threatening injuries. In the responsive
patient, symptoms should be sought before and during the trauma assessment.
a) Continue spinal stabilization.
b) Reconsider transport decision.
c) Assess mental status (AVPU).
d) As you inspect and palpate, look and feel for injuries or signs of injury
e) Examination:
(1) Assess the head, inspect and palpate for injuries or signs of injury.
(2) Assess the neck, inspect and palpate for injuries or signs of injury.
(3) Apply cervical spinal immobilization collar (CSIC). May use information
from the head injury lesson at this time.
(4) Assess the chest
(5) Assess the abdomen, inspect and palpate for injuries or signs of injury.
(6) Assess the pelvis, inspect and palpate for injuries or signs of injury.
(7) Assess all four extremities, inspect and palpate for injuries or signs of
injury.
(8) Roll patient with spinal precautions and assess posterior body, inspect
and palpate, examining for injuries or signs of injury.
(9) Assess baseline vital signs.
(10)Assess patient history.
(a) Chief complaint
(b) History of Present Illness
(c) Past medical history
(d) Current health status
3. For patients with no significant mechanism of injury, e.g., cut finger
a) Perform focused history and physical exam of injuries based on the
techniques of examination. The focused assessment is performed on the
specific injury site.
b) Assess baseline vital signs.
c) Assess patient history.
(1) Chief complaint
Section 2: Page 45

E. Detailed Physical Exam
1. Patient and injury specific, e.g., cut finger would not require the detailed
physical exam.
2. Perform a detailed physical examination on the patient to gather additional
information.
3. General Approach
a) Assess patient history
(1) Chief complaint
b) Examine the patient systematically
c) Place special emphasis on areas suggested by the present illness and chief
complaint
d) Keep in mind that most patients view a physical exam with apprehension
and anxiety
(1) They feel vulnerable and exposed
4. Overview of a comprehensive Examination
a) The categories of a physical exam should include
(1) Mental Status
(2) General Survey
(3) Vital Signs
(4) Skin
(5) Head
(6) Eyes
(7) Ears
(8) Nose
(9) Mouth and pharynx
(10)Neck
(11)Thorax and lungs
(12)Cardiovascular system
(13)Abdomen
(14)Genitalia as appropriate
(15)Buttocks as appropriate
(16)Peripheral Vascular system
(17)Musculoskeletal system
(18)Nervous system
5. Mental Status
a) Appearance and behavior
b) Posture and motor behavior
c) Speech and language
d) Mood
e) Thought and Perceptions
f) Assess thought content:
g) Assess perceptions:
h) Assess insight and judgment:
i) Memory and attention
Section 2: Page 46
j) Assess remote memory (i.e. birthdays)

k) Assess recent memory (i.e. events of the day)
l) Assess new learning ability
6. General Survey
a) Level of Consciousness
b) Signs of Distress
c) Apparent state of health
d) Skin color and obvious lesions
e) Height and build
f) Weight
g) Posture, gait and motor activity
h) Dress, grooming and personal hygiene
i) Odors of breath or body
j) Facial expression
k) Vital Signs
7. Body Systems
a) The Skin
b) The Head and Neck
(1) The head
(2) The ears
(3) The nose
(4) The mouth and pharynx
(5) The neck
c) The Cardiovascular System
d) The Abdomen
e) The Genitalia - when appropriate
f) The buttocks as appropriate
g) The Peripheral Vascular System
h) The Musculoskeletal System
i) The Nervous System
8. Recording examination findings
9. Assess Baseline Vital Signs.
F. Ongoing Assessment
1. Repeat initial assessment. For a stable patient, repeat and record every 15
minutes. For an unstable patient, repeat and record at a minimum every 5
minutes.
a) Reassess mental status.
b) Reassess airway.
c) Monitor breathing for rate and quality.
d) Reassess circulation
e) Re-establish patient priorities.
2. Reassess and record vital signs.
3. Repeat focused assessment regarding patient complaint or injuries.
4. Assess interventions
a) Assess response to management
b) Maintain or modify management plan
Section 2: Page 47
NOTES
Section 2: Page 48

Section 2 - Essentials/Lesson 2-3: Clinical Decision Making
OBJECTIVES LEGEND
1=Knowledge
2=Application
1. Explain and demonstrate critical thinking skills(C-1, C-3)
2. Explain and demonstrate decision making skills(C-1, C-3)
3. Explain and demonstrate assessment Based Patient Care(C-1, C-3)
Presentation
DECLARATIVE
I. Introduction and key concepts
A. The cornerstones of effective EMT-Intermediate practice
1. Gathering, evaluating, and synthesizing information
2. Developing and implementing appropriate patient management plans
3. Apply judgment and exercise independent decision making
4. Thinking and working effectively under pressure
B. The prehospital environment
1. Unlike other environments where medical care is traditionally rendered
2. Unique - heavily influenced by factors that don’t exist in other medical settings.
C. The spectrum of patient care in prehospital care
1. Obvious, critical life threats
a) Major, multi-system trauma
b) Devastating single system trauma
c) End stage disease presentations
d) Acute presentations of chronic conditions
2. Potential life threats
a) Serious, multi-system trauma
b) Multiple disease etiologies
3. Non-life threatening presentations
D. Providing guidance and authority for EMT-Intermediate action and treatments
1. Protocols, standing orders, and patient care algorithms
a) Can clearly define and outline performance parameters
b) Promote a standardized approach
2. Limitations of protocols, standing orders & patient care algorithms
a) Only addresses “classic” patient presentations
(1) Non-specific patient complaints don’t follow model
(2) Limited clarity of presenting patient problems
b) Don’t speak to multiple disease etiologies
c) Don’t speak to multiple treatment modalities
Section 2: Page 50
d) Promotes linear thinking, “cookbook medicine” providers

II. Components, stages, and sequence of Critical Thinking process for EMT-Intermediates
A. Concept Formation
1. Mechanism of injury (MOI)/scene assessment
2. Initial assessment and physical examination
3. Chief complaint
4. Patient history
5. Patient affect
6. Diagnostic tests
B. Data interpretation
1. Data gathered
2. EMT-Intermediate knowledge of Anatomy, Physiology, and pathophysiology
3. EMT-Intermediate attitude
4. Previous experience base of EMT-Intermediate
C. Application of principle
1. Field impression/working diagnosis
2. Protocols/standing orders
3. Treatment/intervention
D. Evaluation
1. Reassessment of patient
2. Reflection in action
3. Revision of impression
4. Protocol/standing orders
5. Revision of treatment/intervention
E. Reflection on action
1. Run critique
2. Addition to/ modification of experience base of EMT-Intermediate
III. Fundamental elements of critical thinking for EMT-Intermediates
A. Adequate fund of knowledge
B. Ability to pay attention
C. Ability to gather and organize data and form concepts
D. Ability to identify and deal with medical ambiguity
E. Ability to differentiate between relevant and irrelevant data
F. Ability to analyze and compare similar situations
G. Ability to recall contrary situations
H. Ability to articulate decision making reasoning and construct arguments
IV. Considerations with field application of Assessment Based patient management
A. The Patient Acuity Spectrum
1. EMS is activated for countless reasons
2. Few prehospital calls constitute true life threatening emergencies
a) Minor medical and traumatic events require little critical thinking and have
relatively easy decision making
Section 2: Page 51
b) Patient’s with obvious life threats pose limited critical thinking challenges
c) Patient’s who fall on the acuity spectrum between minor and life threatening
pose the greatest critical thinking challenge
B. Thinking under pressure
1. Hormonal influence i.e. “fight or flight” response impacts EMT-Intermediate
decision making both positively and negatively
a) Enhanced visual and auditory acuity
b) Improved reflexes and muscle strength
c) Impaired critical thinking skills
d) Diminished concentration and assessment ability
2. Mental conditioning is the key to effective performance under pressure
a) Skills learned at a pseudo-instinctive performance level
b) Automatic response for technical treatment requirements
C. Mental checklist for thinking under pressure
1. Stop and think
2. Scan the situation
3. Decide and act
4. Maintain clear, concise control
5. Regularly and continually reevaluate the patient
D. Facilitating behaviors
1. Stay calm, don’t panic
2. Assume and plan for the worst; err on the side of the patient
3. Maintain a systematic assessment pattern
4. Balance analysis, data processing and decision making styles
a) Situation analysis styles: reflective vs. Impulsive
b) Data processing styles: divergent vs. Convergent
c) Decision making styles: anticipatory vs. Reactive
E. Situation awareness
1. Reading the scene
2. Reading the patient
F. Putting it all together - “The Six R’s”
1. Read the patient
a) Observe the patient
(1) Level of responsiveness/consciousness
(2) Skin color
(3) Position and location of patient - obvious deformity or asymmetry
b) Talk to the patient
(1) Determine the chief complaint
(2) New problem or worsening of preexisting condition?
Section 2: Page 52
c) Touch the patient

(1) Skin temperature and moisture
(2) Pulse rate, strength, and regularity
d) Auscultate the patient
(1) Identify problems with the lower airway
e) Status of ABC’s-identifying life threats
f) Complete and accurate set of vital signs
(1) Use as triage tool to estimate severity
(2) Can assist in identifying the majority of life threatening conditions
(3) Influenced by patient age, underlying physical and medical conditions,
and current medications
2. Read the scene
a) General environmental conditions
b) Evaluate immediate surroundings
c) Mechanism of injury
3. React
a) Address life threats in the order they are found
b) Determine the most common and statistically probable that fits the patient’s
initial presentation
c) Consider the most serious condition the fits the patient’s initial presentation
d) If a clear medical problem is elusive, treat based on presenting signs and
symptoms
4. Reevaluate
a) Focused and detailed assessment
b) Response to initial management/interventions
c) Discovery of less obvious problems
5. Revise management plan
6. Review performance at run critique
Section 2: Page 53
NOTES:
Section 2: Page 54
Lesson 2-4: Airway Management and Ventilation
FOR INTERMEDIATE LIFE SUPPORT TECHNICIANS ONLY

This lesson contains instruction for Multi-lumen airways only.
For instruction in ET Intubation and Multi-lumen Airway, see:

Section 2 - Lesson 2-5, for Airway Management
and ILS/Airway Technicians Only
Lesson 2-4: Airway Management and Ventilation - for ILS Technicians Only
OBJECTIVES LEGEND
1=Knowledge
2=Application
LESSON TERMINAL OBJECTIVE:

At the end of this lesson, the EMT-Intermediate student will be able to utilize the
assessment findings to formulate a field impression and implement the management plan
for the patient experiencing an airway or breathing emergency.
COGNITIVE OBJECTIVES:
1. Identify the anatomy of the upper and lower airway. (C-1)
2. Describe the functions of the upper and lower airway. (C-1)
3. Explain the differences in the anatomy of the upper and lower airway between an adult
and a pediatric patient. (C-1)
4. Define gag reflex. (C-1)
5. Establish the relationship between pulmonary circulation and respiration. (C-3)
6. Define the partial pressures and list the concentration of gases, which comprise
atmospheric air. (C-1)
7. Describe the measurement of oxygen in the blood. (C-1)
8. Describe the measurement of carbon dioxide in the blood. (C-1)
9. List factors, which cause decreased oxygen concentrations in the blood. (C-1)
10. Define atelectasis. (C-1)
11. Define:
• Hypoxia. (C-1)
• Hypoxemia. (C-1)
12. List the factors, which increase carbon dioxide production in the body. (C-1)
13. List the factors, which decrease carbon dioxide elimination in the body. (C-1)
14. Describe the voluntary regulation of respiration. (C-1)
15. Describe the involuntary regulation of respiration. (C-1)
16. Describe the modified forms of respiration. (C-1)
17. Define normal respiratory rates for the adult, child, and infant. (C-1)
18. List the factors, which affect respiratory rate. (C-1)
19. List the factors, which affect respiratory depth. (C-1)
20. Define the normal tidal volumes for the adult, child, and infant. (C-1)
21. Explain the risk of infection to EMS providers associated with basic airway and
advanced airway management. (C-1, C-3)
22. Explain the risk of infection to EMS providers associated with ventilation. (C-1, C-3)
23. Define pulsus paradoxes. (C-1)
Section 2: Page 56
24. Define partial airway obstruction: (C-1)

• With good air exchange.
• With poor air exchange.
25. Define complete airway obstruction. (C-1)
26. Review causes of upper airway obstruction, including: (C-1)
• The tongue
• Foreign body aspiration
• Laryngeal spasm
• Laryngeal edema
• Trauma
27. Review causes of respiratory distress, including: (C-1)
• Upper and lower airway obstruction
• Inadequate ventilation
• Impairment of the respiratory muscles
• Impairment of the nervous system
28. Review and describe manual airway maneuvers, including: (C-1)
• Opening the mouth
• Head-tilt/chin-lift maneuver
• Jaw-thrust maneuver
• Modified jaw-thrust maneuver
29. Review and describe complete airway obstruction maneuvers, including: (C-1)
• The Heimlich maneuver
• Finger sweep
• Chest thrusts
30. Review the purpose for suctioning the upper airway. (C-1)
31. Review types of suction equipment, including: (C-1)
• Hand-powered suction devices
• Oxygen-powered portable suction devices
• Battery-operated portable suction devices
• Mounted vacuum-powered suction devices
32. Review types of suction catheters, including: (C-1)
• Hard or rigid catheters
• Soft catheters
33. Review techniques of suctioning the upper airway. (C-1)
34. Review special considerations of suctioning the upper airway. (C-1)
35. Describe the indications for suctioning the upper airway. (C-3)
36. Identify gastric distention. (C-1)
37. Describe indications for gastric decompression. (C-1)
38. Identify techniques of gastric decompression. (C-1)
39. Identify special considerations of gastric decompression. (C-1)
Section 2: Page 57
40. Describe indications and contraindications for inserting an airway adjunct, including: (C-1)
• An oropharyngeal airway
• A nasopharyngeal airway
41. Review the steps to insert an oropharyngeal airway. (C-1)
42. Review the steps to insert a nasopharyngeal airway. (C-1)
43. Review methods to perform ventilation, including: (C-1)
• Mouth-to-mouth
• Mouth-to-nose
• Mouth-to-mask
• 1 person bag-valve-mask
• Flow-restricted oxygen-powered ventilation device
44. Review the advantage of the 2 person method to perform ventilation with the bag-valve-
mask. (C-1)
45. Review and describe complications of ventilation with a bag-valve-mask. (C-1)
46. Identify the flow-restricted oxygen-powered ventilation device. (C-1)
47. List the steps to perform ventilation with the flow-restricted oxygen-powered ventilation
device (C-1)
48. Describe complications of ventilation with the flow-restricted oxygen-powered ventilation
device. (C-1)
49. Identify the automatic transport ventilator (ATV). (C-1)
50. List the steps to perform ventilation with the ATV. (C-1)
51. Describe complications of ventilation with the ATV. (C-1)
52. Identify oxygen delivery equipment, liter flow range, and concentration of delivered
oxygen, including: (C-1)
• Nasal cannula
• Simple face mask
• Partial rebreather mask
• Nonrebreather mask
• Venturi mask
• Small volume nebulizer
53. Identify a stoma. (C-1)
54. Define laryngectomy. (C-1)
55. Identify a tracheostomy. (C-1)
56. Identify a tracheostomy tube. (C-1)
57. Describe mouth-to-stoma ventilation. (C-1)
58. Describe bag-valve-mask-to-stoma ventilation. (C-1)
59. Describe stoma suctioning. (C-1)
60. Identify special considerations in airway management and ventilation for the pediatric
patient. (C-1)
61. Identify special considerations in airway management and ventilation for patients with
facial injuries. (C-1)
Section 2: Page 58
62. Describe indications to perform advanced airway management. (C-1)

63. Identify indications for multi-lumen intubation. (C-1)
64. Describe indications and contraindications for inserting the multi-lumen airway. (C-1)
65. Discuss and understand the use of quantitative measurement of patient oxygenation
and end-tidal CO2. (C-1)
66. Describe selection of a multi-lumen airway to perform ventilation. (C-1, C-3)
67. List the equipment used to perform insertion of the multi-lumen airway. (C-1)
68. List the steps to insert a multi-lumen airway. (C-1)
69. Describe complications of insertion of a multi-lumen airway. (C-1)
70. Describe extubation of a multi-lumen airway. (C-1)
71. Identify the indications for extubation of a multi-lumen airway. (C-1)
72. Describe the complications of extubation of a multi-lumen airway. (C-1)
AFFECTIVE OBJECTIVES:
73. Explain the rationale for selection of each of the following basic approaches to airway
management: (A-1)
• Manual airway maneuvers
• Oropharyngeal airway
• Nasopharyngeal airway
74. Explain the rationale for use of the multi-lumen airway for airway management. (A-1)
75. Explain quantitative measurement of patient oxygenation and end-tidal CO2. (A-1)
76. Explain the rationale for selection of each of the following approaches to ventilation: (A-
1)
• Mouth-to-mask ventilation
• Flow-restricted, oxygen powered ventilation device
• Automatic transport ventilator
PSYCHOMOTOR OBJECTIVES:
At the completion of this lesson, EMT-Intermediate student will be able to:
1. Perform body substance isolation (BSI) procedures during basic airway management,
advanced airway management, and ventilation. (P-1, P-2)
2. Perform quantitative measurement of patient oxygenation and end-tidal CO2. (P-1, P-2)
3. Perform manual airway maneuvers, including: (P-1, P-2)
• Modified Jaw-thrust maneuver
4. Describe manual airway maneuvers for pediatric patients, including: (P-1, P-2)
Section 2: Page 59
5. Perform complete airway obstruction maneuvers, including: (P-1, P-2)
• Finger sweep
• Chest thrusts
6. Perform suctioning of the upper airway by selecting a suction device, catheter, and
technique. (C-3, P-2)
7. Perform suctioning of an advanced airway device by selecting a suction device,
catheter, and technique. (C-3, P-2)
8. Perform insertion of an oropharyngeal airway. (P-1, P-2)
9. Perform insertion of a nasopharyngeal airway. (P-1, P-2)
10. Perform mouth-to-mask ventilation (P-1,P-2)
11. Perform ventilation with a bag-valve-mask, including:(P-1,P-2)
• 1 person method
• 2 person method
12. Perform ventilations with a bag-valve-mask with an in-line small-volume nebulizer.(P-1, P-2)
13. Perform ventilation with the flow-restricted oxygen-powered ventilation device. (P-1, P-2)
14. Perform ventilation with the ATV. (P-1, P-2)
15. Perform oxygen delivery with an oxygen humidifier. (P-1, P-2)
16. Perform oxygen delivery with oxygen delivery equipment, including: (P-1, P-2)
• The nasal cannula
• The simple face mask
• The partial rebreather mask
• The nonrebreather mask
• The Venturi mask
17. Perform medication administration with a small-volume nebulizer. (P-1, P-2)
18. Perform bag-valve-mask-to-stoma ventilation. (P-1, P-2)
19. Perform stoma suctioning. (P-1, P-2)
20. Perform insertion of a multi-lumen airway. (P-1, P-2)
21. Perform extubation of a multi-lumen airway. (P-1, P-2)
Section 2: Page 60
Presentation
Declarative:
I. Introduction
A. Need for oxygenation
1. Primary Objective:
a) Insure optimal Ventilation
(1) Delivery of Oxygen
(2) Elimination of CO2
b) Brain Death within 6 to 10 minutes
B. Major prehospital causes of death
1. Preventable with:
a) Early Detection
b) Early Intervention
c) Lay-Person BLS Education
C. Most neglected of prehospital skills
1. Basics taken for granted
a) Poor Technique i.e.,:
(1) BVM Seal
(2) Improper Positioning
(3) Failure to reassess
II. Anatomy of Upper Airway
A. Function of the upper airway
1. Warm
2. Filter
3. Humidify
B. Separated into
1. Nasopharynx
2. Oropharynx
C. Nasopharynx
1. Formed by the union of facial bones
2. Orientation of Nasal floor is towards the ear not the eye
3. Separated by Septum
4. Lined with:
a) Mucous Membranes
b) Cilia
5. Has Turbinates
a) Parallel to nasal floor
b) Provide increased surface area for air:
(1) Filtration
(2) Humidifying
(3) Warming
Section 2: Page 61
6. Contain Sinuses
a) Cavities that appear to further trap bacteria and act as tributaries for fluid to
and from eustachian Tubes and Tear Ducts
(1) Commonly become infected
(2) Fracture of certain sinus bones may cause cerebrospinal Fluid (CSF)
leak
7. Tissues extremely delicate and vascular
a) Improper or overly aggressive placement of tubes or airways will cause
significant bleeding which may not be controlled by direct pressure.
8. Oropharynx
a) Teeth
(1) 32 Adult
(2) Requires significant force to dislodge
(3) May fracture or avulse causing obstruction
b) Tongue
(1) Large muscle attached at the Mandible and Hyoid Bones
(2) Most common Airway Obstruction
c) Palate
(1) Roof of mouth separates oro/naso pharynx
(a) Anterior is Hard Palate
(b) Posterior (beyond the teeth) is Soft Palate
d) Adenoids
(1) Lymph tissue located in the mouth and nose that filters bacteria.
(2) Frequently infect and swell
9. Hypopharynx
a) Posterior Tongue
b) Epiglottis
(1) Vallecula - "Pocket" formed by the base of the tongue and epiglottis.
10. Larynx
a) Attached to Hyoid Bone
(1) "Horseshoe" shaped bone between the chin and Mandibular Angle
(2) Supports Trachea
b) Made of Cartilage
(1) Thyroid Cartilage
(a) First Tracheal Cartilage
(i) "Shield Shaped"
(a) Cartilage Anterior
(b) Smooth Muscle Posterior
(ii) Laryngeal Prominence
(a) "Adam's Apple" anterior prominence of Thyroid Cartilage
(b) Glottic opening directly behind
Section 2: Page 62
(2) Glottic Opening

(a) Patency heavily dependent on muscle tone
(b) Contain Vocal Bands
(i) White bands of cartilage produce voice
(ii) Arytenoid Cartilage
(a) "Pyramid Like" Posterior attachment of Vocal Bands.
Important landmark for Endotracheal Intubation
(iii) Pyriform Fossae: "Hollow Pockets" along the lateral borders of
the Larynx
(3) Cricoid Ring
(a) First Tracheal Ring
(b) Completely Cartilaginous
(c) Compression of cricoid ring occludes Esophagus (Sellick
Maneuver)
(4) Cricothyroid Membrane
(a) Fibrous Membrane between Cricoid and Thyroid Cartilage.
(b) Site for Surgical and Alternative Airway placement
c) Associated Structures
(1) Thyroid Gland
(a) Located below Cricoid Cartilage.
(b) Lies Across Trachea
(2) Carotid Arteries
(a) Branches cross and lie closely alongside Trachea.
(3) Jugular Veins
(a) Branch across and lie close to Trachea
III. Anatomy of Lower Airway
A. Function of the lower airway
1. Exchange of O2 and CO2
B. Location of the lower airway
1. From Fourth Cervical Vertebrae to Xyphoid Process
2. From Glottic Opening to Pulmonary Capillary Membrane
C. Structures of the lower airway
1. Trachea
a) Trachea Bifurcates at Carina into:
(1) Right and left main stem bronchi
(2) Right main stem has lesser Angle
(3) Foreign bodies, ET Tubes commonly displace here
(4) Lined with
(a) Mucous Cells
(b) Beta 2 Cells
(i) Dilate Bronchioles
Section 2: Page 63
b) Main stem Bronchi enter Lungs at Hilum

(1) Branch into narrowing:
(a) Secondary and Tertiary Bronchi which branch into:
(i) Bronchioles
(a) Branch into Alveolar Ducts which end at Alveolar Sacs
c) Alveoli
(1) "Balloon like clusters"
(2) Site of Gas Exchange
(3) Lined with Surfactant
(a) Decreases Surface Tension of Alveoli which facilitates ease of
expansion
(b) Alveoli become thinner as they expand which makes diffusion of
O2/CO2 Easier
(c) If Surfactant is decreased or Alveoli are not inflated, Alveoli
collapse (Atelectasis)
2. Lungs
a) Right lung
(1) 3 Lobes
b) Left lung
(1) 2 Lobes
c) Lobes made of Parenchymal Tissue
d) Membranous outer lining called Pleura
e) Lung capacity
(1) Total Lung Volume
(a) Adult male, 6 liters
(2) Not all inspired air enters Alveoli
(3) Minor diffusion of O2 takes place in Alveolar ducts and Terminal
Bronchioles
f) Tidal volume
(1) Volume of gas inhaled or exhaled during a single respiratory cycle
(a) 5-7 cc/kg (500 cc normally)
g) Dead space air
(1) Air remaining in air passageways, unavailable for gas exchange
(Approximately 150 cc)
(a) Anatomic Dead Space
(i) Trachea
(ii) Bronchi
(b) Physiologic Dead Space
(i) Dead space formed by factors like disease or obstruction
(a) COPD
(b) Atelectasis
Section 2: Page 64
h) Minute volume
(1) Amount of gas moved in and out of the respiratory tract per minute
(2) Determined by:
(a) Tidal Vol.- Dead Space Volume x Respiratory Rate
i) Functional Reserve Capacity
(1) After Optimal inspiration, the optimum amount of air that can be forced
from the lungs in a single forced exhalation
j) Residual Volume (DEFINE)
3. Alveolar air
a) Air reaching the alveoli for gas exchange (Alveolar Volume)
b) Approximately 350 cc
4. Inspiratory reserve (DEFINE)
5. Expiratory reserve (DEFINE)
D. Differences in Pediatric Airway
1. Pharynx
a) Disproportionately large tongue
b) Large floppy epiglottis
c) Absent or very delicate dentition
2. Trachea
a) Airway is smaller
b) Trachea lies more superior
c) Trachea is "Funnel Shaped" due to narrow, undeveloped Cricoid Cartilage.
d) Narrowest Point is at Cricoid Ring before 10 years of age
e) Small change in Airway Size results in Major increase in airway Resistance
3. Chest Wall
a) Ribs and Cartilage are softer
(1) Cannot optimally contribute to lung expansion
(2) Infants and children tend to depend more heavily on the diaphragm for
breathing.
IV. Mechanics of Respiration
A. Respiration
1. Definition:
a) Exchange of gases between a living organism and its environment
b) Primary Control From the Medulla and Pons
2. Types
a) External Respiration: Exchange of gasses between the Lungs and the
Blood Cells
b) Internal Respiration: Exchange of gases between the Blood Cells and
Tissues
c) Pulmonary Ventilation: Movement of air into and out of the lungs
Section 2: Page 65
3. Phases
a) Inspiratory/ Expiratory
(1) Inspiration
(a) Stimulus to breath from Respiratory Center
(b) Impulse Transmitted to Diaphragm via Phrenic Nerve
(i) Diaphragm: "Muscle of Respiration". Separates Thoracic from
Abdominal Cavity
(c) Diaphragm contracts "flattens"
(i) Causes Intrapulmonary Pressure to fall slightly below
Atmospheric Pressure
(d) Intercostal Muscles Contract
(e) Ribs elevate and expand
(f) Air is drawn into lungs like a vacuum
(g) Alveoli Inflate
(h) O2/CO2 Diffuse across membrane
b) Expiration
(1) Stretch Receptors in Lungs signal Respiratory Center via Vagus Nerve
to inhibit inspiration (Hering-Breuer Reflex)
(2) Natural elasticity (recoil) of the lungs passively expires air
4. Regulation of Respiration
a) Influenced by
(1) Chemical Stimuli
(a) Receptors for O2/CO2 Balance
(i) Cerebrospinal Fluid pH
(ii) Carotid Bodies (Sinus)
(iii) Aortic Arch
(b) Hypoxic Drive
(i) Respiratory Stimulus dependent on O2 rather than CO2
concentration in the blood. Normally, it's the other way around.
(2) CNS Regulation and Nerve Receptors
(a) Medulla
(i) Primary Involuntary Respiratory Center
(a) Connected to Respiratory muscles by Vagus Nerve
(b) Pons
(i) Apneustic Center
(a) Secondary Control Center if Medulla fails to initiate
Respiration
(ii) Pneumotaxic Center
(a) Controls Expiration
(3) Muscle Movement
(a) Connected to Respiratory Center by Vagus Nerve
Section 2: Page 66
V. The Measurement of Gases

A. Total pressure
1. The combined pressure of all Atmospheric gasses
a) 100% or 760 TORR at Sea Level
B. Partial pressure
1. The pressure exerted by a specific atmospheric gas
C. Concentration of gases in the atmosphere
1. Nitrogen 78.62%
2. Oxygen 20.84%
3. CO2 0.04%
4. Water 0.50%
D. Water vapor pressure
E. Alveolar Gas concentration
1. Nitrogen 74.9%
2. Oxygen 13.7%
3. CO2 5.2%
4. Water 6.2%
VI. Exchange and Transport of Gases in the Body
A. Diffusion
1. Diffusion of gases
a) O2/CO2 dissolve in Water and pass through Alveolar Membrane by
Diffusion
(1) Diffusion: Passage of Solution from area of Higher concentration to
Lower concentration
B. Oxygen Content of Blood
1. Dissolved O2 Crosses Pulmonary Capillary membrane and binds to Hemoglobin
(Hgb) of red blood cell
2. Oxygen is carried on Hemoglobin molecule as well as dissolved in Plasma
3. Approximately 97% of total O2 is bound to Hemoglobin
4. O2 Saturation:
a) Compares Available O2 (the O2 dissolved in Plasma) to O2 carrying
Capacity of blood
C. Carbon Dioxide Content of the Blood
1. CO2 is a byproduct of cellular work (Cellular Respiration)
2. CO2 is transported in blood as Bicarbonate ion
a) About 33% is bound to Hemoglobin
3. As O2 Crosses into blood, CO2 diffuses into Alveoli
D. Inadequate Ventilation
1. Occurs when body cannot compensate for increased O2 demand or maintain
O2/CO2 balance
2. Many Causes
a) Infection
b) Trauma
Section 2: Page 67
c) Brain stem Insult

d) Noxious or Hypoxic Atmosphere
e) Renal Failure
3. Multiple Symptoms
a) Altered Response
b) Respiratory Rate Changes (Up or Down)
c) Respiratory Pattern Changes
(1) Cheyne-Stokes
(a) Gradually Increasing Rate and Tidal Volume followed by gradual
decrease.
(b) Associated with Brain Stem Insult
(2) Kussmall's
(a) Deep, gasping respirations
(b) Common in Diabetic Coma
(c) Increased Intracranial Pressure
(3) Central Neurogenic Hyperventilation
(a) Deep Rapid Respirations similar to Kussmall's
(b) Increased Intracranial Pressure
4. Common Endpoints
a) Tissue / Brain ischemia, injury, and death
E. Control of Respiration by Other Factors
1. Body temperature
a) Respirations increase with Fever
(1) Response to Metabolic changes due to infection
b) Drug and medications
(1) May Increase or Decrease Respirations depending on their physiologic
action
c) Pain
(1) Increases Respirations
d) Emotion
e) Hypoxia
f) Acidosis
(1) Respirations Increase as compensatory response to increased CO2
production
g) Sleep
(1) Respirations decrease
2. Modified Forms of Respiration
a) Protective Reflexes
(1) Cough
(a) Forceful, Spastic Exhalation aids in clearing bronchi and
bronchioles
Section 2: Page 68
(2) Sneeze
(a) Clears Nasopharynx
(3) Gag Reflex
(a) Spastic Pharyngeal and Esophageal reflex from stimulus of the
posterior pharynx
b) Sighing
(1) Involuntary deep breath that increases opening of Alveoli
(2) Normally sigh about once per minute
c) Hiccough
(1) Spasm of Diaphragm from Vagal Stimulus
VII. Pathophysiology
A. Obstruction
1. Tongue
a) Most common Airway Obstruction
b) Snoring respirations
c) Corrected with positioning
2. Foreign body
a) May cause partial or full obstruction
b) Symptoms include
(1) Choking
(2) Gagging
(3) Stridor
(4) Dyspnea
(5) Aphonia (Unable to Speak)
(6) Dysphonia (Difficulty Speaking)
3. Laryngeal spasm
a) Spasmotic closure of Vocal Cords
b) Glottic opening becomes extremely narrow or totally obstructed
c) Most frequently caused by
(1) Epiglottitis (A Bacterial infection of the epiglottis)
(2) Anaphylaxis (Severe Allergic Reaction)
(3) Trauma from over aggressive technique during Intubation
(4) Immediately upon Extubation especially when patient is semiconscious
d) Relieved by
(1) Aggressive Ventilation
(2) Forceful upward pull of the Jaw
(3) Muscle Relaxants, IV
4. Fractured larynx
a) Airway Patency dependent upon muscle tone
b) Fractured Laryngeal Tissue
(1) Increases Airway Resistance by decreasing Airway size through
(a) Decreasing Muscle Tone
Section 2: Page 69
(b) Laryngeal Edema

(c) Ventilatory Effort
5. Aspiration
a) Significantly increases Mortality
(1) Obstructs Airway
(2) Destroys Delicate Bronchiolar Tissue
(3) Introduces Pathogens
(4) Decrease ability to Ventilate
VIII.Airway Evaluation
A. Essential Parameters
1. Rate
a) Normal Resting Rate in Adults: 12-24
2. Regularity
a) Steady Pattern
(1) Irregular respiratory patterns are significant until proven otherwise
3. Effort
a) Breathing at rest should be effortless
b) Effort changes may be subtle in Rate or Regularity
c) Patients often compensate by preferential positioning
(1) Upright Sniffing
(2) Semi-Fowler’s
(3) Frequently avoid Supine
B. Recognition of airway problems
1. Difficulty in Rate , Regularity, or Effort is defined: Dyspnea
2. Dyspnea may be result of or result in Hypoxia
a) Hypoxia: Lack of Oxygen
b) Hypoxemia: Lack of Oxygen to Tissues
c) Anoxia: Total absence of Oxygen
3. Recognition and treatment of Dyspnea is crucial to patient survival
a) Expert Assessment and Management is essential
(1) The brain can survive only a few minutes of anoxia
(2) All therapies fail if Airway is inadequate
4. Visual Signs and Symptoms
a) Position: i.e.,: "tripod", upright with dangling feet
b) Anxiety
(1) Range from mild to extreme
c) Rise and fall of chest
(1) Normal, Deep, Shallow, Absent
d) Color of skin
e) Flaring of nares
f) Gasping
g) Pursed lips
Section 2: Page 70
h) Retractions: "Pulling in of skin" between thoracic skeleton during inspiration

(1) Intercostal
(2) Suprasternal notch
(3) Supraclavicular fossa
(4) Subcostal
5. Auscultation Techniques
a) Air movement at mouth and nose
b) Bilateral lung fields Equal
6. Palpation Techniques
b) Chest wall
(1) Paradoxical Motion
(2) Retractions
7. Bag Valve Mask
a) Resistance or changing compliance with Bag-Valve-Mask ventilations
8. History
a) Evolution
(1) Sudden, gradual over "x" time
(2) Known cause or "Trigger"
b) Duration
(1) Constant, Recurrent
c) Ease
(1) What makes it better?
d) Exacerbate
(1) What makes it worse?
e) Associate
(1) Other Symptoms (Productive cough, Chest Pain, Fever, etc.)
f) Interventions
(1) Evaluations/Admissions to Hospital
(2) Medications (include compliance)
(3) Ever Intubated
C. Quantitative measurement of patient oxygenation and end-tidal CO2
1. Oxygen Therapy
a) Oxygen therapy is used to treat hypoxemia.
b) Oxygen saturation (SaO2) readings can help determine which oxygen
adjunct should be placed on the patient and the liter flow to be
administered.
(1) A SaO2 in the range of 95% to 99% is ideal and no supplemental
oxygen is needed unless the patient’s chief complaint or injury
mechanism warrants.
(2) An SaO2 of 91% to 94% represents mild hypoxemia and indicates that
the airway should be checked and oxygen therapy started a 4 to 6L via
nasal cannula.
Section 2: Page 71
(3) An SaO2 of 85% to 90% represents moderate hypoxemia. The airway

must be checked and aggressive oxygen therapy started at 15L/min via
nonrebreather mask.
(4) An SaO2 reading of less than 85% indicates severe hypoxemia. In
these cases, the EMT-I should prepare to intubate or assist ventilations
with a bag-valve-mask and 100% oxygen.
2. Pulse oximetry
a) Pulse oximetry is a simple, noninvasive procedure used to determine the
effectiveness of patient oxygenation.
(1) Oxygen bound Vs unbound Hemoglobin in the red blood cell absorbs
infrared light at different rates.
(2) Pulse Oximeters emit an infrared beam that passes through the
capillary bed. The absorption of Infrared light by Hemoglobin is
measured in % as Infrared light passes from one end of the probe to
the other
(3) Normal Pulse Ox values are between 94 to 100% on room air. Values
below 93 to 94% are abnormal and may suggest acute or chronic
hypoxia, i.e., COPD
b) It allows for continuous monitoring, detecting trends in patient’s oxygenation
status within 6 seconds.
c) Pulse oximetry can:
(1) Reaffirm perceived hypoxia
(2) Reveal hidden hypoxia
(3) Assist in determining what oxygenation adjunct should be applied and
liter flow to be administered
(4) Aid in monitoring clinical improvement of deterioration in acutely
dyspneic patients
(5) Identify when to intubate
(6) Identify changes during intubation or other airway manipulations
d) Pulse oximetry should be taken on all patients and recorded as part of their
vital signs, because normal evaluation of oxygenation is notoriously
unreliable.
e) Saturation readings should be taken before and after oxygen is
administered to any patient.
f) It is important to keep a patient’s oxygen saturation in a normal range,
because declines in saturation result in a reduction in oxygen content.
(1) With 90% saturation, PO2 drops to 60 mm Hg.
g) In addition to oxygen saturation (SaO2), a visual pulse rate is displayed (and
is audible). However, this unit should not be used in place of the cardiac
monitor when the situation dictates the use of one.
h) Procedure
(1) Prior to use, the EMT-I should test the unit on themselves to confirm
that it is in good operating condition.
Section 2: Page 72
(2) To do this, the EMT-I should turn on the unit and follow all operating
recommendations set forth by the manufacturer.
(3) After it is found that the unit is in good operating condition, the EMT-I
should place the finger clip on the patient’s index finger with the outline
of the finger facing up.
(4) All dirt and nail polish or any obstructive covering should be removed to
prevent the unit from giving a false reading.
(5) When these steps are completed, the unit will show a red number on
the left, which is the SaO2, and a red light on the right showing the
patient’s heart rate.
(6) The EMT-I should consider pulse oximetry as only another tool to assist
in patient monitoring.
(7) A variety of circumstances produce false readings, including:
(a) Patients who smoked prior to pulse Ox.
(b) COPD patients
(c) Carbon monoxide
(d) Excessive ambient light on the sensor probe
(e) Patient movement
(f) Hypotension (low flow states)
(g) Hypothermia
(h) Use of vasoconstrictive drugs by the patient
(i) Nail polish
(j) Jaundice
3. End Tidal Carbon Dioxide (CO2) Detectors
a) End-tidal carbon dioxide detectors are an effective way of verifying correct
airway device placement.
b) End-tidal air, which closely correlates with the percentages of gases found
in mixed venous blood, contains approximately 6% carbon dioxide.
c) A lack of carbon dioxide in the end-tidal air strongly suggests the tube has
been misplaced into the esophagus.
d) The devices detect the amount of CO2 in the patient’s expired air.
(1) CO2 is a by-product of cellular metabolism.
(2) CO2 is carried to lungs and is expired
(3) Patient's expired air passes through a measurement device.
e) There are two types of end-tidal CO2 detectors currently available.
(1) Disposable colormetric device (least expensive)
(a) Designed for single patient use
(b) Contains a non-toxic chemical indicator that reacts instantly to
expired tracheal carbon dioxide by changing color.
(c) The reversibility of this color change allows the EMT-I to determine
esophageal or tracheal ventilation (after the required 6 breaths).
(d) The presence of a yellow color on expiration indicates correct
ventilation into the trachea.
Section 2: Page 73
(e) The presence of a purple color indicates improper ventilation into

the esophagus.
(f) The color varies from expiration to inspiration as carbon dioxide
leaves rise and fall in a phasic manner
(2) Electric monitor (most expensive)
(a) Portable or hand-held device that uses an infrared analyzer to
measure the percentage of carbon dioxide gas at each phase of
respiration.
(i) Information is displayed on a digital readout or printout.
(ii) Can provide verification of correct placement of airway device.
(iii) Can provide continuous carbon dioxide monitoring with a
cannula during transport.
(b) Newer models combine pulse oximetry, pulse rate, and respiratory
rate in one unit.
f) These devices are attached in-line between the airway device and the
ventilatory device after tube placement.
g) Mainly used for confirming Tube placement but other applications such as
predicting Cardiac Arrest Outcome as well as detecting improvement or
deterioration during prehospital care has been suggested
h) Because of the potential for inaccurate readings in some conditions, the
end-tidal carbon dioxide detector should be used as just one of the many
tools the EMT-I has available to assess correct placement of airway devices
and ventilatory status.
(1) End-tidal carbon dioxide detectors weakness/limitations
(a) Carbon dioxide sometimes inadvertently enters the stomach - Six
breaths can quickly wash out any retained carbon dioxide.
(b) Adequate circulation and pulmonary perfusion are required to
obtain diffusion of carbon dioxide from the pulmonary capillary bed.
(i) Initial end-tidal carbon dioxide levels may be considerably lower
during cardiac arrest.
(c) With adequate CPR, these levels should rise enough to allow the
end-tidal carbon dioxide detector to verify proper placement of the
airway device.
(d) Does not conclusively confirm proper Tube placement.
(i) Confirms tube is in an area that contains CO2 such as the
hypopharynx.
(ii) Cannot detect main stem placement or displacement
IX. Universal Precautions and Body Substance Isolation (BSI) in airway management
X. Airway Management
A. Noninvasive Maneuvers
1. Opening the mouth
a) Head-tilt/chin-lift maneuver
(1) Most basic airway maneuver
(a) Tilt head back
Section 2: Page 74
(b) Lift chin forward

(c) Open mouth
(2) Indications
(a) Unresponsive patients who:
(i) Do not have mechanism for C-Spine injury
(ii) Unable to protect their own Airway
(3) Contraindications
(a) Awake patients
(b) Possible C-Spine Injury
(4) Advantages
(a) No equipment required
(b) Simple
(c) Safe
(d) Non-invasive
(5) Disadvantages
(a) Head tilt hazardous to C-Spine Injury patients
(b) Does not protect from Aspirate
b) Jaw-thrust maneuver lift
(1) Head is maintained Neutral
(a) Jaw is displaced forward
(i) Lift by grasping under chin and behind teeth
(b) Mouth opened
(2) Indications:
(a) Patients who:
(i) Unresponsive
(iii) May have C-Spine Injury
(a) Responsive Patients
(b) Resistance to opening mouth
(4) Advantages
(a) May be used in C-Spine injury
(b) May be performed with Cervical Collar in place
(c) Does not require special equipment
(5) Disadvantages
(a) Cannot maintain if pt becomes responsive or combative
(b) Difficult to maintain for extended period
(c) Very difficult to use in conjunction with Bag Valve Mask Ventilation
(d) Thumb must remain in patient's mouth in order to maintain
displacement
(e) Separate rescuer required to perform Bag Valve Mask Ventilation
(f) Does not protect against aspiration
Section 2: Page 75
c) Modified Jaw-Thrust Maneuver

(1) Head maintained Neutral
(a) Jaw is displaced forward at Mandibular Angle
(2) Indications
(a) Unresponsive
(b) Cervical Spine Injury
(c) Unable to protect own airway
(d) Resistance to opening mouth
(a) Awake Patients
(4) Advantages
(a) Non-invasive
(b) Requires no special equipment
(c) May be used with Cervical Collar in place
(5) Disadvantages
(a) Difficult to maintain
(b) Requires Second Rescuer for Bag Valve Mask Ventilation
(c) Does not protect against aspirate
(d) Cricoid pressure
B. Suctioning
1. Types of suctioning equipment
a) Hand-powered suction devices
(1) Advantages
(a) Lightweight
(b) Portable
(c) Mechanically Simple
(d) Inexpensive
(2) Disadvantages
(a) Limited Volume
(b) Manually Powered
(c) Fluid contact components not disposable
b) Oxygen-powered portable suction devices
c) Battery-operated portable suction devices
(1) Advantages
(a) Lightweight
(b) Portable
(c) Excellent Suction power
(d) May "Field Strip" Troubleshoot most components
(2) Disadvantages
(a) More complicated mechanics
(b) May lose battery integrity over time
(c) Some fluid contact components not disposable
Section 2: Page 76
d) Mounted vacuum-powered suction devices

(1) Advantages
(a) Extremely strong vacuum
(b) Adjustable Vacuum power
(c) Fluid contact components disposable
(2) Disadvantages
(a) Non-portable
(b) Cannot "Field Service" or substitute power source
2. Types of suctioning catheters
a) Hard or rigid catheters
(1) AKA: "Yankauer" or "Tonsil Tip"
(2) Suction large volumes of fluid rapidly
(3) Standard Size
b) Soft catheters
(1) Can be placed in Oropharynx, Nasopharynx, or down Endotracheal
Tube
(2) Various Sizes
(3) Smaller inside diameter than hard tip catheters
3. Suctioning the upper airway
a) Prevention of aspirate critical
(1) Mortality increases significantly if aspiration occurs
(2) Pre-oxygenate if possible
(3) Hyperoxygenate after
b) Description:
(1) Soft Tip Catheters must be pre-lubricated
(2) Place Catheter
(3) Suction during extraction of catheter
(4) Do not exceed 15 seconds
(5) Hyperoxygenate
4. Suctioning trachea when using Multi-Lumen Airways
a) Pre-oxygenation Essential
b) Description:
(1) Pre-lubricate Soft Tip Catheter
(2) Hyperoxygenate
(a) May be necessary to inject 3 to 5 cc's of Sterile Water down airway
tube to loosen secretions
(3) Gently insert catheter until resistance is felt
(4) Suction upon extraction of catheter
(6) Hyperoxygenate
Section 2: Page 77
C. Gastric Distention
1. Air becomes trapped in the stomach
a) Very common when ventilating non-intubated patients
(1) Stomach diameter increases
(2) Pushes against diaphragm
(3) Interferes with lung expansion
(a) Abdomen becomes increasingly distended
(b) Resistance to Bag Valve Mask Ventilation
2. Management
a) May be reduced by increasing Bag Valve Mask Ventilation time
(1) Adults: 1.5-2 seconds
(2) Peds: 1-1.5 seconds
b) Prepare for large volume suction
c) Position Patient Left Lateral
d) Slowly apply pressure to epigastric region
e) Suction as necessary
D. Basic Airway Management
1. Nasal airway
a) Soft rubber with beveled tip
(1) Distal tip rests in hypopharynx
(2) For adults, length measured from nostril to earlobe
(3) Diameter roughly equal to patient's little finger
b) Indications
(1) Unconscious patients
(2) Altered Response patients with suppressed gag reflex
c) Contraindications
(1) Patient intolerance
(2) Caution in presence of facial fracture or Skull fracture
d) Advantages
(1) Can be suctioned through
(2) Provides patent airway
(3) Can be tolerated by awake patients
(4) Can be safely placed "blindly"
(5) Does not require mouth to be open
e) Disadvantages
(1) Poor technique may result in severe bleeding
(a) Resulting epistaxis may be extremely difficult to control
(2) Does not protect from aspirate
f) Placement
(1) Determine correct length and diameter
(2) Lubricate Nasal Airway
Section 2: Page 78
(3) With bevel towards Septum, insert gently along the nasal floor parallel
to the mouth
(4) Do Not Force
(a) Measurement from corner of the mouth to the Jaw Angle rather
than tip of the ear.
(i) Too long airway causes Airway Obstruction
2. Oral airway
a) Hard plastic airway designed to prevent the tongue from obstructing glottis
(1) Indications
(a) Unconscious Patients
(b) Absent Gag Reflex
(a) Conscious Patients
(3) Advantages
(a) Non-invasive
(b) Easily placed
(c) Prevents blockage of glottis by tongue
(4) Disadvantages
(a) Does not prevent aspiration
(b) Unexpected gag may produce vomiting
(5) Complications
(a) Unexpected gag may produce vomiting
(b) Pharyngeal or Dental Trauma with poor technique
(6) Placement
(a) Open mouth
(b) Remove visible obstructions
(c) Place with distal tip toward glottis using tongue depressor as
adjunct
(d) Alternate: Place airway with distal tip toward palate. Rotate into
place
b) Special considerations
(1) Pediatrics
(a) Place with Tongue Depressor
(b) Place with tip toward cheek not palate
E. Methods to perform ventilation
1. Mouth-to-mouth
a) Most basic form of ventilation
(1) Indications
(a) Apnea from any mechanism when other ventilation devices are not
available
(a) Awake patients
(b) Communicable disease risk limitations
Section 2: Page 79
(3) Advantages
(a) No special equipment required
(b) Delivers excellent Tidal Volume
(c) Delivers adequate Oxygen
(4) Disadvantages
(a) Psychological barriers from:
(i) Sanitary issues
(ii) Communicable disease issues
(a) Direct Blood /Body Fluid contact
(b) Unknown communicable disease risks at time of event
(iii) May be difficult to seal mouth
(5) Complications
(a) Hyperinflation of patient's lungs
(b) Gastric distension
(c) Blood/Body fluid contact manifestations
(d) Hyperventilation of rescuer
2. Mouth-to-nose
a) Ventilating through nose rather than mouth
(1) Indications
(a) Apnea from any mechanism
(a) Awake Patients
(3) Advantages
(b) May decrease Blood/Body fluid contact
(4) Disadvantages
(a) Direct Blood/Body Fluid contact
(b) Psychological limitations of rescuer
(5) Complications
(b) Gastric Distension
(c) Blood/Body Fluid Manifestations
3. Mouth-to-mask
a) Adjunct to Mouth to Mouth Ventilation
(1) Indications
(a) Awake Patients
(3) Advantages
(a) Physical barrier between rescuer and patient Blood/Body Fluids
(b) One-way valve to prevent Blood/Body Fluid splash to rescuer
Section 2: Page 80
(c) May be easier to obtain face seal

(4) Disadvantages
(a) Useful only if readily available
(5) Complications
(b) Hyperventilation of rescuer
(6) Method for use
(a) Position head by appropriate method
(b) Position and seal mask over mouth and nose
(c) Ventilate as appropriate
4. One person bag-valve-mask
a) Fixed Volume self inflating bag can deliver adequate Tidal Volumes and O2
enrichment
(1) Indications
(b) Unsatisfactory Respiratory effort
(a) Awake, intolerant patients
(3) Advantages
(a) Excellent Blood /Body Fluid barrier
(b) Good Tidal Volumes
(c) Oxygen Enrichment
(d) Rescuer can ventilate for extended periods without fatigue
(4) Disadvantages
(a) Difficult Skill to master
(b) Mask seal may be difficult to obtain and maintain
(c) Tidal Volume delivered is dependent on mask seal integrity
(5) Complications
(a) Inadequate Tidal Volume Delivery with:
(i) Poor technique
(ii) Poor mask seal
(6) Method for use
(a) Position appropriately
(b) Choose proper mask size
(i) Seats from bridge of nose to chin
(c) Position, Spread/Mold/Seal mask
(d) Hold mask in place
(e) Squeeze Bag completely over 1.5 to 2 seconds for Adults
(f) Avoid overinflation
(g) Re-inflate completely over several seconds
Section 2: Page 81
(7) Special considerations

(a) Medical
(i) Observe for:
(a) Gastric Distension
(b) Changes in compliance of bag with ventilation
(c) Improvement or deterioration of ventilation status ( i.e.,
Color change, Responsiveness, Air Leak around Mask
(b) Trauma
(i) Very difficult to perform with Cervical Spine Immobilization in
place
(c) Pediatrics
(i) Flat Nasal Bridge makes achieving mask seal more difficult
(ii) Compressing mask against face to improve Mask seal results
in obstruction
(iii) Mask seal best achieved with Jaw displacement
5. Two person bag-value-mask
a) Alternate Bag Valve Mask Ventilation Method
b) Most efficient method
(1) Indications
(a) Bag Valve Mask Ventilation on any patient
(i) Especially useful for Cervical Spine immobilized patients
(ii) Difficulty obtaining or maintaining adequate mask seal
(3) Advantages
(a) Superior Mask Seal
(b) Superior Volume Delivery
(4) Disadvantages
(a) Requires extra personnel
(5) Complications
(a) Hyperinflation of patient's Lungs
(6) Method for use
(a) First Rescuer maintains mask seal by appropriate method
(b) Second Rescuer Squeezes Bag
(7) Special Considerations
(a) Observe Chest Movement
(b) Avoid overinflation
(c) Monitor Lung Compliance with Ventilations
Section 2: Page 82
6. Flow-restricted oxygen powered ventilation devices

a) Demand Valve
(1) Trigger when patient inhales. Delivers O2 as long as inspiratory strength
is enough to "hold the gate open"
7. Automatic transport ventilators
a) Volume/Rate controlled
b) Indications
(1) Extended ventilation of Intubated patients
(1) Awake patients
(2) Obstructed Airway
(3) Increased Airway Resistance
(a) Pneumothorax
(b) Asthma
(c) Pulmonary Edema
(4) Advantages
(a) Lightweight
(b) Portable
(c) Durable
(d) Mechanically Simple
(e) Adjustable Tidal Volume
(f) Adjustable Rate
(g) Adapts to portable O2 Tank
(5) Disadvantages
(a) Cannot detect tube displacement
(b) Does not detect increasing airway resistance
(c) Difficult to secure
(d) Dependent on O2 Tank Pressure
F. Oxygen delivery
1. Enriched O2 Atmosphere increases Oxygen to cells
a) Increasing available O2 increases Patient's ability to compensate
2. O2 delivery method must be reassessed to determine adequacy and efficiency
3. Oxygen delivery equipment
a) Nasal cannula
(1) Nasally placed O2 Catheter for Oxygen enrichment
(a) Optimal Delivery: 40% at 6 L/min
(2) Indications
(a) Low to Moderate O2 Enrichment
(b) Long term O2 maintenance therapy
(a) Poor Respiratory Effort
(b) Severe Hypoxia
Section 2: Page 83
(c) Apnea
(d) Mouth Breathing
(4) Advantages
(a) Well Tolerated
(5) Disadvantages
(a) Does not deliver High Volume/ High Concentration
b) Simple face mask
(1) Full Airway enclosure with open side ports
(a) Room Air is drawn through side ports on inspiration, diluting O2
concentration
(2) Indications
(a) Delivery of moderate to High O2 concentrations
(b) Range: 40-60% at 10 L/min
(3) Advantages
(a) Higher O2 concentrations
(4) Disadvantages
(a) Delivery of volumes beyond 10 L/min does not enhance O2
concentration
(a) Mask leak around face decreases O2 concentration
c) Partial Rebreather
(1) Mask vent ports covered by one-way disc
(a) Expired air escapes through vents
(b) Residual expired air mixed in mask and rebreathed
(c) Room Air not pulled into mask with inspiration
(2) Indications
(a) Higher O2 concentration
(a) Apnea
(b) Poor Respiratory Effort
(4) Advantages
(a) Inspired gas not mixed with room air
(i) Higher O2 concentrations attainable
(5) Disadvantages
concentration
d) Non-rebreather mask
(1) Mask side ports covered by one-way disc
(2) Reservoir Bag attached
(3) Range: 80-95+% at 15 L/min
(4) Indications
Section 2: Page 84
(a) Delivery of highest O2 concentration

(a) Apnea
(b) Poor respiratory effort
(6) Advantages
(a) Highest O2 concentration
(b) Delivers High volume/ High O2 enrichment
(c) Patient inhales enriched O2 from reservoir bag rather than residual
air
(7) Disadvantages
(8) Complications
(9) Method for use
(10)Special considerations
(a) Pediatrics
e) Venturi mask
(1) Mask with interchangeable adapters
(a) Adapters have port holes that pull in room air as O2 passes
(b) Patient receives a Highly specific concentration of O2
(c) Air is pulled into mask by Venturi Principle:
f) Small volume nebulizer
(1) Delivers Aerosolized medication
(2) O2 enters an Aerosol chamber containing 3-5 cc's of fluid
(3) Pressurized O2 Mists fluid
G. Advanced Airway Management - Multi-lumen airways
1. Pharyngo-tracheal lumen airway (PTL)
a) A two tube, two cuff system
(1) The first tube is a short, wide tube with a large cuff along its lower
portion
(a) When inflated, this cuff seals off the oropharynx and air is
introduced through the tube as its proximal end enters the pharynx
(2) A second, longer tube travels through the first, extending past its distal
end
(a) Because of its longer length, it can be passed into either the
trachea or the esophagus
(b) At the distal end of the longer tube is a cuff that, when inflated,
seals off whichever anatomic structure it is in
(c) When the longer tube is in the esophagus, the device acts like an
EOA and the patient is ventilated through the first tube
(d) When the longer tube is in the trachea, the device acts like an
endotracheal tube and the patient is ventilated through it
b) Designed to be passed blindly
c) Multiple ventilation ports provide means to ventilate regardless of whether
the long tube is placed in the Esophagus or the Trachea
Section 2: Page 85
d) Indications
(1) Pulseless, apneic patient (no spontaneous respirations)
(2) Patients that are apneic and can tolerate an oropharyngeal airway
(3) Alternative Airway control when conventional Intubation procedures are
not available or successful
e) Advantages
(1) Can ventilate with Tracheal or Esophageal Placement
(2) No face mask to seal
(3) No Special Equipment
(4) Does not require Sniffing Position
f) Disadvantages
(1) Cannot be used in Awake patients
(2) Adults only
(3) Unconscious Only
(4) Short tube (Pharyngeal) tube balloon cuff mitigates but does not
eliminate aspiration risk
(5) Can only be passed orally
(6) Extremely difficult to Intubate around
g) Method
(1) Head Neutral
(2) Pre-Intubation Precautions
(3) Insert at the midline using Jaw-Lift
(4) Ventilate through short tube (green) first
(a) Chest rise indicates long tube is in esophagus
(b) Inflate short tube balloon cuff and Ventilate
(c) No chest rise indicates long tube in Trachea
(d) Inflate long tube balloon cuff
(e) Ventilate through long tube
h) Complications
(1) Pharyngeal or Esophageal Trauma from poor technique
(2) Unrecognized displacement of long tube into esophagus
(3) Displacement of short (Pharyngeal) tube balloon cuff
2. Combitube
a) A double lumen tube with two balloon cuffs
b) Indications
(1) Alternative Airway control when conventional Intubation measures are
unsuccessful or unavailable
(1) Children too small for the tube
(2) Esophageal Trauma or disease
(3) Caustic ingestion
d) Advantages
(1) Rapid Insertion
Section 2: Page 86

e) Disadvantages
(1) Impossible to suction Trachea when tube is in Esophagus
(2) Adults Only
(4) Very difficult to Intubate around
f) Method
(1) Head Neutral
(2) Preintubation Precautions
(3) Insert with Jaw-Lift at midline
(4) Inflate Pharyngeal Cuff with 100 cc air
(5) Inflate Distal Cuff with 10-15 cc air
(6) Ventilate through longest tube First (Pharyngeal)
(a) Chest rise indicates esophageal placement of distal tip
(b) No chest rise indicates Tracheal placement. Switch ports and
ventilate
3. Field extubation
a) The only reason to field extubate is if the patient is unreasonably intolerant
of the tube
b) Ordinarily you do not extubate for these reasons:
(1) Awake patients are, in particular, at highest risk of laryngospasm
immediately following extubation.
(2) The possibility of airway occlusion due to emesis
(3) Difficulty of reintroducing the airway due to laryngospasm
H. Special patient considerations
1. Patients with a laryngectomy (stoma)
a) Laryngectomy Patients have a permanent or semi-permanent surgical
opening below the glottis, which acts as their primary airway. The opening
is called a Stoma
b) Airway is kept open by a short tube device that fits into the Stoma
(1) Part or entire tube assembly may be removed for normal cleaning
c) Since protective function of the upper airway is bypassed, laryngectomy
patients commonly produce moderately large amounts of mucous.
Coughing is also not as efficient or forceful
d) Most common Laryngectomy problems
(1) Mucous Plug
(a) Usually occurs while coughing
(b) Mucous builds up and cannot be forcibly expelled from bronchi or
Tube
(c) Treatment
(i) Suction Trachea
(a) Pre-oxygenate
Section 2: Page 87
(b) Inject 1 to 3 cc's Sterile Water into trachea to loosen

secretions. Patient will cough.
(c) Gently insert flexible suction catheter into trachea. Suction
on the way out. Encourage patient to cough
(d) Oxygenate
(e) Reassess
(f) Repeat as necessary
(2) Stenosis
(a) Stoma narrows and patient cannot replace their Tube
(b) Particularly dangerous for patients with a recent laryngectomy
(c) May require placement of smaller tube into the Stoma to prevent
complete occlusion
(d) If tube placement is not immediately successful, rapid transport is
necessary. Give 100% O2
e) Dental Appliances - Loose Dentures, Retainers, etc.,: Should be removed
when possible
2. Additional considerations
a) Pulse oximetry cannot give information about alveolar ventilation. For this
reason, the EMT-I should be careful not to accept adequate SaO2 values
while neglecting gross hypoventilation.
b) Patients with chronic obstructive pulmonary disease may have a normally
low SaO2, so adequate histories must be obtained.
XI. Medical/legal considerations
NOTES:
Section 2: Page 88
Lesson 2-5: Airway Management and Ventilation
FOR ILS/AIRWAY AND AIRWAY MANAGEMENT

TECHNICIAN TRAINING ONLY
This lesson contains instruction for ET Tube and Multi-lumen airway.
For instruction in, Multi-lumen airway only, see:

Section 2 - Lesson 2-4, for ILS Technicians Only
Lesson 2-5: Airway Management and Ventilation - for Airway Technicians Only
OBJECTIVES LEGEND
1=Knowledge
2=Application

assessment findings to formulate a field impression and implement the management plan
for the patient experiencing an airway or breathing emergency.
3. Explain the differences in the anatomy of the upper and lower airway between an adult
and a pediatric patient. (C-1)
6. Define partial pressures and list the concentration of gases, which comprise
11. Define:
• Hypoxia. (C-1)
Section 2: Page 90

• The tongue
• Laryngeal spasm
• Laryngeal edema
• Trauma
29. Describe the Sellick's (cricoid pressure) maneuver (C-1)
• Finger sweep
• Chest thrusts
• Removal with Magill Forceps
• Soft catheters
37. Identify techniques of tracheobronchial suctioning in the intubated patient. (C-1)
38. Identify special considerations of tracheobronchial suctioning in the intubated patient.
(C-1)
Section 2: Page 91
39. Describe indications for tracheobronchial suctioning in the intubated patient. (C-3)
• Mouth-to-mouth
• Mouth-to-nose
• Mouth-to-mask
48. Review the method of mouth-to-mouth ventilation. (C-1)
49. Review the steps of mouth-to-nose ventilation. (C-1)
50. Review the steps of mouth-to-mask method to perform ventilation. (C-1)
51. Review the ventilator mask. (C-1)
52. Review the steps to perform mouth-to-mask ventilation. (C-1)
53. Review complications of mouth-to-mask ventilation. (C-1)
54. Review methods to perform ventilation with the bag-valve-mask, including: (C-1)
• 1 person method
• 2 person method
55. Review the advantage of the 2 person method to perform ventilation with the bag-valve-
mask. (C-1)
56. Review the bag-valve-mask used to perform ventilation. (C-1)
57. Review the steps to perform ventilation with a bag-valve-mask, including: (C-1)
• 1 person method
• 2 person method
60. List the steps to perform ventilation with the flow-restricted oxygen-powered ventilation
device (C-1)
61. Describe complications of ventilation with the flow-restricted oxygen-powered ventilation
device. (C-1)
65. Explain safety considerations of oxygen storage and delivery. (C-1)
Section 2: Page 92
66. Identify types of oxygen cylinders. (C-1)

67. Identify types of pressure regulators, including: (C-1)
• High-pressure regulator
• Therapy regulator
68. List the steps for delivering oxygen from a cylinder and regulator. (C-1)
69. Identify an oxygen humidifier. (C-1)
• Nasal cannula
• Venturi mask
78. Identify special considerations in airway management and ventilation for the pediatric
patient. (C-1)
79. Identify special considerations in airway management and ventilation for patients with
facial injuries. (C-1)
80. Describe laryngoscopy for foreign body airway obstruction. (C-1)
81. Identify equipment used to retrieve foreign bodies from the upper airway. (C-1)
83. Differentiate endotracheal intubation from other methods of advanced airway
management. (C-3)
84. Describe endotracheal intubation. (C-1)
85. Identify indications for endotracheal intubation. (C-1)
86. Identify contraindications for endotracheal intubation. (C-1)
87. Describe general precautions for endotracheal intubation. (C-1)
88. Describe cricoid pressure. (C-1)
89. Describe complications of endotracheal intubation. (C-1)
90. Describe methods of endotracheal intubation in the trauma patient. (C-1)
91. Describe methods of endotracheal intubation in the pediatric patient. (C-1)
92. Discuss appropriate endotracheal intubation equipment for adults, infants and children.
(C-1)
93. Identify complications of improper endotracheal intubation procedure in adults, infants and
children. (C-1)
Section 2: Page 93
94. Determine when endotracheal intubation is appropriate for a newborn. (C-1)

95. Discuss appropriate endotracheal intubation techniques for a newborn. (C-1)
96. Assess patient improvement due to endotracheal intubation. (C-3)
97. Identify complications related to endotracheal intubation for a newborn. (C-1)
100.Discuss and understand the use of quantitative measurement of patient oxygenation
and end-tidal CO2. (C-1)
101.List the equipment used to perform insertion of the multi-lumen airway. (C-1)
102.List the steps to insert a multi-lumen airway. (C-1)
103.Describe complications of insertion of a multi-lumen airway. (C-1)
104.Describe extubation. (C-1)
105.Identify the indications for extubation. (C-1)
106.Describe the complications of extubation. (C-1)
107.Explain the rationale for selection of each of the following basic approaches to airway
management: (A-1)
108.Explain the rationale for selection of each of the following advanced approaches to
airway management: (A-1)
• Multi-lumen airway
• Endotracheal intubation
109.Explain quantitative measurement of patient oxygenation and end-tidal CO2. (A-1)
110.Explain the rationale for selection of each of the following approaches to ventilation: (A-
1)
• Flow-restricted, oxygen-powered ventilation device
1. Perform body substance isolation (BSI) procedures during basic airway management,
advanced airway management, and ventilation. (P-1, P-2)
Section 2: Page 94
4. Perform the Sellick's (cricoid pressure) maneuver. (P-1, P-2)
• Finger sweep
• Chest thrusts
7. Perform tracheobronchial suctioning in the intubated patient by selecting a suction
device, catheter, and technique. (C-3, P-2)
10. Perform mouth-to-mask ventilation. (P-1, P-2)
11. Perform ventilation with a bag-valve-mask, including: (P-1, P-2)
• 1 person method
• 2 person method
12. Perform ventilations with a bag-valve-mask with an in-line small-volume nebulizer. (P-1, P-2)
20. Perform retrieval of foreign bodies from the upper airway. (P-1, P-2)
21. Describe assessment to confirm correct placement of the endotracheal tube. (P-1, P-2)
22. Perform cricoid pressure during endotracheal intubation. (P-1, P-2)
23. Perform orotracheal intubation. (P-1, P-2)
24. Perform endotracheal intubation in the trauma patient. (P-1, P-2)
Section 2: Page 95
25. Perform endotracheal intubation in the pediatric patient. (P-1, P-2)

27. Perform extubation. (P-1, P-2)
NOTES
Section 2: Page 96
Presentation
Declarative:
I. Introduction
A. Need for oxygenation
1. Primary Objective:
a) Insure optimal Ventilation
(1) Delivery of Oxygen
(2) Elimination of CO2
b) Brain Death within 6 to 10 minutes
B. Major prehospital causes of death
1. Preventable with:
a) Early Detection
b) Early Intervention
c) Lay-Person BLS Education
C. Most neglected of prehospital skills
1. Basics taken for granted
a) Poor Technique i.e.,:
(1) BVM Seal
(2) Improper Positioning
(3) Failure to reassess
II. Anatomy of Upper Airway
A. Function of the upper airway
1. Warm
2. Filter
3. Humidify
B. Separated into
1. Nasopharynx
2. Oropharynx
C. Nasopharynx
1. Formed by the union of facial bones
2. Orientation of Nasal floor is towards the ear not the eye
3. Separated by Septum
4. Lined with:
a) Mucous Membranes
b) Cilia
5. Has Turbinates
a) Parallel to nasal floor
b) Provide increased surface area for air:
(1) Filtration
(2) Humidifying
(3) Warming
Section 2: Page 97
6. Contain Sinuses
a) Cavities that appear to further trap bacteria and act as tributaries for fluid to
and from Eustachian Tubes and Tear Ducts
(1) Commonly become infected
(2) Fracture of certain sinus bones may cause cerebrospinal Fluid (CSF)
Leak
7. Tissues extremely delicate and vascular
a) Improper or overly aggressive placement of tubes or airways will cause
significant bleeding which may not be controlled by direct pressure.
8. Oropharynx
a) Teeth
(1) 32 Adult
(2) Requires significant force to dislodge
(3) May fracture or avulse causing obstruction
b) Tongue
(1) Large muscle attached at the Mandible and Hyoid Bones
(2) Most common Airway Obstruction
c) Palate
(1) Roof of mouth separates oro/naso pharynx
(a) Anterior is Hard Palate
(b) Posterior (beyond the teeth) is Soft Palate
d) Adenoids
(1) Lymph tissue located in the mouth and nose that filters bacteria.
(2) Frequently infect and swell
9. Hypopharynx
a) Posterior Tongue
b) Epiglottis
c) Vallecula
(1) "Pocket" formed by the base of the tongue and epiglottis.
(2) Important Landmark for Endotracheal Intubation
10. Larynx
a) Attached to Hyoid Bone
(1) "Horseshoe" shaped bone between the chin and Mandibular Angle
(2) Supports Trachea
b) Made of Cartilage
(1) Thyroid Cartilage
(a) First Tracheal Cartilage
(i) "Shield Shaped"
(a) Cartilage Anterior
(b) Smooth Muscle Posterior
(ii) Laryngeal Prominence
(a) "Adam's Apple" anterior prominence of Thyroid Cartilage
Section 2: Page 98
(b) Glottic Opening directly behind

(2) Glottic Opening
(a) Patency heavily dependent on muscle tone
(b) Contain Vocal Bands
(i) White bands of cartilage produce voice
(ii) Arytenoid Cartilage
(a) "Pyramid Like" Posterior attachment of Vocal Bands.
Important landmark for Endotracheal Intubation
(iii) Pyriform Fossae: "Hollow Pockets" along the lateral borders of
the Larynx
(3) Cricoid Ring
(a) First Tracheal Ring
(b) Completely Cartilaginous
(c) Compression of cricoid ring occludes Esophagus (Sellick
Maneuver)
(4) Cricothyroid Membrane
(a) Fibrous Membrane between Cricoid and Thyroid Cartilage.
(b) Site for Surgical and Alternative Airway placement
c) Associated Structures
(1) Thyroid Gland
(a) Located below Cricoid Cartilage.
(b) Lies Across Trachea
(2) Carotid Arteries
(a) Branches cross and lie closely alongside Trachea.
(3) Jugular Veins
(a) Branch across and lie close to Trachea
III. Anatomy of Lower Airway
A. Function of the lower airway
1. Exchange of O2 and CO2
B. Location of the lower airway
1. From Fourth Cervical Vertebrae to Xyphoid Process
2. From Glottic Opening to Pulmonary Capillary Membrane
C. Structures of the lower airway
1. Trachea
a) Trachea Bifurcates at Carina into:
(1) Right and left main stem bronchi
(2) Right main stem has lesser Angle
(3) Foreign bodies, ET Tubes commonly displace here
(4) Lined with
(a) Mucous Cells
(b) Beta 2 Cells
(i) Dilate Bronchioles
b) Main stem Bronchi enter Lungs at Hilum
Section 2: Page 99
(1) Branch into narrowing:

(a) Secondary and Tertiary Bronchi which branch into:
(i) Bronchioles
(a) Branch into Alveolar Ducts which end at Alveolar Sacs
c) Alveoli
(1) "Balloon like clusters"
(2) Site of Gas Exchange
(3) Lined with Surfactant
(a) Decreases Surface Tension of Alveoli which facilitates ease of
expansion
(b) Alveoli become thinner as they expand which makes diffusion of
O2/CO2 Easier
(c) If Surfactant is decreased or Alveoli are not inflated, Alveoli
collapse (Atelectasis)
2. Lungs
a) Right lung
(1) 3 Lobes
b) Left lung
(1) 2 Lobes
c) Lobes made of Parenchymal Tissue
d) Membranous outer lining called Pleura
e) Lung capacity
(1) Total Lung Volume
(a) Adult male, 6 liters
(2) Not all inspired air enters Alveoli
(3) Minor diffusion of O2 takes place in Alveolar ducts and Terminal
Bronchioles
f) Tidal volume
(1) Volume of gas inhaled or exhaled during a single respiratory cycle
(a) 5-7 cc/kg (500 cc normally)
g) Dead space air
(1) Air remaining in air passageways, unavailable for gas exchange
(Approximately 150 cc)
(a) Anatomic Dead Space
(i) Trachea
(ii) Bronchi
(b) Physiologic Dead Space
(i) Dead space formed by factors like disease or obstruction
(a) COPD
(b) Atelectasis
Section 2: Page 100

h) Minute volume
(1) Amount of gas moved in and out of the respiratory tract per minute
(2) Determined by:
(a) Tidal Vol.- Dead Space Volume x Respiratory Rate
i) Functional Reserve Capacity
(1) After Optimal inspiration, the optimum amount of air that can be forced
from the lungs in a single forced exhalation
j) Residual Volume (DEFINE)
3. Alveolar air
a) Air reaching the alveoli for gas exchange (Alveolar Volume)
b) Approximately 350 cc
4. Inspiratory reserve (DEFINE)
5. Expiratory reserve (DEFINE)
D. Differences in Pediatric Airway
1. Pharynx
a) Disproportionately large tongue
b) Large floppy epiglottis
c) Absent or very delicate dentition
2. Trachea
a) Airway is smaller
b) Trachea lies more superior
c) Trachea is "Funnel Shaped" due to narrow, undeveloped Cricoid Cartilage.
d) Narrowest Point is at Cricoid Ring before 10 years of age
e) Small change in Airway Size results in Major increase in airway Resistance
3. Chest Wall
a) Ribs and Cartilage are softer
(1) Cannot optimally contribute to lung expansion
(2) Infants and children tend to depend more heavily on the diaphragm for
breathing.
IV. Mechanics of Respiration
A. Respiration
1. Definition:
a) Exchange of gases between a living organism and its environment
b) Primary Control From the Medulla and Pons
2. Types
a) External Respiration: Exchange of gasses between the Lungs and the
Blood Cells
b) Internal Respiration: Exchange of gases between the Blood Cells and
Tissues
c) Pulmonary Ventilation: Movement of air into and out of the lungs
Section 2: Page 101

3. Phases
a) Inspiratory/ Expiratory
(1) Inspiration
(a) Stimulus to breath from Respiratory Center
(b) Impulse Transmitted to Diaphragm via Phrenic Nerve
(i) Diaphragm: "Muscle of Respiration". Separates Thoracic from
Abdominal Cavity
(c) Diaphragm contracts "flattens"
(i) Causes Intrapulmonary Pressure to fall slightly below
Atmospheric Pressure
(d) Intercostal Muscles Contract
(e) Ribs elevate and expand
(f) Air is drawn into lungs like a vacuum
(g) Alveoli Inflate
(h) O2/CO2 Diffuse across membrane
b) Expiration
(1) Stretch Receptors in Lungs signal Respiratory Center via Vagus Nerve
to inhibit inspiration (Hering-Breuer Reflex)
(2) Natural elasticity (recoil) of the lungs passively expires air
4. Regulation of Respiration
a) Influenced by
(1) Chemical Stimuli
(a) Receptors for O2/CO2 Balance
(i) Cerebrospinal Fluid pH
(ii) Carotid Bodies (Sinus)
(iii) Aortic Arch
(b) Hypoxic Drive
(i) Respiratory Stimulus dependent on O2 rather than CO2
concentration in the blood. Normally, it's the other way around.
(2) CNS Regulation and Nerve Receptors
(a) Medulla
(i) Primary Involuntary Respiratory Center
(a) Connected to Respiratory muscles by Vagus Nerve
(b) Pons
(i) Apneustic Center
(a) Secondary Control Center if Medulla fails to initiate
Respiration
(ii) Pneumotaxic Center
(a) Controls Expiration
(3) Muscle Movement
(a) Connected to Respiratory Center by Vagus Nerve
Section 2: Page 102

V. The Measurement of Gases

A. Total pressure
1. The combined pressure of all Atmospheric gasses
a) 100% or 760 TORR at Sea Level
B. Partial pressure
1. The pressure exerted by a specific atmospheric gas
C. Concentration of gases in the atmosphere
1. Nitrogen 78.62%
2. Oxygen 20.84%
3. CO2 0.04%
4. Water 0.50%
D. Water vapor pressure
E. Alveolar Gas concentration
1. Nitrogen 74.9%
2. Oxygen 13.7%
3. CO2 5.2%
4. Water 6.2%
VI. Exchange and Transport of Gases in the Body
A. Diffusion
1. Diffusion of gases
a) O2/CO2 dissolve in Water and pass through Alveolar Membrane by
Diffusion
(1) Diffusion: Passage of Solution from area of Higher concentration to
Lower concentration
B. Oxygen Content of Blood
1. Dissolved O2 Crosses Pulmonary Capillary membrane and binds to Hemoglobin
(Hgb) of red blood cell
2. Oxygen is carried on Hemoglobin molecule as well as dissolved in Plasma
3. Approximately 97% of total O2 is bound to Hemoglobin
4. O2 Saturation:
a) Compares Available O2 (the O2 dissolved in Plasma) to O2 carrying
Capacity of blood
C. Carbon Dioxide Content of the Blood
1. CO2 is a byproduct of cellular work (Cellular Respiration)
2. CO2 is transported in blood as Bicarbonate ion
a) About 33% is bound to Hemoglobin
3. As O2 Crosses into blood, CO2 diffuses into Alveoli
D. Inadequate Ventilation
1. Occurs when body cannot compensate for increased O2 demand or maintain
O2/CO2 balance
2. Many Causes
a) Infection
b) Trauma
Section 2: Page 103
c) Brainstem Insult
d) Noxious or Hypoxic Atmosphere
e) Renal Failure
3. Multiple Symptoms
a) Altered Response
b) Respiratory Rate Changes (Up or Down)
c) Respiratory Pattern Changes
(1) Cheyne-Stokes
(a) Gradually Increasing Rate and Tidal Volume followed by gradual
decrease.
(b) Associated with Brain Stem Insult
(2) Kussmall's
(a) Deep, Gasping respirations
(b) Common in Diabetic Coma
(3) Central Neurogenic Hyperventilation
(a) Deep Rapid Respirations similar to Kussmall's
(b) Increased Intracranial Pressure
4. Common Endpoints
a) Tissue / Brain ischemia, injury, and death
E. Control of Respiration by Other Factors
1. Body temperature
a) Respirations increase with Fever
(1) Response to Metabolic changes due to infection
b) Drug and medications
(1) May Increase or Decrease Respirations depending on their physiologic
action
c) Pain
d) Emotion
e) Hypoxia
f) Acidosis
(1) Respirations Increase as compensatory response to increased CO2
production
g) Sleep
(1) Respirations decrease
2. Modified Forms of Respiration
a) Protective Reflexes
(1) Cough
(a) Forceful, Spastic Exhalation aids in clearing bronchi and
bronchioles
Section 2: Page 104

(2) Sneeze
(a) Clears Nasopharynx
(3) Gag Reflex
(a) Spastic Pharyngeal and Esophageal reflex from stimulus of the
posterior pharynx
b) Sighing
(1) Involuntary deep breath that increases opening of Alveoli
(2) Normally sigh about once per minute
c) Hiccough
(1) Spasm of Diaphragm from Vagal Stimulus
VII. Pathophysiology
A. Obstruction
1. Tongue
a) Most common Airway Obstruction
b) Snoring respirations
c) Corrected with positioning
2. Foreign body
a) May cause partial or full obstruction
b) Symptoms include
(1) Choking
(2) Gagging
(3) Stridor
(4) Dyspnea
(5) Aphonia (Unable to Speak)
(6) Dysphonia (Difficulty Speaking)
3. Laryngeal spasm
a) Spasmotic closure of Vocal Cords
b) Glottic opening becomes extremely narrow or totally obstructed
c) Most frequently caused by
(1) Epiglottitis (A Bacterial infection of the epiglottis)
(2) Anaphylaxis (Severe Allergic Reaction)
(3) Trauma from over aggressive technique during Intubation
(4) Immediately upon Extubation especially when patient is semiconscious
d) Relieved by
(1) Aggressive Ventilation
(2) Forceful upward pull of the Jaw
(3) Muscle Relaxants, IV
4. Fractured larynx
a) Airway Patency dependent upon muscle tone
b) Fractured Laryngeal Tissue
(1) Increases Airway Resistance by decreasing Airway size through
(a) Decreasing Muscle Tone
Section 2: Page 105

(b) Laryngeal Edema

(c) Ventilatory Effort
5. Aspiration
a) Significantly increases Mortality
(1) Obstructs Airway
(2) Destroys Delicate Bronchiolar Tissue
(3) Introduces Pathogens
(4) Decrease ability to Ventilate
VIII.Airway Evaluation
A. Essential Parameters
1. Rate
a) Normal Resting Rate in Adults: 12-24
2. Regularity
a) Steady Pattern
(1) Irregular respiratory patterns are significant until proven otherwise
3. Effort
a) Breathing at rest should be effortless
b) Effort changes may be subtle in Rate or Regularity
c) Patients often compensate by preferential positioning
(1) Upright Sniffing
(2) Semi-Fowler’s
(3) Frequently avoid Supine
B. Recognition of airway problems
1. Difficulty in Rate , Regularity, or Effort is defined: Dyspnea
2. Dyspnea may be result of or result in Hypoxia
a) Hypoxia: Lack of Oxygen
b) Hypoxemia: Lack of Oxygen to Tissues
c) Anoxia: Total absence of Oxygen
3. Recognition and treatment of Dyspnea is crucial to patient survival
a) Expert Assessment and Management is essential
(1) The brain can survive only a few minutes of anoxia
(2) All therapies fail if Airway is inadequate
4. Visual Signs and Symptoms
a) Position: i.e.,: "tripod", upright with dangling feet
b) Anxiety
(1) Range from mild to extreme
c) Rise and fall of chest
(1) Normal, Deep, Shallow, Absent
d) Color of skin
e) Flaring of nares
f) Gasping
g) Pursed lips
Section 2: Page 106

h) Retractions: "Pulling in of skin" between thoracic skeleton during inspiration

(1) Intercostal
(2) Suprasternal notch
(3) Supraclavicular fossa
(4) Subcostal
5. Auscultation Techniques
b) Bilateral lung fields Equal
6. Palpation Techniques
b) Chest wall
(1) Paradoxical Motion
(2) Retractions
7. Bag Valve Mask
a) Resistance or Changing Compliance with Bag Valve Mask Ventilations
8. History
a) Evolution
(1) Sudden, gradual over "x" time
(2) Known cause or "Trigger"
b) Duration
(1) Constant, Recurrent
c) Ease
(1) What makes it better?
d) Exacerbate
(1) What makes it worse?
e) Associate
(1) Other Symptoms (Productive cough, Chest Pain, Fever, etc.)
f) Interventions
(1) Evaluations/Admissions to Hospital
(2) Medications (include compliance)
(3) Ever Intubated
C. Quantitative measurement of patient oxygenation and end-tidal CO2
1. Oxygen Therapy
a) Oxygen therapy is used to treat hypoxemia.
b) Oxygen saturation (SaO2) readings can help determine which oxygen
adjunct should be placed on the patient and the liter flow to be
administered.
(1) A SaO2 in the 95% to 99% range is ideal and no supplemental oxygen
is needed unless the patient’s chief complaint or injury mechanism
warrants.
(2) An SaO2 of 91% to 94% represents mild hypoxemia and indicates that
the airway should be checked and oxygen therapy started a 4 to 6L via
nasal cannula.
Section 2: Page 107
(3) An SaO2 of 85% to 90% represents moderate hypoxemia. The airway

must be checked and aggressive oxygen therapy started at 15L/min via
nonrebreather mask.
(4) An SaO2 reading of less than 85% indicates severe hypoxemia. In
these cases, the EMT-I should prepare to intubate or assist ventilations
with a bag-valve-mask and 100% oxygen.
2. Pulse oximetry
a) Pulse oximetry is a simple, noninvasive procedure used to determine the
effectiveness of patient oxygenation.
(1) Oxygen bound Vs unbound Hemoglobin in the red blood cell absorbs
infrared light at different rates.
(2) Pulse Oximeters emit an infrared beam that passes through the
capillary bed. The absorption of Infrared light by Hemoglobin is
measured in % as Infrared light passes from one end of the probe to
the other
(3) Normal Pulse Ox values are between 94 to 100% on room air. Values
below 93 to 94% are abnormal and may suggest acute or chronic
hypoxia i.e.,.: COPD
b) It allows for continuous monitoring, detecting trends in patient’s oxygenation
status within 6 seconds.
c) Pulse oximetry can:
(1) Reaffirm perceived hypoxia
(2) Reveal hidden hypoxia
(3) Assist in determining what oxygenation adjunct should be applied and
liter flow to be administered
(4) Aid in monitoring clinical improvement of deterioration in acutely
dyspneic patients
(5) Identify when to intubate
(6) Identify changes during intubation or other airway manipulations
d) Pulse oximetry should be taken on all patients and recorded as part of their
vital signs, because normal evaluation of oxygenation is notoriously
unreliable.
e) Saturation readings should be taken before and after oxygen is
administered to any patient.
f) It is important to keep a patient’s oxygen saturation in a normal range,
because declines in saturation result in a reduction in oxygen content.
g) In addition to oxygen saturation (SaO2), a visual pulse rate is displayed (and
is audible). However, this unit should not be used in place of the cardiac
monitor when the situation dictates the use of one.
h) Procedure
(1) Prior to use, the EMT-I should test the unit on themselves to confirm
that it is in good operating condition.
Section 2: Page 108
(2) To do this, the EMT-I should turn on the unit and follow all operating
recommendations set forth by the manufacturer.
(3) After it is found that the unit is in good operating condition, the EMT-I
should place the finger clip on the patient’s index finger with the outline
of the finger facing up.
(4) All dirt and nail polish or any obstructive covering should be removed to
prevent the unit from giving a false reading.
(5) When these steps are completed, the unit will show a red number on
the left, which is the SaO2, and a red light on the right showing the
patient’s heart rate.
(6) The EMT-I should consider pulse oximetry as only another tool to assist
in patient monitoring.
(7) A variety of circumstances produce false readings, including:
(a) Patients who smoked prior to pulse Ox.
(b) COPD patients
(c) Carbon monoxide
(d) Excessive ambient light on the sensor probe
(e) Patient movement
(f) Hypotension (low flow states)
(g) Hypothermia
(h) Use of vasoconstrictive drugs by the patient
(i) Nail polish
(j) Jaundice
3. End Tidal Carbon Dioxide (CO2) Detectors
a) End-tidal carbon dioxide detectors are an effective way of verifying correct
airway devise placement.
b) End-tidal air, which closely correlates with the percentages of gases found
in mixed venous blood, contains approximately 6% carbon dioxide.
c) A lack of carbon dioxide in the end-tidal air strongly suggests the tube has
been misplaced into the esophagus.
d) The devices detect the amount of CO2 in the patient’s expired air.
(1) CO2 is a by-product of cellular metabolism.
(2) CO2 is carried to lungs and is expired
(3) Patient's expired air passes through a measurement device.
e) There are two types of end-tidal CO2 detectors currently available.
(1) Disposable colormetric device (least expensive)
(a) Designed for single patient use
(b) Contains a non-toxic chemical indicator that reacts instantly to
expired tracheal carbon dioxide by changing color.
(c) The reversibility of this color change allows the EMT-I to determine
esophageal or tracheal ventilation (after the required 6 breaths).
(i) The presence of a yellow color on expiration indicates correct
ventilation into the trachea.
Section 2: Page 109

(ii) The presence of a purple color indicates improper ventilation

into the esophagus.
(d) The color varies from expiration to inspiration as carbon dioxide
leaves rise and fall in a phasic manner
(2) Electric monitor (most expensive)
(a) Portable or hand-held device that uses an infrared analyzer to
measure the percentage of carbon dioxide gas at each phase of
respiration.
(i) Information is displayed on a digital readout or printout.
(ii) Can provide verification of correct placement of airway device.
(iii) Can provide continuous carbon dioxide monitoring with a
cannula during transport.
(b) Newer models combine pulse oximetry, pulse rate, and respiratory
rate in one unit.
f) These devices are attached in-line between the airway device and the
ventilatory device after tube placement.
g) Mainly used for confirming Tube placement but other applications such as
predicting Cardiac Arrest Outcome as well as detecting improvement or
deterioration during prehospital care has been suggested
h) Because of the potential for inaccurate readings in some conditions, the
end-tidal carbon dioxide detector should be used as just one of the many
tools the EMT-I has available to assess correct placement of airway devices
and ventilatory status.
(1) End-tidal carbon dioxide detectors weakness/limitations
(a) Carbon dioxide sometimes inadvertently enters the stomach - Six
breaths can quickly wash out any retained carbon dioxide.
(b) Adequate circulation and pulmonary perfusion are required to
obtain diffusion of carbon dioxide from the pulmonary capillary bed.
(i) Initial end-tidal carbon dioxide levels ma be considerably lower
during cardiac arrest.
(c) With adequate CPR, these levels should rise enough to allow the
end-tidal carbon dioxide detector to verify proper placement of the
airway device.
(d) Does not conclusively confirm proper Tube placement.
(i) Confirms tube is in an area that contains CO2 such as the
hypopharynx.
(ii) Cannot detect main stem placement or displacement
IX. Universal Precautions and Body Substance Isolation (BSI) in airway management
X. Airway Management
A. Noninvasive Maneuvers
1. Opening the mouth
a) Head-tilt/chin-lift maneuver
(1) Most basic airway maneuver
(a) Tilt head back
Section 2: Page 110

(b) Lift chin forward

(c) Open mouth
(2) Indications
(a) Unresponsive patients who:
(i) Do not have mechanism for C-Spine injury
(a) Awake patients
(b) Possible C-Spine Injury
(4) Advantages
(a) No equipment required
(b) Simple
(c) Safe
(d) Non-invasive
(5) Disadvantages
(a) Head tilt hazardous to C-Spine Injury patients
(b) Does not protect from Aspirate
b) Jaw-thrust maneuver lift
(1) Head is maintained Neutral
(a) Jaw is displaced forward
(i) Lift by grasping under chin and behind teeth
(b) Mouth opened
(2) Indications:
(a) Patients who:
(i) Unresponsive
(iii) May have C-Spine Injury
(a) Responsive Patients
(b) Resistance to opening mouth
(4) Advantages
(a) May be used in C-Spine injury
(b) May be performed with Cervical Collar in place
(c) Does not require special equipment
(5) Disadvantages
(a) Cannot maintain if pt becomes responsive or combative
(b) Difficult to maintain for extended period
(c) Very difficult to use in conjunction with Bag Valve Mask Ventilation
(d) Thumb must remain in patient's mouth in order to maintain
displacement
(e) Separate rescuer required to perform Bag Valve Mask Ventilation
(f) Does not protect against aspiration
Section 2: Page 111

c) Modified Jaw-Thrust Maneuver

(1) Head maintained Neutral
(a) Jaw is displaced forward at Mandibular Angle
(2) Indications
(a) Unresponsive
(b) Cervical Spine Injury
(c) Unable to protect own airway
(d) Resistance to opening mouth
(a) Awake Patients
(4) Advantages
(a) Non-invasive
(b) Requires no special equipment
(c) May be used with Cervical Collar in place
(5) Disadvantages
(a) Difficult to maintain
(b) Requires Second Rescuer for Bag Valve Mask Ventilation
(c) Does not protect against aspirate
(d) Cricoid pressure
(6) Sellick’s maneuver
(a) Pressure on Cricoid Ring
(i) Occludes Esophagus
(ii) Helps to prevent passive Emesis
(iii) Can help minimize Gastric Distension During Bag Valve Mask
Ventilation
(b) Indications
(i) Vomiting is imminent or occurring
(ii) Patient cannot protect own Airway
(c) Contraindications
(i) Use with caution in Cervical Spine Injury
(d) Advantages
(i) Noninvasive
(ii) Easy to perform
(iii) Protects from aspirate as long as pressure is maintained
(e) Disadvantages
(i) May have extreme emesis if pressure is removed
(ii) Second Rescuer required for Bag Valve Mask Ventilation
(iii) May further compromise injured Cervical Spine
(f) Complications
(i) Laryngeal Trauma with excessive force
(ii) Esophageal Rupture from unrelieved High Gastric Pressures
Section 2: Page 112

B. Suctioning
1. Types of suctioning equipment
a) Hand-powered suction devices
(1) Advantages
(a) Lightweight
(b) Portable
(c) Mechanically Simple
(d) Inexpensive
(2) Disadvantages
(a) Limited Volume
(b) Manually Powered
(c) Fluid contact components not disposable
b) Oxygen-powered portable suction devices
c) Battery-operated portable suction devices
(1) Advantages
(a) Lightweight
(b) Portable
(c) Excellent Suction power
(d) May "Field Strip" Troubleshoot most components
(2) Disadvantages
(a) More complicated mechanics
(b) May lose battery integrity over time
(c) Some fluid contact components not disposable
d) Mounted vacuum-powered suction devices
(1) Advantages
(a) Extremely strong vacuum
(b) Adjustable Vacuum power
(c) Fluid contact components disposable
(2) Disadvantages
(a) Non-portable
(b) Cannot "Field Service" or substitute power source
2. Types of suctioning catheters
a) Hard or rigid catheters
(1) AKA: "Yankauer" or "Tonsil Tip"
(2) Suction large volumes of fluid rapidly
(3) Standard Size
b) Soft catheters
(1) Can be placed in Oropharynx, Nasopharynx, or down Endotracheal
Tube
(2) Various Sizes
(3) Smaller inside diameter than hard tip catheters
Section 2: Page 113

3. Suctioning the upper airway

a) Prevention of aspirate critical
(1) Mortality increases significantly if aspiration occurs
(2) Pre-oxygenate if possible
(3) Hyperoxygenate after
b) Description:
(1) Soft Tip Catheters must be prelubricated
(2) Place Catheter
(3) Suction during extraction of catheter
(5) Hyperoxygenate
4. Tracheobronchial Suctioning
a) Pre-oxygenation Essential
b) Description:
(1) Pre-lubricate Soft Tip Catheter
(2) Hyperoxygenate
(a) May be necessary to inject 3 to 5 cc's of Sterile Water down
Endotracheal Tube to loosen secretions
(3) Gently insert catheter until resistance is felt
(4) Suction upon extraction of catheter
(6) Hyperoxygenate
C. Gastric Distention
1. Air becomes trapped in the stomach
a) Very common when ventilating non-intubated patients
(1) Stomach diameter increases
(2) Pushes against diaphragm
(3) Interferes with lung expansion
(a) Abdomen becomes increasingly distended
(b) Resistance to Bag Valve Mask Ventilation
2. Management
a) May be reduced by increasing Bag Valve Mask Ventilation time
(1) Adults: 1.5-2 seconds
(2) Peds: 1-1.5 seconds
b) Prepare for large volume suction
c) Position Patient Left Lateral
d) Slowly apply pressure to epigastric region
e) Suction as necessary
D. Basic Airway Management
1. Nasal airway
a) Soft rubber with beveled tip
(1) Distal tip rests in hypopharynx
Section 2: Page 114

(2) For adults, length measured from nostril to earlobe

(3) Diameter roughly equal to patient's little finger
b) Indications
(1) Unconscious patients
(2) Altered Response patients with suppressed gag reflex
(1) Patient intolerance
(2) Caution in presence of facial fracture or Skull fracture
d) Advantages
(1) Can be suctioned through
(2) Provides patent airway
(3) Can be tolerated by awake patients
(4) Can be safely placed "blindly"
(5) Does not require mouth to be open
e) Disadvantages
(1) Poor technique may result in severe bleeding
(a) Resulting epistaxis may be extremely difficult to control
(2) Does not protect from aspirate
f) Placement
(1) Determine correct length and diameter
(2) Lubricate Nasal Airway
(3) With bevel towards Septum, insert gently along the nasal floor parallel
to the mouth
(4) Do Not Force
(a) Measurement from tip of the nose to the Jaw Angle rather than tip
of the ear.
(i) Too long airway causes Airway Obstruction
2. Oral airway
a) Hard plastic airway designed to prevent the tongue from obstructing glottis
(1) Indications
(a) Unconscious Patients
(b) Absent Gag Reflex
(a) Conscious Patients
(3) Advantages
(a) Non-invasive
(b) Easily placed
(c) Prevents blockage of glottis by tongue
(4) Disadvantages
(a) Does not prevent aspiration
(b) Unexpected gag may produce vomiting
Section 2: Page 115

(5) Complications
(a) Unexpected gag may produce vomiting
(b) Pharyngeal or Dental Trauma with poor technique
(6) Placement
(a) Open mouth
(b) Remove visible obstructions
(c) Place with distal tip toward glottis using tongue depressor as
adjunct
(d) Alternate: Place airway with distal tip toward palate. Rotate into
place
b) Special considerations
(1) Pediatrics
(a) Place with Tongue Depressor
(b) Place with tip toward cheek not palate
E. Methods to perform ventilation
1. Mouth-to-mouth
a) Most basic form of ventilation
(1) Indications
(a) Apnea from any mechanism when other ventilation devices are not
available
(a) Awake patients
(b) Communicable disease risk limitations
(3) Advantages
(b) Delivers excellent Tidal Volume
(c) Delivers adequate Oxygen
(4) Disadvantages
(a) Psychological barriers from:
(i) Sanitary issues
(ii) Communicable disease issues
(a) Direct Blood /Body Fluid contact
(b) Unknown communicable disease risks at time of event
(iii) May be difficult to seal mouth
(5) Complications
(b) Gastric distension
(c) Blood/Body fluid contact manifestations
Section 2: Page 116

2. Mouth-to-nose
a) Ventilating through nose rather than mouth
(1) Indications
(a) Awake Patients
(3) Advantages
(b) May decrease Blood/Body fluid contact
(4) Disadvantages
(a) Direct Blood/Body Fluid contact
(b) Psychological limitations of rescuer
(5) Complications
(c) Blood/Body Fluid Manifestations
3. Mouth-to-mask
a) Adjunct to Mouth to Mouth Ventilation
(1) Indications
(a) Awake Patients
(3) Advantages
(a) Physical barrier between rescuer and patient Blood/Body Fluids
(b) One-Way Valve to prevent Blood/Body Fluid splash to rescuer
(c) May be easier to obtain face seal
(4) Disadvantages
(a) Useful only if readily available
(5) Complications
(b) Hyperventilation of rescuer
(6) Method for use
(a) Position head by appropriate method
(b) Position and seal mask over mouth and nose
(c) Ventilate as appropriate
4. One person bag-value-mask
a) Fixed Volume self inflating bag can deliver adequate Tidal Volumes and O2
enrichment
(1) Indications
(b) Unsatisfactory Respiratory effort
Section 2: Page 117

(3) Advantages
(a) Excellent Blood /Body Fluid barrier
(b) Good Tidal Volumes
(c) Oxygen Enrichment
(d) Rescuer can ventilate for extended periods without fatigue
(4) Disadvantages
(a) Difficult Skill to master
(b) Mask seal may be difficult to obtain and maintain
(c) Tidal Volume delivered is dependent on mask seal integrity
(5) Complications
(a) Inadequate Tidal Volume Delivery with:
(i) Poor technique
(ii) Poor mask seal
(6) Method for use
(a) Position appropriately
(b) Choose proper mask size
(i) Seats from bridge of nose to chin
(c) Position, Spread/Mold/Seal mask
(d) Hold mask in place
(e) Squeeze Bag completely over 1.5 to 2 seconds for Adults
(f) Avoid Overinflation
(g) Reinflate completely over several seconds
(a) Medical
(i) Observe for:
(a) Gastric Distension
(b) Changes in compliance of bag with ventilation
(c) Improvement or deterioration of ventilation status ( i.e.,
Color change, Responsiveness, Air Leak around Mask
(b) Trauma
(i) Very difficult to perform with Cervical Spine Immobilization in
place
(c) Pediatrics
(i) Flat Nasal Bridge makes achieving mask seal more difficult
(ii) Compressing mask against face to improve Mask seal results
in obstruction
(iii) Mask seal best achieved with Jaw displacement
5. Two person bag-value-mask
a) Alternate Bag Valve Mask Ventilation Method
Section 2: Page 118

b) Most efficient method

(1) Indications
(a) Bag Valve Mask Ventilation on any patient
(i) Especially useful for Cervical Spine immobilized patients
(ii) Difficulty obtaining or maintaining adequate mask seal
(3) Advantages
(a) Superior Mask Seal
(b) Superior Volume Delivery
(4) Disadvantages
(a) Requires extra personnel
(5) Complications
(a) Hyperinflation of patient's Lungs
(6) Method for use
(a) First Rescuer maintains mask seal by appropriate method
(b) Second Rescuer Squeezes Bag
(a) Observe Chest Movement
(b) Avoid Overinflation
(c) Monitor Lung Compliance with Ventilations
6. Flow-restricted oxygen powered ventilation devices
a) Demand Valve
(1) Trigger when patient inhales. Delivers O2 as long as inspiratory strength
is enough to "hold the gate open"
7. Automatic transport ventilators
a) Volume/Rate controlled
b) Indications
(1) Extended ventilation of Intubated patients
(1) Awake patients
(2) Obstructed Airway
(3) Increased Airway Resistance
(a) Pneumothorax
(b) Asthma
(c) Pulmonary Edema
(4) Advantages
(a) Lightweight
(b) Portable
(c) Durable
(d) Mechanically Simple
Section 2: Page 119

(e) Adjustable Tidal Volume

(f) Adjustable Rate
(g) Adapts to portable O2 Tank
(5) Disadvantages
(a) Cannot detect tube displacement
(b) Does not detect increasing airway resistance
(c) Difficult to secure
(d) Dependent on O2 Tank Pressure
F. Oxygen delivery
1. Enriched O2 Atmosphere increases Oxygen to cells
a) Increasing available O2 increases Patient's ability to compensate
2. O2 delivery method must be reassessed to determine adequacy and efficiency
3. Oxygen delivery equipment
a) Nasal cannula
(1) Nasally placed O2 Catheter for Oxygen enrichment
(a) Optimal Delivery: 40% at 6 L/min
(2) Indications
(a) Low to Moderate O2 Enrichment
(b) Long term O2 maintenance therapy
(a) Poor Respiratory Effort
(b) Severe Hypoxia
(c) Apnea
(d) Mouth Breathing
(4) Advantages
(a) Well Tolerated
(5) Disadvantages
(a) Does not deliver High Volume/ High Concentration
b) Simple face mask
(1) Full Airway enclosure with open side ports
(a) Room Air is drawn through side ports on inspiration, diluting O2
concentration
(2) Indications
(a) Delivery of moderate to High O2 concentrations
(b) Range: 40-60% at 10 L/min
(3) Advantages
(a) Higher O2 concentrations
(4) Disadvantages
concentration
Section 2: Page 120

c) Partial Rebreather
(1) Mask vent ports covered by one-way disc
(a) Expired air escapes through vents
(b) Residual expired air mixed in mask and rebreathed
(c) Room Air not pulled into mask with inspiration
(2) Indications
(a) Higher O2 concentration
(a) Apnea
(b) Poor Respiratory Effort
(4) Advantages
(a) Inspired gas not mixed with room air
(i) Higher O2 concentrations attainable
(5) Disadvantages
concentration
d) Non-rebreather mask
(1) Mask side ports covered by one-way disc
(2) Reservoir Bag attached
(3) Range: 80-95+% at 15 L/min
(4) Indications
(a) Delivery of highest O2 concentration
(a) Apnea
(b) Poor respiratory effort
(6) Advantages
(a) Highest O2 concentration
(b) Delivers High volume/ High O2 enrichment
(c) Patient inhales enriched O2 from reservoir bag rather than residual
air
(7) Disadvantages
(8) Complications
(9) Method for use
(10)Special considerations
(a) Pediatrics
e) Venturi mask
(1) Mask with interchangeable adapters
(a) Adapters have port holes that pull in room air as O2 passes
(b) Patient receives a Highly specific concentration of O2
(c) Air is pulled into mask by Venturi Principle:
Section 2: Page 121

f)
Small volume nebulizer
(1) Delivers Aerosolized medication
(2) O2 enters an Aerosol chamber containing 3-5 cc's of fluid
(3) Pressurized O2 Mists fluid
G. Advanced Airway Management
1. Endotracheal intubation (ET)
a) Airway passed into the trachea in order to provide externally controlled
breathing through a BVM or Ventilator
b) Indications
(1) Present or impending Respiratory Failure
(2) Apnea
(3) Failure to protect own Airway
(1) Equipment to resolve complications is not available
d) Advantages
(1) Provides a secure airway
(2) Protects against aspiration
(3) Route for medication
e) Disadvantages
(1) Special Equipment needed
(2) Bypasses physiologic function of upper airway
(a) Warming
(b) Filtering
(c) Humidifying
f) Complications
(1) Bleeding
(2) Laryngeal Swelling
(3) Laryngospasm
(4) Anoxia
(5) Unrecognized misplacement
(6) Barotrauma
g) Special Considerations
(1) Pediatrics
(a) Right main stem displacement most common
(b) Tube depth determined by:
(i) Distal tube markings
(ii) Cm Markings
(iii) Tube depth calculation: 3 x (inside diameter.)
h) Equipment
(1) Endotracheal Tubes
(a) Size Range
(i) 2.5-9.0 mm Inside Diameter (id)
Section 2: Page 122

(ii) Length 12-32 cm

(b) Types
(i) Cuffed 5.0-9.0
(a) Proximal End 15 mm Adapter
(b) Proximal End Inflation Port with Pilot Balloon
(c) Cm markings along length
(d) Distal End Beveled Tip
(e) F)Distal End Balloon Cuff
(ii) Uncuffed 2.5-4.5
(a) Proximal End 15 mm Adapter
(b) Distal End Bevel Tip
(c) Distal End Depth Markings
(d) No Balloon Cuff or Pilot Balloon
(2) Laryngoscope
(a) Device used to visualize Glottis during Endotracheal Intubation
(b) Battery Pack/Handle with interchangeable Blades
(i) Blade Types
(a) Straight (Miller) Lifts Epiglottis
(b) Curved (Macintosh) Lifts Epiglottis by fitting into Vallecula
(3) Adjunct Equipment
(a) 10 cc Syringe
(i) To inflate/Deflate Balloon Cuff
(b) Water Soluble Lubricant
(i) To Lubricate Endotracheal Tube, promote ease of passage,
and decrease Trauma
(c) Stylet
(i) Semi-rigid wire for molding and maintaining Tube shape
(d) Securing Device
(i) Tape or commercially available endotracheal tube Holder
(e) Suction
(4) Body Substance Precautions
(a) Gloves
(b) Mask
(c) Eyewear or Face shield
(5) Pre-Intubation precautions
(a) Essential prior to performing any Intubation
(i) Positioning
(a) Both patient and Intubator
(ii) Pre-oxygenation
(iii) Suction
(iv) Equipment preparation
Section 2: Page 123

2. Direct Orotracheal Intubation

a) Directly visualizing the passage of an ET Tube into the Trachea
b) Indications
(1) Apnea
(2) Hypoxia
(3) Poor Respiratory Effort
(4) Suppression or absence of Gag Reflex
(1) Caution in unsuppressed Gag Reflex
d) Advantages
(1) Direct Visualization of Anatomy and Tube placement
(2) Ideal method for confirming placement
(3) May be performed in breathing and apneic patients
e) Disadvantages
(1) Requires Special Equipment
f) Complications
(1) Dental Trauma
(2) Laryngeal Trauma
(3) Misplacement
(a) Right main stem
(b) Esophageal
g) Method
(1) Position
(a) Sniffing Position
(i) Optimal Hyperextension of head with Elevation of Occiput
(a) Brings the axis of the Mouth, the Pharynx, and the Trachea
into alignment
(2) Insure Optimal Oxygenation and Ventilation with 100% O2
(3) Insure All Equipment is prepared
(a) Lubricated Tube with Stylet in place
(i) Best position is "Hockey Stick" bend directly behind Balloon
Cuff
(b) Working Laryngoscope
(i) Blade locks securely in place
(ii) Light is Bright and Steady (unpleasant to look at)
(c) Syringe
(d) Securing Device
(e) Suction
(f) Body Substance Precautions
(4) Ideally, hyperoxygenate Patient for 30 sec to 1 min.
Section 2: Page 124

(5) Insert Laryngoscope Blade

(a) Gently insert to Hypopharynx
(b) Lift Tongue and Jaw with firm, steady pressure
(i) Avoid fulcrum against Teeth
(c) Identify Vocal Cords
(d) Gently pass ET Tube
(i) Observe passage of Balloon Cuff past Cords
(e) Remove Stylet
(f) Inflate Balloon Cuff
(g) Ventilate Patient
(h) Confirm Placement with Multiple methods
(i) Reconfirm Placement with major patient movement or Head
movement
3. Confirming Placement
a) Single greatest reason misplacement goes unrecognized
b) Methods
(1) Direct Re-visualization
(a) Re-visualize Glottis
(b) Note Tube Depth
(i) "Teeth and Tube at 22 cm"
(c) Note condensation in the Tube
(2) Auscultation
(a) Epigastric Area
(i) Air entry into stomach indicates esophageal placement
(b) Bilateral Bases
(i) Equal volume and expansion
(c) Apices
(i) Equal volume
(d) Unequal or absent Breath Sounds indicate
(i) Esophageal Placement
(ii) Right main stem Placement
(iii) Pneumothorax
(iv) Bronchial Obstruction
(3) Palpation of Balloon Cuff at Sternal notch by compressing Pilot Balloon
(4) Pulse Oximetry
(a) In intubated patients with pulse, O2 saturation should increase
rapidly
(5) Expired CO2
(a) Measures Presence of CO2 in Expired Air
(i) Colormetric
(ii) Digital
(iii) Digital/Waveform
Section 2: Page 125

(6) Bag Valve Mask Ventilation Compliance

(a) Increased resistance to BVM compliance may indicate
(i) Gastric Distension
(ii) Esophageal Placement
(iii) Tension Pneumothorax
c) Evidence of a misplaced tube regardless when it was last checked must be
reconfirmed
d) Confirmation must be performed
(1) By multiple methods
(2) Immediately after Tube placement
(3) After any major move
(4) After manipulation of Neck
(a) Manipulation of neck may displace tube up to 5 cm
e) Methods to properly place an endotracheal tube after misplacement
4. Securing Tube
a) As critical as the intubation itself
b) Multiple methods and products available
c) Adjuncts include
(1) Securing to Maxilla rather than Mandible
(2) Tincture of Benzoin to facilitate tape adhesion
H. Multi-lumen airways
1. Pharyngo-tracheal lumen airway (PTL)
a) An Endotracheal Tube encased in a large Pharyngeal Tube
b) Designed to be passed blindly
c) Multiple ventilation ports provide means to ventilate regardless of whether
the ET Tube is placed in the Esophagus or the Trachea
d) Indications
(1) Pulseless, apneic patient (no spontaneous respirations)
(2) Patients that are apneic and can tolerate an oropharyngeal airway
(3) Alternative Airway control when conventional Intubation procedures are
not available or successful
e) Advantages
(1) Can ventilate with Tracheal or Esophageal Placement
(2) No Face mask to seal
f) Disadvantages
(1) Cannot be used in Awake patients
(2) Adults only
(4) Pharyngeal Balloon mitigates but does not eliminate aspiration risk
(5) Can only be passed orally
(6) Extremely difficult to Intubate around
Section 2: Page 126
g) Method
(1) Head Neutral
(2) Pre-Intubation Precautions
(3) Insert at the midline using Jaw-Lift
(4) Ventilate through Pharyngeal Tube (green) First
(a) Chest Rise indicates ET Tube is in Esophagus
(b) Inflate Pharyngeal Balloon and Ventilate
(c) No Chest Rise indicates ET Tube in Trachea
(d) Inflate ET Tube Balloon Cuff
(e) Ventilate through ET Tube
h) Complications
(1) Pharyngeal or Esophageal Trauma from poor technique
(2) Unrecognized displacement of ET Tube into esophagus
(3) Displacement of Pharyngeal balloon
2. Combitube
a) Pharyngeal and Endotracheal Tube molded into a single Unit
b) Indications
(1) Alternative Airway control when conventional Intubation measures are
unsuccessful or unavailable
(1) Children too small for the tube
(2) Esophageal Trauma or disease
(3) Caustic ingestion
d) Advantages
(1) Rapid Insertion
e) Disadvantages
(1) Impossible to suction Trachea when tube is in Esophagus
(2) Adults Only
(4) Very difficult to Intubate around
f) Method
(1) Head Neutral
(2) Preintubation Precautions
(3) Insert with Jaw-Lift at midline
(4) Inflate Pharyngeal Cuff with 10 cc air
(5) Inflate Distal Cuff with 10-15 cc air
(6) Ventilate through longest tube First (Pharyngeal)
(a) Chest rise indicates esophageal placement of distal tip
(b) No chest rise indicates Tracheal placement. Switch ports and
ventilate
Section 2: Page 127

3. Field extubation
a) The only reason to field extubate is if the patient is unreasonably intolerant
of the tube
b) Ordinarily you do not extubate for these reasons:
(1) Awake patients are, in particular, at highest risk of Laryngospasm
immediately following extubation.
(2) The possibility of airway occlusion due to emesis
(3) Difficulty of reintroducing the airway due to laryngospasm
I. Special patient considerations
1. Patients with a laryngectomy (stoma)
a) Laryngectomy Patients have a permanent or semi-permanent surgical
opening below the glottis, which acts as their primary airway. The opening
is called a Stoma
b) Airway is kept open by a short endotracheal tube device that fits into the
Stoma
(1) Part or entire tube assembly may be removed for normal cleaning
c) Since protective function of the upper airway is bypassed, Laryngectomy
patients commonly produce moderately large amounts of mucous.
Coughing is also not as efficient or forceful
d) Most common Laryngectomy problems
(1) Mucous Plug
(a) Usually occurs while coughing
(b) Mucous builds up and cannot be forcibly expelled from bronchi or
Tube
(c) Treatment
(i) Suction Trachea
(a) Pre-oxygenate
(b) Inject 1 to 3 cc's Sterile Water into trachea to loosen
secretions. Patient will cough.
(c) Gently insert flexible suction catheter into trachea. Suction
on the way out. Encourage patient to cough
(d) Oxygenate
(e) Reassess
(f) Repeat as necessary
(2) Stenosis
(a) Stoma narrows and patient cannot replace their Tube
(b) Particularly dangerous for patients with a recent laryngectomy
(c) May require placement of smaller endotracheal tube into the Stoma
to prevent complete occlusion
(d) If tube placement is not immediately successful, rapid transport is
necessary. Give 100% O2
e) Dental Appliances - Loose Dentures, Retainers, etc.,: Should be removed
when possible
2. Additional considerations
Section 2: Page 128
a) Pulse oximetry cannot give information about alveolar ventilation. For this
reason, the EMT-I should be careful not to accept adequate SaO2 values
while neglecting gross hypoventilation.
b) Patients with chronic obstructive pulmonary disease may have a normally
low SaO2, so adequate histories must be obtained.
XI. Medical/legal considerations
NOTES
Section 2: Page 129

NOTES:
Section 2: Page 130


Section 2 - Essentials/Lesson 2-6: Assessment and Management of Shock
OBJECTIVES LEGEND
1=Knowledge
2=Application

assessment findings to formulate a field impression and implement the treatment plan for
the bleeding patient or the patient in shock.
At the conclusion of this lesson, the EMT-Intermediate student will be able to:
GENERAL
1. Describe the epidemiology, including the morbidity/mortality and prevention strategies,
for shock and hemorrhage. (C-1)
2. Discuss the anatomy and physiology of the cardiovascular system. (C-1)
3. Predict shock and hemorrhage based on mechanism of injury. (C-3)
4. Discuss the various types and degrees of shock and hemorrhage. (C-1)
PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Cardiovascular System

5. Discuss the pathophysiology of hemorrhage and shock. (C-1)
6. Discuss the assessment findings associated with hemorrhage and shock. (C-1)
7. Identify the need for intervention and transport of the patient with hemorrhage or shock.
(C-1)
8. Discuss the treatment plan and management of hemorrhage and shock. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Hemorrhage

9. Describe the incidence, morbidity, and mortality of hemorrhage.(C-1)
10. Discuss the management of external hemorrhage.(C-1)
11. Differentiate between the administration rate and amount of IV fluid in a patient with
controlled versus uncontrolled hemorrhage.(C-3)
12. Relate internal hemorrhage to the pathophysiology of compensated and
uncompensated hemorrhagic shock.(C-3)
13. Relate internal hemorrhage to the assessment findings of compensated and
14. Discuss the management of internal hemorrhage.(C-1)
Section 2: Page 132

SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Shock

15. Describe the incidence, morbidity, and mortality of shock.(C-1)
16. Describe the body's physiologic response to changes in perfusion.(C-1)
17. Discuss the assessment findings of hemorrhagic shock.(C-1)
18. Relate pulse pressure changes to perfusion status.(C-3)
19. Relate orthostatic vital sign changes to perfusion status.(C-3)
20. Define compensated and uncompensated hemorrhagic shock.(C-1)
21. Discuss the pathophysiological changes associated with compensated shock.(C-1)
22. Discuss the assessment findings associated with compensated shock.(C-1)
23. Identify the need for intervention and transport of the patient with compensated shock.
24. Discuss the treatment plan and management of compensated shock.(C-1)
25. Discuss the pathophysiological changes associated with uncompensated shock.(C-1)
26. Discuss the assessment findings associated with uncompensated shock.(C-1)
27. Identify the need for intervention and transport of the patient with uncompensated shock.
28. Discuss the treatment plan and management of uncompensated shock.(C-1)
29. Differentiate between compensated and uncompensated shock.(C-3)
30. Relate external hemorrhage to the pathophysiology of compensated and
31. Relate external hemorrhage to the assessment findings of compensated and
32. Differentiate between the administration of fluid in the normotensive, hypotensive, and
profoundly hypotensive patient.(C-3)
33. Discuss the physiologic changes associated with the pneumatic anti-shock garment
(PASG).(C-1)
34. Discuss the indications and contraindications for the application and inflation of the
PASG.(C-1)
INTEGRATION
35. Apply epidemiology to develop prevention strategies for hemorrhage and shock. (C-1)
36. Integrate the pathophysiological principles to the assessment of a patient with
hemorrhage or shock. (C-1)
37. Synthesize assessment findings and patient history information to form a field
impression for the patient with hemorrhage or shock. (C-2)
38. Develop, execute and evaluate a treatment plan based on the field impression for the
hemorrhage or shock patient. (C-1)
Section 2: Page 133

39. Demonstrate the assessment of a patient with signs and symptoms of hemorrhagic
shock. (P-2)
40. Demonstrate the management of a patient with signs and symptoms of hemorrhagic
shock. (P-2)
41. Demonstrate the assessment of a patient with signs and symptoms of compensated
hemorrhagic shock.(P-2)
42. Demonstrate the management of a patient with signs and symptoms of compensated
hemorrhagic shock. (P-2)
43. Demonstrate the assessment of a patient with signs and symptoms of uncompensated
44. Demonstrate the management of a patient with signs and symptoms of uncompensated
hemorrhagic shock. (P-2)
45. Demonstrate the assessment of a patient with signs and symptoms of external
hemorrhage.(P-2)
46. Demonstrate the management of a patient with signs and symptoms of external
hemorrhage. (P-2)
47. Demonstrate the assessment of a patient with signs and symptoms of internal
hemorrhage.(P-2)
48. Demonstrate the management of a patient with signs and symptoms of internal
hemorrhage. (P-2)
Section 2: Page 134

Presentation
DECLARATIVE
I. Pathophysiology, assessment, and management of hemorrhage
A. Hemorrhage
1. Epidemiology
a) Incidence
b) Mortality/morbidity
c) Prevention strategies
2. Pathophysiology
a) Location
(1) External
(2) Internal
(a) Trauma
(b) Non-trauma
(i) Common sites
(ii) Uncommon sites
b) Anatomical type
(1) Arterial
(2) Venous
(3) Capillary
c) Timing
(1) Acute
(2) Chronic
d) Severity
(1) Amounts of blood loss adults, children and infants can tolerate
e) Physiological response to hemorrhage
(1) Clotting
(2) Localized vasoconstriction
f) Stages of hemorrhage
(1) Stage 1
(a) Up to 15% intravascular loss
(b) Compensated by constriction of vascular bed
(c) Blood pressure maintained
(d) Normal pulse pressure, respiratory rate, and renal output
(e) Pallor of the skin
(f) Central venous pressure low to normal
(2) Stage 2
(a) 15-25% intravascular loss
(b) Cardiac output can not be maintained by arteriolar constriction
(c) Reflex tachycardia
(d) Increased respiratory rate
(e) Blood pressure maintained
Section 2: Page 135
(f) Catecholamines increase peripheral resistance

(g) Increased diastolic pressure
(h) Narrow pulse pressure
(i) Diaphoresis from sympathetic stimulation
(j) Renal output almost normal
(3) Stage 3
(a) 25-35% intravascular loss
(b) Classic signs of hypovolemic shock
(i) Marked tachycardia
(ii) Marked tachypnea
(iii) Decreased systolic pressure
(iv) 5-15 ml per hour urine output
(v) Alteration in mental status
(vi) Diaphoresis with cool, pale skin
(4) Stage 4
(a) Loss greater than 35%
(b) Extreme tachycardia
(c) Pronounced tachypnea
(d) Significantly decreased systolic blood pressure
(e) Confusion and lethargy
(f) Skin is diaphoretic, cool, and extremely pale
3. Assessment
a) Bright red blood from wound, mouth, rectum or other orifice
b) Coffee ground appearance of vomitus
c) Melena and hematochezia
d) Dizziness or syncope on sitting or standing
e) Orthostatic hypotension
f) Signs and symptoms of hypovolemic shock
4. Management
a) Airway and ventilatory support
b) Circulatory support
(1) Bleeding from nose or ears after head trauma
(a) Refrain from applying pressure
(b) Apply loose sterile dressing to protect from infection
(2) Bleeding from other areas
(a) Control bleeding
(i) Direct pressure
(ii) Elevation if appropriate
(iii) Pressure points
(iv) Tourniquet
(v) Splinting
(vi) Packing of large gaping wounds with sterile dressings
Section 2: Page 136

(vii) PASG
(b) Apply sterile dressing and pressure bandage
(3) Transport considerations
(4) Psychological support/Communication strategies
II. Shock
A. Epidemiology
1. Mortality/morbidity
2. Prevention strategies
3. Pathophysiology
a) Stages of shock
(1) Compensated or nonprogressive
(a) Characterized by signs and symptoms of early shock
(b) Arterial blood pressure is normal or high
(c) Treatment at this stage will typically result in recovery
(2) Decompensated or progressive
(a) Characterized by signs and symptoms of late shock
(b) Arterial blood pressure is abnormally low
(c) Treatment at this stage will sometimes result in recovery
(3) Irreversible
(a) Characterized by signs and symptoms of late shock
(b) Arterial blood pressure is abnormally low
(c) Even aggressive treatment at this stage does not result in recovery
b) Etiologic classifications
(1) Hypovolemic
(a) Hemorrhage
(b) Plasma loss
(c) Fluid and electrolyte loss
(d) Endocrine
(2) Distributive (vasogenic)
(a) Increased venous capacitance
(b) Low resistance, vasodilatation
(3) Cardiogenic
(a) Myocardial insufficiency
(b) Filling or outflow obstruction (obstructive)
4. Assessment - Hypovolemic shock due to hemorrhage
a) Early or compensated
(1) Tachycardia
(2) Pale, cool skin
(3) Diaphoresis
(4) Level of consciousness
(a) Normal
(b) Anxious or apprehensive
Section 2: Page 137

(5) Blood pressure maintained

(6) Narrow pulse pressure
(a) Pulse pressure is the difference between the systolic and diastolic
pressures, i.e., Pulse pressure = systolic - diastolic
(b) Pulse pressure reflects the tone of the arterial system and is more
sensitive to changes in perfusion than the systolic or diastolic alone
(7) Orthostatic hypotension
(8) Dry mucosa
(9) Complaints of thirst
(10)Weakness
(11)Possible delay of capillary refill
b) Late or progressive
(1) Extreme tachycardia
(2) Extreme pale, cool skin
(3) Diaphoresis
(4) Significant decrease in level of consciousness
(5) Hypotension
(6) Dry mucosa
(7) Nausea
(8) Cyanosis with white waxy looking skin
5. Differential shock assessment findings
a) Shock is assumed to be hypovolemic until proven otherwise
b) Cardiogenic shock is differentiated from hypovolemic shock by one or more
of following
(1) Chief complaint, e.g., Chest pain, dyspnea, tachycardia
(2) Heart rate, i.e., Bradycardia or excessive tachycardia
(3) Signs of congestive heart failure, i.e., Jugular vein distention (JVD), rales
(4) Dysrhythmias
c) Obstructive shock (filling or outflow obstruction) is differentiated from hypovolemic
shock by presence of signs and symptoms suggestive of
(1) Cardiac tamponade
(2) Tension pneumothorax
d) Distributive shock (Vasogenic) is differentiated from hypovolemic shock by
presence of one or more of following
(1) Mechanism that suggests vasodilatation, e.g., Spinal cord injury, drug
overdose, sepsis, anaphylaxis
(2) Warm, flushed skin, especially in dependent areas
(3) Lack of tachycardia response (not reliable, though, since significant
number of hypovolemic patients never become tachycardic)
B. Management/Treatment Plan
1. Airway and ventilatory support
a) Ventilate and suction as necessary
b) Administer high concentration oxygen
Section 2: Page 138
2. Circulatory support
a) Hemorrhage control
b) Intravenous volume expanders
(1) Types
(a) Isotonic solutions
(2) Rate of administration
(a) External hemorrhage that can be controlled
(b) External hemorrhage that can not be controlled
(c) Internal hemorrhage
(i) Blunt trauma
(ii) Penetrating trauma
c) Pneumatic anti-shock garment
(1) Effects
(a) Increased arterial blood pressure above garment
(b) Increased systemic vascular resistance
(c) Immobilization of pelvis and possibly lower extremities
(d) Increased intraabdominal pressure
(2) Mechanism
(a) Increases systemic vascular resistance through direct compression
of tissues and blood vessels inferior to costal margin
(b) Negligible autotransfusion effect
(3) Indications
(a) Hypoperfusion with unstable pelvis
(b) Conditions of decreased Systemic Vascular Resistance (SVR) not
corrected by other means
(c) As approved locally, other conditions characterized by
hypoperfusion with hypotension
(4) Research studies
(a) Advanced pregnancy (no inflation of abdominal compartment)
(b) Object impaled in abdomen or evisceration (no inflation of
abdominal compartment)
(c) Ruptured diaphragm
(d) Cardiogenic shock
(e) Pulmonary edema
3. Pharmacological interventions - Medications only to be administered by ILS or
ILS/AW Techs following approval by on-line or off-line medical direction/control.
a) Hypovolemic shock
(1) Volume expanders
b) Cardiogenic shock
c) Distributive (vasogenic) shock
Section 2: Page 139
(2) PASG/MAST trousers

d) Obstructive shock (filling or outflow obstruction)
4. Psychological support/Communication strategies
5. Transport considerations
a) Indications for rapid transport
b) Indications for transport to a Trauma Center
III. Medical/legal considerations
IV. Integration
Section 2: Page 140

Lesson 2-7: Intravenous & Intraosseous Line Placement and Infusion

OBJECTIVES LEGEND
1=Knowledge
2=Application
At the end of this lesson, the student will be able to:
1. Define the term intravenous cannulation. (C-1)
2. Describe universal precautions and body substance isolation (BSI) procedures when
performing an intravenous cannulation. (C-1)
3. Discuss medical asepsis. (C-1)
4. Differentiate among the different solutions and intravenous cannulation devices used
when administering intravenous cannulations for the management of trauma and
medical emergencies. (C-3)
5. Identify anatomic landmarks utilized in administering intravenous cannulations. (C-1)
6. Correctly locate three appropriate sites for intraosseous needle insertion. (C-1)
7. Describe the equipment needed, indications, contraindications, complications, and
procedures for the preparation and administration of intravenous cannulations, including
saline locks. (C-1)
8. Identify the equipment needed and procedures used for discontinuing an intravenous
cannulation. (C-1)
9. Describe the procedures, the preparation and administration of a fluid challenge.(C-1)
10. Describe on-line and off-line medical direction/control for intravenous cannulation. (C-1)
11. State the indications and contraindications for insertion of an intraosseous line. (C-1)
12. List the necessary equipment for an intraosseous insertion. (C-1)
13. Describe the steps required for intraosseous needle insertion and confirmation of correct
placement. (C-1)
14. Describe the process of securing the intraosseous needle. (C-1)
15. Compare the rate of fluid infusion through a peripheral line versus an intraosseous line,
and describe methods of increasing the rate of infusion through an intraosseous line. (C-
1)
16. Describe the concept of fluid limitation in patients under 100 pounds. (C-1)
17. State the potential complications of intraosseous needle insertion and infusion. (C-1)
18. Differentiate among the different techniques for obtaining a blood sample. (C-3)
19. Identify locations utilized in obtaining a blood sample. (C-1)
20. Describe the equipment needed, techniques utilized, complications, and general
principles for obtaining a blood sample. (C-1)
21. Describe and understand the use and testing of blood glucose monitoring devices. (C-1)
22. Describe disposal of contaminated items and sharps. (C-1)
Section 2: Page 142

23. Comply with universal precautions and body substance isolation (BSI). (A-1)
24. Serve as a model for disposing contaminated items and sharps. (A-3)
25. Perform universal precautions and body substance isolation (BSI) procedures during
medication administration. (P-1, P-2)
26. Perfect clean technique during intravenous cannulation, blood draws and glucose
monitoring. (P-3)
27. Demonstrate preparation and techniques for performing an intravenous cannulation. (P-
1, P-2)
28. Demonstrate the procedures, the preparation and administration of a fluid challenge.(P-
1, P-2)
29. Demonstrate preparation and techniques for performing an intraosseous needle
insertion and confirmation of correct placement. (P-1, P-2)
30. Locate sites utilized in obtaining a blood sample. (P-1, P-2)
31. Demonstrate preparation and techniques for obtaining a blood sample. (P-1, P-2)
32. Demonstrate preparation and techniques for using blood glucose monitoring devices.
(P-1, P-2)
33. Perfect disposal of contaminated items and sharps. (P-3)
Section 2: Page 143

Presentation
Declarative:
I. Intravenous Cannulation
A. Definition:
1. The placement of a catheter into a vein. It is used to administer fluids, or
medications directly into the circulatory system. It can also be used to obtain
venous blood specimens for laboratory determinations.
2. Because IV fluids are drugs, on-line medical direction/control or standing
orders are required for the EMT-I to administer IV fluids.
B. Indications
1. Replacement of circulatory volume
2. To establish a medication administration route
C. Contraindications - Cannulation of a particular site is contraindicated in:
1. Sclerotic veins
2. Burned extremities
D. Universal Precautions and Body Substance Isolation (BSI) in Medication
Administration
E. Equipment
1. Intravenous (IV) solutions
a) Types of solutions
(1) Crystalloids
(2) Colloids - Informational only - not for field use
b) Types of containers
c) Variety of volumes
2. Intravenous (IV) administration sets
a) Components
(1) Piercing spike
(2) Drip Chamber
(a) Macrodrip chamber-type
(b) Microdrip chamber-type
b) Flow clamp
c) Drug administration port
d) Connector end
e) Variety of extensions and other pieces of equipment
f) Some IV administration sets are manufacturer specific
3. Needles/Catheters
a) Types
(1) Over the needle
(2) Through the needle
b) IV catheter size
Section 2: Page 144

4. Supplies and materials

a) Personal protective equipment to maintain BSI
b) Tourniquet
c) Alcohol/povidone iodine
d) Sterile dressings
e) Tape
f) Armboards
g) Vacutainer holder and assorted blood collection tubes for blood samples
F. Sites for peripheral venous cannulation
1. Structure of veins
2. Difference between arteries and veins
3. The skin
a) Epidermis
b) Dermis
4. Sites used in non-critical, routine situations:
a) Distal veins on the dorsum of the hand and arms
b) If available, the EMT-I should use a vein that is:
(1) Fairly straight
(2) Easily accessible
(3) Well-fixed, not rolling
(4) Feels springy when palpated
c) Avoid
(1) Sclerotic veins
(2) Veins near joints
(3) Areas where an arterial pulse is palpable close to the vein
(4) Injured or swollen extremities
5. Sites used in cardiac arrest - antecubital fossa (the area anterior to and below
the elbow)
6. Other sites include peripheral leg veins
G. Procedure for performing IV cannulation - The EMT-I must do the following:
1. Explain the need for IV cannulation and describe the procedure to the patient.
2. Ask if the patient has any allergies (especially to iodine if using iodine pads to
cleanse the skin).
3. Select IV solution to be used and check to make sure it is:
a) The proper solution
b) Clean, without particulate matter
c) Not outdated
d) Not leaking
e) Warmed or cooled as indicated
4. Select an appropriate size catheter:
a) 14 to 16 gauge for trauma, volume replacement, or cardiac arrest
b) 18 to 20 gauge for medical conditions
Section 2: Page 145

5. Select the proper administration set:

a) Macro for trauma
b) Micro for medical conditions and drug administration
6. Prepare the IV bag and administration set using an aseptic technique to prevent
contamination.
a) Remove IV bag from its protective envelope and gently squeeze to detect
any punctures or leakage.
b) Steady the port of the IV bag with one hand, and remove the protective cap
by pulling smoothly to the right.
c) Remove the administration set from its protective wrapping or box
d) Slide the flow control valve close to the drip chamber.
e) Close off the flow control valve.
f) Remove the protective cap from the spiked piercing end of the
administration set.
g) Invert the IV bag.
h) Using sterile technique, insert the spiked end of the administration set into
the tubing insertion port of the IV bag. Use one quick, smooth motion.
i) Turn the IV bag right side up, and squeeze the drip chamber two or three
times to fill it half-way.
j) Open the control valve to flush IV solution through the entire tubing, which
should force out all the air.
7. Cut or tear several pieces of tape of different lengths.
8. Employ BSI precautions.
9. If possible, place the patient into a suitable position with the selected extremity
lower than the heart. This positioning helps distend the distal veins.
10. Apply a tourniquet.
11. Select a suitable vein by palpation and sight.
a) Avoid areas of the veins where a valve is situated.
b) If the vein rolls, or feels hard or rope-like, select another vein.
c) Veins can be distended for easier cannulation by:
(1) Having the patient open and close their fist tightly five or six times.
(2) Flicking the skin over the vein with one or two sharp snaps of the
fingers.
(3) Rubbing or stroking the skin upward toward the tourniquet.
d) If a suitable vein cannot be found, or if the vein still feels small and uniform,
release the tourniquet and apply it closer to the IV site.
e) If that fails to resolve the problem, apply the tourniquet to the other arm.
12. Stabilize the vein by anchoring it with the thumb and stretching the skin
downward.
Section 2: Page 146

13. Perform the venipuncture without contaminating the equipment or site.

a) Tell the patient there will be a small poke or pinch as the needle enters the
skin.
b) Hold the end of the venipuncture device between thumb and the
index/middle fingers:
(1) Maintain visualization of the flashback chamber.
(2) Avoid touching any portion of the catheter, because a contaminated
device is not usable.
c) Depending on the type of venipuncture device and manufacturer
recommendations, hold the needle at a 15, 30 or 45 degree angle to the
skin.
d) Penetrate the skin with the bevel of the needle pointed up.
(1) If significant resistance is felt, do not force the catheter.
(2) Instead, withdraw the needle and catheter together as a unit.
e) If possible, penetrate the vein at its junction or bifurcation with another vein,
because it is more stable at this location.
f) Enter the vein with the needle from either the top or side.
(1) Normally, a slight “pop” or “give” is felt as the needle passes through
the wall of the vein.
(2) Be careful not to enter too fast or too deeply, because the needle can
go through the back wall of the vein.
g) Note when blood fills the flashback chamber.
h) Lower the venipuncture device and advance it another 1 to 2 cm until the tip
of the catheter is well within the vein.
i) Advance the catheter into the vein following the manufacturers
recommendations.
j) Once the catheter is within the vein, apply pressure to the vein beyond the
catheter tip with the little finger to prevent blood from leaking out of the
catheter hub once the needle is completely withdrawn.
k) It may be necessary to use the drawback technique to determine patency.
14. Draw a blood sample. The tourniquet should be left in place while drawing
blood samples.
a) Stabilize the catheter with one hand, and attach a Vacutainer holder with a
multi-sample IV Luer-lock adapter or a syringe to the hub.
(1) Be careful not to disrupt the catheter placement while connecting the
Vacutainer or syringe.
(2) Once the device is connected, release the finger pressure at the distal
tip of the catheter
b) If using a Vacutainer device, insert the blood collection tube fully into the
holder and allow its internal vacuum to draw blood out of the vein.
Section 2: Page 147

c) If using a syringe, slowly withdraw the plunger to fill the syringe with blood.
(1) If blood flow into the syringe stops, it usually means that the sucking
pressure of the syringe is collapsing the vein.
(2) To correct this problem, slow the rate at which the plunger is being
withdrawn.
15. Once enough blood collection tubes have been filled or the syringe is
completely full, release the tourniquet from the patient’s arm.
a) Next reapply pressure to the vein beyond the catheter tip with the little
finger to prevent blood from leaking out of the catheter hub once the blood
drawing device is disconnected.
b) Disconnect the syringe or Vacutainer device from the hub of the catheter by
holding the hub between the first finger and thumb and pulling the device
free with the other hand.
16. Connect the IV tubing to the catheter hub. Be careful not to contaminate either
the hub or connector prior to insertion.
17. Open the IV flow control valve and run the IV for a brief period of time to ensure
the line is patent. To ensure proper IV flow rates, the IV container must hang at
least 30 to 36 inches above the insertion site.
18. Cover the IV site with povidone-iodine ointment and a sterile dressing or a
bandage.
19. Secure the catheter, administration set tubing, and sterile dressing in place with
tape.
a) Tubing should be looped and secured with tape above the IV cannulation
site.
b) This gives the tubing more play, making the catheter less likely to be
dislodged by accidental pulls on the tubing.
c) Do not make the loop so small that it kinks the tubing and restricts fluid flow.
20. Adjust the appropriate flow rate for the patient’s condition.
21. Dispose of the needle(s) in a proper biomedical waste container.
22. If a syringe was used to draw the blood:
a) The necessary blood collection tubes must be filled by attaching needle to
the syringe and inserting it into each blood tube.
b) The tubes should then be labeled and stored in a safe location.
H. Using an armboard. Armboards may be:
1. Avoided simply by choosing a venipuncture site well away from any flexion
areas.
2. Necessary when a venipuncture device is inserted near a joint or in the dorsum
of the hand
3. Used along with restraints in confused or disoriented patients.
Section 2: Page 148

I. Regulating fluid flow rates

1. Flow rates should be adjusted as ordered by medical control/direction.
2. The EMT-I must know the volume to be infused, the period of time over which
the fluid is to be infused, and the number of drops per milliliter the infusion set
delivers.
a) The following formula can be used to calculate IV solution drip rates per
minute
b) Drops per min. = volume to be infused x drops/ml of administration set ÷
total time of infusion in minutes.
3. After determining the rate, open the clamp slowly to start fluid dripping into the
drip chamber.
a) Determine drops per minute and adjust the flow clamp as needed to obtain
the correct drip rate.
b) Check the flow rate periodically.
4. Various types of infusion pumps
J. Documenting IV cannulation
1. Depending on local protocol, when an IV is started, the following must be
documented on the run report:
a) Date and time of the venipuncture
b) Type and amount of solution
c) Type of venipuncture device used, including the length and gauge
d) Venipuncture site
e) Number of insertion attempts (if more than one)
f) IV flow rate
g) Any adverse reactions and the actions taken to correct them
h) Name or identification number of the EMT-I initiating the infusion
2. In addition to documenting correct IV placement, unsuccessful attempts also
should be documented
3. Some local protocols call for the EMT-I to document the following information
directly on the tape that is used to secure the venipuncture device and
administration set tubing in place:
a) Date and time of insertion
b) Type and gauge of needle or catheter
c) Initial of the EMT-I who placed the device
4. To do this procedure:
a) A piece of tape should be cut and placed on a flat surface
b) Information should be written on the tape then applied over the dressing
5. Never label the tape after it has been applied over the dressing. Doing so will
irritate the venipuncture site
K. When the IV does not flow
1. Was the venous tourniquet removed?
2. Is there swelling at the cannulation site?
3. Is the flow regulator in an open position?
Section 2: Page 149

4. Is the tip of the catheter positioned against a valve or wall of the vein?
5. Is the IV bag high enough?
6. Is the drip chamber completely filled with IV solution?
L. Complications
1. Pain
2. Catheter shear
3. Cannulation of an artery
4. Hematoma or infiltration
5. Phlebitis or infection
6. Extravasation
7. Air in tubing/air embolism
8. Circulatory overload and pulmonary edema
9. Allergic reaction
10. Pulmonary embolism
11. Failure to infuse properly
M. Steps in changing to the next container of IV solution
N. Steps to discontinue an intravenous infusion
1. Equipment
a) Gloves
b) Sterile gauze pad
c) adhesive bandage
2. Technique
a) Close the flow control valve completely
b) Taking care not to disturb the catheter, carefully untape and remove the
dressing
c) Hold the sterile gauze pad just above the site to stabilize the tissue and
withdraw the catheter by pulling straight back until the catheter is
completely out of the vein
d) Immediately cover the site with the sterile gauze pad and hold it against the
puncture site until the bleeding has stopped
e) Tape the dressing in place or cover with an adhesive bandage
II. Drawing Blood
A. Purpose - to obtain blood samples from a patient for analysis
B. Equipment needed for obtaining a blood sample:
1. Variety of sizes and types of blood tubes are available to collect and store blood
samples.
a) The rubber caps on the tubes come in several colors and patterns denoting
the specific tests that are conducted with the blood that is stored in them
b) Most commonly used in the field are the red, purple, green, or “jungle” blue,
and gray tops
(1) Blood collection tubes may vary by manufacturer.
(2) Check with your local medical facility.
Section 2: Page 150

c) Some tubes have small amounts of liquids or agents inside the tube to
prevent blood coagulation or to aid in preserving the blood in a way
necessary for a particular type of test
d) During manufacture of blood tubes, a vacuum is created in the tube that
acts to “suck blood” into the tube
C. Locations from which to obtain a blood sample
1. Anatomical sites
2. From the established intravenous catheter
3. Other locations
D. Steps to preparing equipment for obtaining a blood sample
E. Techniques for obtaining a blood sample
1. When drawing blood, each tube should be filled completely
2. Blood tubes can be filled by drawing blood from the vein with a syringe and then
using at least a 19-gauge needle to introduce it into the blood tube or using a
Vacutainer holder that has a multi-sample IV Luer-lock adapter
3. Once the blood is obtained, the outside of the tube should be labeled with the
patient’s name, date, time drawn and by whom
a) In addition, any information that may be useful, such as, “drawn before the
administration of 50% dextrose”
b) During the transportation of the patient to the hospital, the filled blood
collection tubes can be stored in a plastic “zip-lock” bag to prevent
contamination of the EMT-I should one or more of the tubes be accidentally
broken
F. Complications
G. Refer to the local Medical Program Director protocols regarding the blood draw
process and procedures for law enforcement blood draw requests.
III. Saline Intravenous Access Locks
A. Saline lock devices maintain intravenous access while avoiding the risk of
inadvertent rapid-fluid administration and the inconvenience of manipulating IV
tubing and fluid bags while moving and handling patients
B. Equipment
1. Infusion adapter device
2. Vial of normal saline for injection
3. Syringe with needle
4. Alcohol wipe
C. Candidates for saline locks:
1. Patients who would have an IV placed to establish venous access
prophylactically
2. Patients who would have an IV placed to administer medication
D. Candidates for conventional IV therapy with appropriate solutions and
administrations sets:
1. Patients requiring volume resuscitation
2. Patients requiring continuous drip infusion of medication
Section 2: Page 151

3. Patients requiring cardiac or other resuscitation with frequent medications in

sequence
E. If, at any time, the patient’s condition deteriorates and it is felt a conventional IV is
necessary, it may be established by piggybacking into the injection port using a
needle no larger than 18 Ga. due to possible injection port coring with larger sizes
F. Procedure
IV. Fluid Challenge for Cardiogenic Shock
A. Following intravenous cannulation of normal saline at a KVO rate give a 250 to 500
cc fluid challenge if called for by medical direction/control or local protocols
V. Intraosseous Line Placement and Infusion - NOTE: FOR CHILDREN UNDER THE AGE
OF SIX ONLY
A. The chief indications for intraosseous line insertion are:
1. Compensated and Uncompensated Shock
a) Shock is usually the result of:
(1) Hypovolemia
(2) Sepsis
(3) Cardiac problems
b) Children respond to shock by:
(1) an increase in heart rate
(2) an increase in respiratory rate
(3) peripheral vasoconstriction
c) Signs of compensated (early) shock are:
(1) Tachycardia
(2) Tachypnea
(3) cool clammy extremities
d) Note 1: The child’s blood pressure does not decrease until later, when the
child is no longer able to compensate by an increase in heart rate and
vasoconstriction.
e) Note 2: Major symptoms to indicate a need for intervention with IV/IO fluids
would include:
(1) “Quiet” tachycardia (rate over 170)
(2) Altered level of consciousness
(3) Decreased perfusion
f) Signs of uncompensated shock are:
(1) Decreased level of consciousness
(2) Weak or absent pulses
(3) Hypotension
Section 2: Page 152

2. Cardiac Arrest:
a) A protocol for obtaining vascular access is helpful in making a decision
about the use of an intraosseous line when venous access cannot be
obtained rapidly. An intraosseous line is usually attempted after other
means of vascular access are unsuccessful or unavailable.
(1) Peripheral intravenous access often requires more time to insert than
an intraosseous line. A median time of 10 minutes is required to
achieve peripheral vascular access during a cardiac arrests; only 18%
of these attempts are successful within 90 seconds.
(2) If peripheral access is not achieved within 90 seconds, attempts to
insert an intraosseous line should be initiated.
(3) The intraosseous route delivers fluids and medications into the bone
marrow cavity, which acts as a non-collapsible vein and permits access
to the central circulation.
(4) All fluids and medications that are administered through a peripheral IV
can be administered through an intraosseous line. It is generally
recommended that hypertonic and alkaline solutions be diluted prior to
infusion.
B. Contraindications for insertion of an intraosseous line
1. An intraosseous line should not be inserted when there is a known fracture of
the bone chosen for line placement.
2. An intraosseous line should not be inserted when there is infection present in
the leg chosen for line placement.
3. Insertion of an intraosseous needle should not be attempted on the same leg
two times, as the hole made by the attempted insertion does not close rapidly
and fluid will extravasate.
C. Sites for Intraosseous Needle Insertion
1. There are three potential sites for intraosseous needle insertion:
a) Proximal Tibia
(1) The proximal tibia is the preferred location for intraosseous insertion in
a child six years and under because:
(a) The site is easily identified.
(b) A large marrow cavity exists with no adjacent structures that are
likely to be damaged.
(2) The site of insertion is on the flat medial surface of the anterior tibia,
one to two finger breadths below and medial to the tibial tuberosity.
b) Distal Femur
(1) The site of insertion is midline, approximately three centimeters above
the lateral condyle.
c) Distal Tibia
(1) The site of insertion is just above the medial malleolus.
Section 2: Page 153

D. Equipment for Intraosseous Infusion

1. Needles:
a) Either an intraosseous or bone marrow aspiration needle may be used.
They are preferable because of the following:
(1) They may contain a trocar or stylet, which minimizes the risk of
occlusion from bone marrow.
(2) They are shorter, sturdier and less flexible.
(3) They are less likely to be dislodged in transport because they are
threaded and shorter.
(4) Some of these needles have side infusion ports within the threads so a
stylet or trocar is not necessary.
(5) Some needle lengths can be adjusted.
b) A spinal needle can be substituted when an intraosseous or bone marrow
needle is not available, however it is less stable because of the needle’s
length and flexibility.
2. Other Equipment:
a) Iodine solution - for cleaning insertion site
b) Sterile towels and gloves - to maintain sterility during insertion
c) 4x4 gauze pads - for cleaning and for use in applying pressure if needle is
withdrawn
d) Two 5 or 10 cc syringes - to aspirate bone marrow and to infuse saline
e) IV solution (normal saline or lactated Ringer’s solution) and tubing
f) Towel or sandbag or small IV bag - for stabilizing leg during and after
insertion of the intraosseous needle
g) Blood tubes - for bone marrow aspirate
h) Pressure infusion bag
i) Volume limiting device
E. Four steps for intraosseous needle insertion
1. Step one - Stabilize the leg
a) Position the leg with the knee slightly bent.
b) Place a sandbag, or a roll of towels under the knee for support, and to
prevent movement.
c) Tape in place if necessary.
2. Step two - Prepare the insertion site
a) Clean the skin with iodine solution and 4x4 gauze pads.
b) Wipe in a circular motion starting at the planned insertion site and moving
outward.
c) Wipe the area dry with a sterile 4x4 gauze pad.
3. Step three - Insert the needle
a) Check the needle packaging for additional instructions. Some needles
require back and forth or a clockwise motion.
(1) Use aseptic technique.
(2) The needle should be directed away from the knee in order to decrease
the risk of insertion into the growth plate.
Section 2: Page 154
(3) Apply pressure to the top of the needle in order to push through the
cortex of bone.
(4) A slight give will be felt as the tip enters the marrow cavity.
(5) If the needle is properly inserted, it will stand without support.
b) Caution: If too much pressure is applied, the needle may exit through the
bone on the other side.
(1) If this occurs:
(a) Fluid will infiltrate into the tissue and Compartment syndrome may
develop.
(b) Remove the needle
(c) A site on the other leg must be chosen for the next insertion
attempt.
4. Step four - Confirm needle placement
a) Remove the stylet from the needle.
b) Connect a syringe to the hub of the needle.
c) Aspirate approximately I cc of bone marrow. Marrow may not always be
aspirated.
d) Bone marrow aspirate can be used for various lab studies such as
hemoglobin, electrolytes, bilirubin, gluclose, creatinine and bicarbonate.
e) 5 - 10 cc of normal saline may used to initially flush the syringe and
intraosseous needle while observing for extravasation. This fluid should
flush easily. If no extravasation occurs, placement is confirmed.
f) If the needle placement cannot be confirmed, remove the needle.
g) Do not attempt to re-insert the needle on the same site, as this will cause
leakage of fluids from the insertion site into the surrounding tissue.
h) If the needle is removed, apply pressure for 5 minutes and cover the
insertion site with a sterile dressing.
F. Securing the intraosseous needle
1. Connect the IV tubing to the hub of the correctly placed needle.
a) IV fluid should flow without obstruction when the needle is correctly
positioned.
b) IF the IV fluid is not flowing and correct insertion cannot be verified, remove
the intraosseous needle and attempt insertion at another location.
2. When correct insertion is confirmed, tape the tubing onto the child’s leg to assist
in preventing dislodgment.
3. Carefully monitor the insertion site for signs of infiltration.
a) Remove the needle if infiltration is observed.
b) The needle should not be left in place for over 12 hours.
Section 2: Page 155

G. Increasing the Rate of Infusion

1. The flow rate through the intraosseous needle may be a little slower than
through a peripheral line. If fluids need to be administered rapidly, two methods
may be used to increase the flow rate:
a) Pressure bag
(1) To increase the rate of fluid infusion, a pressure bag may be applied to
the IV solution and inflated to 300 torr.
b) A syringe with a three-way stopcock directly attached to the IV line flowing
to the intraosseous needle will allow administration of fluid boluses.
(1) Attach an empty 30 or 60 cc Luer-Lok™ syringe (with the plunger
depressed) to the three-way stopcock.
(2) Close the stopcock valve allowing IV flow to the patient, and open the
valve from the IV bag to the syringe.
(3) Withdraw the plunger to fill the syringe with the desired amount of IV
fluid from the IV bag.
(4) Close off the flow to the IV bag and open the valve allowing fluid to flow
from the syringe to the patient.
(5) Depress the plunger of the syringe to administer the desired amount of
IV fluid to the patient.
(6) Repeat steps (2)-(5) above as necessary until the full amount of fluid
bolus has been administered.
(7) Reopen the valve to the patient so that the IV continues to flow; check
flow rate.
(8) Reassess the patient to determine need for additional fluid, repeating
steps (2)-(6) above, if appropriate.
2. Carefully monitor the amount of fluid administered to the pediatric patient to
prevent fluid overload. The use of small volume IV bags (i.e., 250-500 cc bags)
may be helpful in this monitoring process.
3. A child in shock may require several 20 cc/kg boluses of fluid. Frequent
reassessments are necessary.
H. Potential Complications
1. Potential complications from intraosseous insertion and infusion include:
a) Extravasation of fluid:
(1) This is generally the result of improper needle placement or multiple
insertion attempts.
(2) Collection of fluid in the tissue can lead to compartment syndrome.
b) Skin infection:
(1) The infection rate for intraosseous is lower than that found with
intravenous cannulation.
(2) Osteomelitis (very rare).
2. Overall, complications from intraosseous insertion and infusion are rare.
Section 2: Page 156

VI. Blood Glucose Monitoring

A. To properly perform a finger-stick blood sugar determination:
1. Use either the patient’s index or middle finger
2. Clean the fingertip with an alcohol swab
3. Gently squeeze the finger at the joint below the fingertip
4. At the same time, use either a small needle or special finger-stick lancet to
pierce the skin of the fingertip
a) The tip should not go in more than 1 to 2 mm
b) Do this in a rapid “in and out” fashion
c) Do not leave the lancet or needle in place or twist it around
5. Immediately remove the lancet or needle
6. Using a gloved hand, gently squeeze the fingertip to express a drop of blood
from the wound
7. Place the drop of blood on the chemical reagent strip; begin timing
8. When the proper period of time has passed (this depends on the type of
reagent strip), use a cotton ball and wipe the remaining blood from the strip
9. Use either a measuring device (glucometer) or the color scale on the reagent
container to determine the patient’s blood sugar
VII. Disposal of Contaminated Items and Sharps - Follow local protocol for disposition of
contaminated items and sharps
VIII.Medical/legal considerations
NOTES
Section 2: Page 157

NOTES
Lesson 3-1: Pharmacology of Emergency ILS Medications


At the end of this lesson the EMT-Intermediate student will be able to apply the understanding
of emergency pharmacology to the for the treatment of out of hospital emergencies and safely
and precisely perform medication administration.
OBJECTIVES LEGEND
1=Knowledge
2=Application
1. Discuss the EMT-Intermediate's responsibilities and scope of management pertinent to
the administration of medications, and understand the physiological effects of narcotics.
(C-1)
2. List and differentiate among routes of drug administration. (C-3)
3. Describe mechanisms of drug action. (C-1)
4. Describe factors altering drug responses, predictable drug responses, drug responses
unintentionally producing adverse effects (iatrogenic drug responses), and unpredictable
adverse drug responses pertinent to ILS Medications. (C-1)
5. Differentiate among drug interactions. (C-3)
6. Discuss considerations for storing drugs pertinent to ILS medications. (C-1)
7. List and describe drugs, which the ILS Technician or ILS/Airway Technician may carry on
an ambulance or aid vehicle, and administer according to Washington Administrative code
and local MPD protocol. (C-1)
• Aspirin:
• Classification
• Mechanisms of action
• Indications
• Pharmacokinetics
• Side/adverse effects
• How supplied/Dosages
• Contraindications
• Special considerations
• Albuterol administered by inhalation:
• Classification
• Indications
Section 3: Page 2
• Dextrose 50% and 25%:
• Classification
• Indications
• Epinephrine 1:1000 for anaphylaxis, administered by a commercially pre-loaded
measured dose device:
• Classification
• Indications
• Naloxone:
• Classification
• Indications
• Nitroglycerin administered sublingually and/or spray:
• Classification
• Indications
Section 3: Page 3
8. Discuss obtaining a history by identifying classifications of drugs pertinent to ILS

medications. (C-1)
9. Discuss identifying the pathophysiology of a patient's condition by identifying
classifications of drugs pertinent to ILS medications. (C-1)
10. Discuss considerations for administering a drug when combined with a drug the patient
may have taken. (C-1)
11. Review the specific anatomy and physiology pertinent to medication administration. (C-1)
12. Review pharmacology. (C-1)
13. Define specific terminology of medication administration. (C-1)
14. Define specific abbreviations of medication administration. (C-1)
15. Discuss applying basic principles of mathematics, to the calculation of problems
associated with medication dosages, pertinent to ILS Technicians. (C-1)
16. Discuss legal aspects affecting medication administration. (C-1)
17. Describe on-line medical direction/control for medication administration. (C-1)
18. Describe off-line medical direction/control for medication administration. (C-1)
19. Discuss the "six rights" of drug administration and correlate these with the principles of
medication administration. (C-1)
21. Describe universal precautions and body substance isolation (BSI) procedures when
administering a medication. (C-1)
22. Differentiate among the different parenteral administration routes for medication, which
the EMT-Intermediate may administer according to Washington Administrative code and
local MPD protocol. (C-3)
23. Differentiate among the different dosage forms in administering parenteral medications,
which the EMT-Intermediate may administer according to Washington Administrative code
24. Identify anatomic landmarks utilized in administering parenteral medications, which the
EMT-Intermediate may administer according to Washington Administrative code and local
MPD protocol. (C-1)
25. Describe the equipment needed, techniques utilized, complications, and general principles
for the preparation and administration of parenteral medications, which the EMT-
Intermediate may administer according to Washington Administrative code and local MPD
protocol. (C-1)
26. Differentiate among the different percutaneous administration routes for medication, which
the EMT-Intermediate may administer according to Washington administrative code and
local MPD protocol. (C-3)
27. Differentiate among the different dosage forms in administering percutaneous
medications, which the EMT-Intermediate may administer according to Washington
Administrative code and local MPD protocol. (C-3)
28. Identify anatomic landmarks utilized in administering percutaneous medications, which the
EMT-Intermediate may administer according to Washington Administrative code and local
MPD protocol. (C-1)
Section 3: Page 4
29. Describe the equipment needed, techniques utilized, complications, and general principles
for the preparation and administration of percutaneous medications, which the EMT-
Intermediate may administer according to Washington Administrative code and local MPD
protocol. (C-1)
31. Comply with EMT-Intermediate standards of medication administration. (A-1)
34. Perfect obtaining a history by identifying classifications of drugs pertinent to ILS
medications. (P-3)
35. Perfect applying mathematical equivalents to calculation of problems associated with
medication dosages. (P-3)
36. Perfect documentation of medication administration. (P-3)
37. Perform universal precautions and body substance isolation (BSI) procedures during
medication administration. (P-1, P-2)
38. Perfect clean technique during medication administration. (P-3)
39. Perform medication administration for all medications, which the EMT-Intermediate may
administer according to Washington Administrative code and local MPD protocol. (P-1, P-
2, P-3)
INTEGRATION
41. Integrate pathophysiological principles of pharmacology with patient assessment. (C-3)
42. Synthesize patient history information and assessment findings to form a field impression.
(C-3)
43. Synthesize a field impression to implement a pharmacologic management plan. (C-3)
44. Synthesize a pharmacologic management plan including medication administration. (C-3)
45. Integrate pathophysiological principles of medication administration with patient
management. (C-3)
Section 3: Page 5
Presentation
DECLARATIVE
I. Pharmacology of Emergency ILS Medications
A. The Scope of Management
1. EMT-Intermediates are held responsible for safe and therapeutically effective
drug administration
2. EMT-Intermediates are personally responsible - legally, morally, and ethically, for
each drug they administer
3. EMT-Intermediates:
a) Use correct precautions and techniques
b) Observe and document the effects of drugs
c) Keep their knowledge base current to changes and trends in pharmacology
d) Establish and maintain professional relationships
e) Understand pharmacology
f) Perform evaluation to identify drug indications and contraindications
g) Seek drug reference literature
h) Take a drug history from their patients including:
(1) Prescribed medications (name, strength, and daily dosage)
(2) Over-the-counter medications
(3) Vitamins
(4) Drug reactions
i) Consult with medical direction/control
j) Comply with medical direction/control
B. Overview of the Routes of Drug Administration
1. The mode of drug administration affects the rate at which onset of action occurs
and the therapeutic response that results
2. The choice of the route of administration is crucial in determining the suitability of
a drug
a) Define the following drug administration routes:
(1) IM (intramuscular)
(2) IV (intravenous)
(a) KVO (keep vein open)
(b) TKO (to keep open)
(3) IO (intraosseous)
(a) KVO (keep vein open)
(b) TKO (to keep open)
(4) SQ (subcutaneous)
(5) PO (by mouth)
(6) Inhalation
(7) sublingual
3. Drugs are given for either their local or systemic effects
Section 3: Page 6
C. Mechanisms of Drug Action

1. To produce optimal desired or therapeutic effects, a drug must reach appropriate
concentrations at its site of action
2. Molecules of the chemical compound must proceed from point of entry into the
body to the tissues with which they react
3. The magnitude of the response depends on the dosage and the time course of
the drug in the body
D. Pharmacokinetics - Study of the metabolism and action of drugs with particular
emphasis on the time required for absorption, duration of action, distribution in the
body and method of excretion
E. Pharmacodynamics - Study of drugs and their actions on living organisms.
1. Factors altering drug responses
a) Age
b) Body mass
c) Sex
d) Environmental milieu
e) Time of administration
f) Pathologic state
g) Genetic factors
h) Psychological factors
2. Predictable adverse responses
a) Desired action
3. Adverse effects produced unintentionally (Iatrogenic responses)
4. Unpredictable adverse responses
a) Drug allergy
(1) Medications frequently implicated in allergic reactions
b) Anaphylactic reaction
c) Delayed reaction ("serum sickness")
d) Hypersensitivity
e) Idiosyncrasy
f) Tolerance
g) Cross tolerance
h) Cumulative effect
i) Drug dependence
j) Drug interaction
k) Drug antagonism
l) Synergism
m) Potentiation
n) Additive
o) Interference
p) Vs. Side effects
Section 3: Page 7
5. Contraindications - Any symptom or circumstance indicating thin

inappropriateness of a form of treatment, otherwise advisable
F. Drug Storage
1. Certain precepts should guide the manner in which drugs are secured, stored,
distributed, and accounted for
2. Refer to local protocol
3. Drug potency can be affected by:
a) Temperature
b) Light
c) Moisture
d) Expiration date
4. Applies also to diluents
G. Cardiac drugs that may be carried on an ambulance or aid vehicle by ILS or
ILS/Airway Technicians and administered according to Washington Administrative
code and local MPD protocol for the prehospital management of cardiac emergencies
1. Nitroglycerin
a) Classification
(1) Pharmacologic
(2) Therapeutic
b) Mechanisms of action
c) Indications
d) Pharmacokinetics
e) Side/adverse effects
f) How supplied/Dosages
g) Contraindications
h) Special considerations
(1) Pediatric patients
(2) Geriatric patients
(3) Pregnant patients
2. Aspirin (per MPD protocol)
a) Classification
(1) Pharmacologic
(2) Therapeutic
c) Indications
d) Pharmacokinetics
Section 3: Page 8
H. Respiratory drugs that may be carried on an ambulance or aid vehicle by ILS or
ILS/Airway Technicians and administered according to Washington Administrative
code and local MPD protocol for the prehospital management of respiratory
emergencies
1. Albuterol
a) Classification
(1) Pharmacologic
(2) Therapeutic
c) Indications
d) Pharmacokinetics
I. Metabolic emergency drugs that may be carried on an ambulance or aid vehicle by
ILS or ILS/Airway Technicians and administered according to Washington
Administrative code and local MPD protocol for he prehospital management of
metabolic emergencies
1. Dextrose 25% and 50% in water
a) Classification
(1) Pharmacologic
(2) Therapeutic
c) Indications
d) Pharmacokinetics
Section 3: Page 9
J. Anaphylaxis emergency drugs that may be carried on an ambulance or aid vehicle by

ILS or ILS/Airway Technicians and administered according to Washington
Administrative code and local MPD protocol for the prehospital management of
anaphylactic emergencies
1. Epinephrine 1:1,000 (Epinephrine for anaphylaxis administered by a commercially
pre-loaded measured dose device)
a) Classification
(1) Pharmacologic
(2) Therapeutic
c) Indications
d) Pharmacokinetics
II. Administration of Emergency ILS Medications
A. Calculating Drug Dosages
1. Oral medications
2. Parenteral medications
3. Calculating dosages for infants and children
B. Medical Direction/Control
1. Medication administration is bound by the EMT-Intermediate's on-line or off-line
medical direction/control
2. Role of the medical director
3. County patient care protocols
a) Written standing orders
4. Legal considerations: policies and procedures which specify regulations of
medication administration
C. Principles of Medication Administration
1. Local drug distribution system: policies which establish stocking and supply of
drugs
2. EMT-Intermediate's responsibility associated with the drug order
a) Verification of the drug order
Section 3: Page 10
3. The "six rights" of medication administration

a) The right drug
b) The right expiration date
c) The right patient
d) The right dose
e) The right concentration
f) The right route
D. Universal Precautions and Body Substance Isolation (BSI) in Medication
Administration
E. Parenteral Administration of Medications
1. Parenteral routes
a) Intravenous (IV)
b) Subcutaneous (SQ)
c) Intramuscular (IM)
d) Intraosseous (IO)
2. Reasons for parenteral administration of medications
F. Preparation of Parenteral Medication
1. Equipment needed for preparing a parenteral medication
a) Syringes
(1) Calibration of the syringe
(2) Prefilled syringes
b) Needles/Parts of the needle
c) Selection of the syringe and needle
d) Packaging of syringes and needles
e) Forms of parenteral medications
(1) Ampules
(2) Vials
2. Standard procedures for preparing all parenteral medications
3. Guidelines for preparing medications
a) Prepare a medication from an ampule
b) Removal of a volume of liquid from a vial
G. Administration of Medication by Intramuscular (IM) Route - Epinephrine 1:1000 and
Naloxone; and Subcutaneous (SQ) Route - Epinephrine 1:1000
1. Administration of Epinephrine 1:1000 using a commercially pre-loaded measured
dose device
a) Medication name
(1) Generic - Epinephrine
(2) Trade - Adrenalin™
b) Actions
(1) Dilates the bronchioles.
(2) Constricts blood vessels.
c) Indications:
Section 3: Page 11
(1) Acute bronchospasm: anaphylaxis

(2) Medical direction/control authorizes use for this patient
d) Contraindications:
(1) Pulmonary edema, hypothermia, hypertension.
(2) No contraindications when used in a life-threatening situation.
e) Adverse reactions
(1) Ventricular arrhythmias
(2) Precipitation of angina or myocardial infarction
(3) Tachycardia
(4) Anxiety
(5) Hypertension
(6) Headache
(7) Pallor
(8) Dizziness
(9) Nausea
(10) Vomiting
f) Incompatibilities/Drug interactions
(1) Potentiates other sympathomimetics
(2) Patients on monoamine oxidase inhibitors, antihistamines, and tricyclic
antidepressants may have heightened effects.
(3) Medication form - liquid administered via a commercially pre-loaded,
measured dose, injectable needle and syringe system.
g) Dosage
(1) Adult:
(a) Intramuscular - one adult auto-injector (0.3 mg)
(b) Subcutaneous - one adult measured dose device (0.1 to 0.5 mg
1:1000 SQ)
(2) Infant and child:
(a) Intramuscular - one pediatric auto-injector (0.15 mg)
(b) Subcutaneous - one infant/child measured dose devise (0.01 to .03
mg/kg 1:1000 SQ)
h) Administration
(1) Use body substance isolation precautions
(2) Identify the need for medication based on patient history and presenting
signs and symptoms.
(3) Obtain order from medical direction/control either on-line or off-line.
(4) Medication is not expired or discolored (if able to see).
(5) Technique for administration of epinephrine 1:1000, using a commercially
pre-loaded measured dose device
Section 3: Page 12
(a) Intramuscular route using an epinephrine auto-injector:

(i) Injections are made by penetrating a needle through the dermis
and the subcutaneous tissue into the muscle layer
(ii) Equipment needed for administration of epinephrine 1:1000
using an auto-injector:
(a) Adult epinephrine auto-injector
(b) Pediatric epinephrine auto-injector
(iii) Reassure the patient and check for allergies
(iv) Use body substance isolation precautions
(v) Locate anatomical sites for adults and children
(vi) Expose and cleanse the area to be used for medication
administration
(vii) Remove the cap from the injector
(viii)Insert the injector at a 90 degree angle laterally to the patient’s
thigh, between the waist and the knee
(ix) Hold the injector in place until the medication is injected
(b) Subcutaneous route using a commercially pre-loaded, measured
dose epinephrine syringe (Pre-filled epinephrine syringes must be
commercially pre-filled with the correct adult or pediatric dose
to be used by ILS Technicians. Consult with local medical
direction/control for the appropriateness of using epinephrine
1:1000 in pre-filled syringes).
(i) Injections are made by penetrating a needle through the dermis
into the subcutaneous tissue layer
(ii) Equipment needed for administration of a medication by the
subcutaneous route
(iii) Reassure the patient and check for allergies
(iv) Use body substance isolation precautions
(v) Locate anatomical sites for adults and children
(vi) Expose and cleanse the area to be used for medication
administration. Usually the lateral aspect of either an upper arm
or thigh is selected.
(vii) To make sure the needle does not go in to deeply, pinch the skin
and dart the needle in rapidly at a 45 degree angle
(a) Pull back on the syringe plunger to aspirate for blood.
(b) If blood is seen in the syringe, withdraw the needle and apply
firm pressure over the site with a sterile dressing.
(c) Select another site for administering the medication.
(viii)Inject the medication and remove the needle from the skin
(ix) Apply circular pressure to the injection site to disperse the
medication throughout the tissue
Section 3: Page 13
i) Dispose of device in biohazard container. DO NOT recap the needle.

j) Record activity and time on run report.
k) Re-assessment strategies
(1) Transport.
(2) Continue focused assessment of airway, breathing and circulatory status.
(a) Patient condition continues to worsen.
(i) Decreasing mental status
(ii) Increasing breathing difficulty
(iii) Decreasing blood pressure
(iv) Obtain medical direction/control
(a) Additional dose(s) of Epinephrine 1:1000 by a commercially
pre-loaded measured dose device
(b) Treat for shock (hypoperfusion).
(c) Prepare to initiate Basic Cardiac Life support measures.
(i) CPR
(ii) AED
(b) Patient condition improves. Provide supportive care.
(i) Oxygen
(ii) Treat for shock (hypoperfusion).
l) Precautions
2. Naloxone IM
a) Medication Name
(1) Generic - Naloxone
(2) Trade - Narcan
b) Action
(1) Competitive inhibition at narcotic receptor sites
(2) Reverses respiratory depression secondary to depressant drugs
c) Indications
(1) Antidote for: Narcotics, Lomotil, Talwin, Darvon
(2) Given for acutely depressed levels of responsiveness (differentiates
drug-induced coma from other causes)
d) Contraindications
(1) Known hypersensitivity
(2) Incompatibilities/Drug interactions
(3) May cause narcotic withdrawal in the narcotic-dependent. In cases of
suspected narcotic dependence, administer only enough of the drug to
reverse respiratory depression.
e) Side Effects
(1) Withdrawal symptoms, especially in neonates (nausea, vomiting,
diaphoresis, increased heart rate, falling blood pressure, tremors)
Section 3: Page 14
f) Precautions
(1) Should be used during pregnancy only if clearly needed
(2) Caution should be exercised when administered to a nursing woman
(3) Short-acting, should be augmented every 5 minutes
g) Medication Form
(1) Vials, 0.4 mg/ml (1 ml, 10 ml) 1 mg/ml (2 ml)
h) Dosage
(1) Adult:
(a) Initial dose of 2 mg
(b) If necessary, dose may be repeated in 2 to 3 min intervals to a
maximum of 10 mg
(c) For ET administration, dilute medication with normal saline to a
volume of 3-5 ml and follow with several positive-pressure
ventilations
(2) Pediatric:
(a) If less than or equal to 5 years of age or less than or equal to 20 kg:
0.1 mg/kg
(b) If greater than 5 years of age or greater than 20 kg: 2.0 mg
i) Administration of Naloxone IM
signs and symptoms
(3) Contact medical direction/control for permission to administer medication
or follow off-line standing orders
(a) If orders are obtained from medical direction/control:
(i) Repeat the orders back to medical direction/control physician
(ii) Write down the information on the run report
(4) Reassure the patient and check for allergies
(5) Expose and cleanse the area to be used for medication administration -
use either the deltoid muscle in the shoulder or the upper outer quadrant
of the gluteal area
(6) To make sure the needle goes into the muscle and not the subcutaneous
layer, stretch the skin over the injection site and insert the needle at a 90
degree angle to the skin
(a) Pull back on the syringe plunger to aspirate for blood
(b) If blood is seen in the syringe, withdraw the needle and apply firm
pressure over the site with a sterile dressing.
(c) Select another site for administering the medication.
(7) Inject the medication and remove the needle from the skin
(8) Apply circular pressure to the injection site to disperse the medication
throughout the tissue
j) Dispose of device in biohazard container. DO NOT recap the needle.
k) Record activity and time on run report.
Section 3: Page 15
l) Watch the patient for any responses to the medication:

(1) Desired response
(2) Adverse effects
H. Administration of Medication by the Intravenous Route
1. Intravenous route: places the drug directly into the bloodstream, bypassing all
barriers to drug absorption
2. Purpose for a peripheral IV site
3. Dosage forms for IV administration
a) Dextrose - bolus
b) Naloxone - vials
4. Equipment needed for administration of a medication by the peripheral IV route
5. Procedure for administration of Intravenous Medications ( Dextrose 25% and
50%, and Naloxone)
a) Dextrose 25% and 50%
signs and symptoms
(i) Repeat the orders back to medical direction/control physician
(ii) Write down the information on the run report
(5) Administer via large-bore catheter in a large vein, if at all possible
(a) Dosage:
(i) Adult dosage: 25-50 g IV bolus (50-100 ml of a 50% solution)
(ii) Pediatric Dosage 25 % dextrose at 0.5-1.0g/kg IV bolus. A 50 %
solution may be diluted 1:1 with normal saline or sterile water
(b) Double check the patency of the IV prior to administration of
Dextrose (use drawback technique to determine patency).
(c) Keep the injection site and the area above it as visible as possible.
(d) Steps:
(i) Cleanse the medication injection site (y-port or hub) of the IV
tubing
(ii) Penetrate the injection site with the needle
(iii) Infuse into a fast-flowing IV line, instead of pinching the tubing
above the injection port; depend on flow, not pressure, to
administer Dextrose.
(iv) Administer Dextrose slowly; 2 minutes is considered a minimum
by many.
(v) Flush the IV tubing by briefly running it wide open or following the
drug bolus with a 20 ml bolus of IV fluid
Section 3: Page 16
(vi) Adjust the IV flow rate to a keep open rate (TKO)

(6) Dispose of the needle/syringe in an appropriate “sharps” container. DO
NOT recap the needle
(7) Store any unused medication appropriately
(8) Confirm the medication administration with medical direction/control
(9) Record the administration time
(10) Watch the patient for any responses to the medication:
(a) Desired response
(b) Adverse effects
(i) If IV is not properly in vein, necrosis of tissue surrounding IV site
could occur.
b) Naloxone
signs and symptoms
(b) Repeat the orders back to medical direction/control physician
(c) Write down the information on the run report
(5) Administer IV
(a) Dosage
(i) Adult:
(a) Initial dose of 2 mg IV
(b) If necessary, dose may be repeated in 2 to 3 minute
intervals to a maximum of 10 mg
(ii) Pediatric:
(a) If less than or equal to 5 years of age or less than or equal to
20 kg: 0.1 mg/kg
(b) Steps:
(i) Cleanse the medication injection site (y-port or hub) of the IV
tubing
(ii) Penetrate the injection site with the needle
(iii) Stop the IV flow by:
(a) Pinching the IV tubing above the injection site
(b) Using the stop-cock device on the tubing
(iv) Closing the tubing leading to the IV bag prevents the medication
from flowing up into the IV bag instead of into the patient
(v) Administer the correct dose of medication at the correct push
rate
Section 3: Page 17
(vi) Flush the IV tubing by briefly running it wide open or following the
drug bolus with a 20 ml bolus of IV fluid
(vii) Adjust the IV flow rate to a keep open rate (TKO)
(6) Dispose of the needle/syringe in an appropriate “sharps” container. DO
NOT recap the needle
(7) Store any unused medication appropriately
(8) Confirm the medication administration with medical direction/control
(9) Record the administration time
(10) Watch the patient for any responses to the medication:
(a) Desired response
(b) Adverse effects
I. Steps in performing administration of medication by a saline lock
J. Administration of Percutaneous Medications - (Albuterol, Nitroglycerin Tablets and/or
spray)
1. Percutaneous route: application of a medication for absorption through the
mucous membranes
2. Factors which influence the amount of medication absorbed through the mucous
membranes
3. Methods of percutaneous administration of medications
4. Steps in preparing percutaneous medications
5. Administering medications to mucous membranes
a) Places where medications are commonly applied
(1) Under the tongue (sublingual)
(2) Inhaled into the lungs through an aerosol or nebulizer
b) Dosage forms
(1) Tablets
(2) Sprays
(3) Solutions
(4) Metered-dose inhalers
c) Equipment needed for administration of each type of medication
d) Steps for the administration of the dosage form of medication to the place it is
commonly applied:
(1) Albuterol
(a) Indications:
(i) Bronchospasm from emphysema or asthma
(ii) Authorization by medical direction/control.
(b) Contraindications
(i) Use with caution in patients with diabetes, hypertension,
hyperthyroidism, and cerebrovascular disease.
(c) Medication form - metered dose inhaler, solution for nebulized inhaler
Section 3: Page 18
(d) Dosage - based upon order from medical direction/control.

(i) Adult:
(a) Solution: 2.5 mg; dilute 0.5 ml of the 0.5% solution for
inhalation with 2-4 ml normal saline in nebulizer over 5-15
min
(b) Metered dose inhaler: 1-2 inhalations (90 µg each). May be
repeated every 15 min as needed.
(ii) Pediatric:
(a) Age younger than 12 yrs: Solution: 0.03 ml/kg of a 0.5%
solution up to 1 ml over 5-10 min
(b) Age 12 and over: Use full adult dose
(e) Administration
(i) Use body substance isolation
(ii) Identify the need for medication based on patient history and
presenting signs and symptoms.
(iii) Obtain order from medical direction/control either on-line or
off-line. If orders are receive on-line, repeat orders back to
medical/control and write down the information on the run report.
(iv) Reassure the patient and check for allergies.
(v) Prepare and/or administer medication:
(a) Metered-dose inhaler
(i) Assure the inhaler is at room temperature or warmer.
(ii) Shake the inhaler vigorously several times.
(iii) Remove oxygen adjunct from patient.
(iv) Have the patient exhale deeply.
(v) Have the patient put his lips around the opening of the
inhaler.
(vi) Depress the handheld inhaler as the patient begins to
inhale deeply.
(vii) Instruct the patient to hold his breath for as long as it is
comfortable (so medication can be absorbed).
(viii)Replace oxygen on patient.
(ix) Allow patient to breathe a few times and repeat second
dose per medical direction/control.
(x) If a spacer device is available, it should be used. A
spacer device is an attachment between inhaler and
patient that allows for more effective use of medication.
Section 3: Page 19
(b) Solution for nebulized inhaler

(i) Mix the prescribed medication (using aseptic technique)
with a specified amount of normal saline and pour it into
the nebulizer.
(ii) Some medications are available in a packaged unit dose
and contain a fixed amount of diluent (usually 0.9%
normal saline).
(iii) Attach the nebulizer to a T-piece and mouth piece and
connect it to the oxygen regulator with oxygen
connecting tubing. Alternatively, a nebulizer face mask
may be used instead of a mouthpiece.
(iv) Adjust the oxygen flowmeter to 4 to 6 L/min to produce a
steady, visible mist.
(v) When the mist is visible, treatment should be started.
(vi) Instruct the patient to inhale slowly and deeply through
the mouth and to hold the breaths 3 to 5 seconds before
exhaling.
(vii) Inhalation and exhalation should be continued until the
aerosol canister is depleted of the medication.
(viii)Confirm the medication with medical direction/control,
record the administration time, and watch for patient
response to the medication administration (for both
desired effects as well as adverse effects).
(ix) If changes in heart rate or dysrhythmias are noted,
nebulization should be stopped and medical
direction/control contacted for further orders.
(f) Actions - Relaxes bronchial smooth muscle, resulting in
bronchodilation.
(g) Adverse reactions
(i) Arrhythmias
(ii) Tachycardia
(iii) Tremors
(iv) Nervousness
(v) Nausea/vomiting
(h) Re-assessment strategies
(i) Obtain vital signs and perform focused reassessment.
(ii) Patient may deteriorate and need positive pressure artificial
ventilation.
(i) Infant and child considerations
(i) Use of handheld inhalers is very common in children.
(ii) Retractions are more commonly seen in children than adults.
Section 3: Page 20
(iii) Cyanosis (blue-gray) is a late finding in children.

(iv) Very frequent coughing may be present, rather than wheezing, in
some children.
(v) Emergency care using handheld inhalers is the same for the ill
child if the indications for the medication is met.
(2) Nitroglycerin
(a) Medication name
(i) Generic - nitroglycerin
(ii) Trade - Nitrostat™
(b) Indications - must meet all of the following criteria:
(i) Angina Pectoris/chest pain, congestive heart failure
(ii) Has specific authorization by medical direction/control.
(c) Contraindications
(i) Hypovolemia, increased intracranial pressure, severe hepatic or
renal disease
(ii) Hypotension or blood pressure below 100 mm Hg systolic.
(iii) Head injury
(iv) Infants and children
(v) Patient has already met maximum prescribed dose prior to
arrival.
(d) Medication form - tablet, sublingual spray
(e) Dosage - one dose (0.4 mg), repeated in 3-5 minutes if no relief; BP
greater than 100, and authorized by medical direction/control. Up to
a maximum of three doses.
(f) Administration
(i) Obtain order from medical direction/control either on-line or off-
line.
(ii) Perform focused assessment for cardiac patient.
(iii) Take blood pressure - above 100 mm Hg systolic.
(iv) Contact medical control if no standing orders.
(v) Check expiration date of nitroglycerin.
(vi) Question patient on last dose administration, effects of dose, and
assure understanding of route of administration.
(vii) Ask patient to lift tongue and place tablet or spray dose under
tongue (while wearing gloves) or have patient place tablet or
spray under tongue.
(viii)Have patient keep mouth closed with tablet under tongue
(without swallowing) until dissolved and absorbed.
(ix) Recheck blood pressure within two minutes.
Section 3: Page 21
(x) Record activity and time on run report.

(xi) Perform reassessment, especially the presence or absence of
chest pain
(g) Actions
(i) Coronary artery vasodilatation
(ii) Decreases workload of heart
(iii) Smooth muscle relaxant acting on vascular, uterine, bronchial
and intestinal smooth muscle
(h) Adverse reactions
(i) Hypotension
(ii) Headache
(iii) Bradycardia
(i) Reassessment strategies
(i) Monitor blood pressure.
(ii) Ask patient about effect on pain relief.
(iii) Seek medical direction/control before re-administering.
(iv) Record reassessments.
K. Administration of Oral medications - (Aspirin)
1. Steps in preparing oral medications
2. Steps for the administration of the dosage form of aspirin
a) Indications - Chest pain of cardiac origin
b) Contraindications:
(1) Known hypersensitivity
(2) Asthmatic
c) Precautions:
(1) GI bleed
(2) Any bleeding disorder
d) Medication form - Tablets
e) Dosage - based on local MPD protocols
(1) Initial:
(a) 160 or 325 mg; may use chewable children’s aspirin which tastes
better
f) Administration
(1) Use body substance isolation
signs and symptoms.
Section 3: Page 22
(3) Obtain order from medical direction/control either on-line or off-line. If

orders are receive on-line, repeat orders back to medical/control and
write down the information on the run report.
(4) Reassure the patient and check for allergies.
(5) Prepare and/or administer medication
(a) Record activity and time on run report.
(6) Actions - Blocks platelet aggregation
g) Adverse reactions
(1) Heartburn
(2) Nausea
(3) Vomiting
(4) Wheezing
h) Perform reassessment, especially the presence or absence of chest pain
L. Disposal of Contaminated Items and Sharps - Follow local protocol for disposition of
contaminated items and sharps
NOTES
Section 3: Page 23
NOTES
Section 3: Page 24

Section 3 - Pharmacology and Emergency Care/Lesson 3-2: Cardiology
OBJECTIVES LEGEND
1=Knowledge
2=Application
At the end of this lesson, the EMT-Intermediate student will be able to utilize the assessment
findings to formulate a field impression and implement the management plan for the patient
experiencing a cardiac emergency.
At the completion to this lesson, the EMT-Intermediate student will be able to:
1. Review the position of the heart within the thoracic cavity (C-1)
2. Describe each of four cardiac chambers (C-1)
3. Review the major structures of the vascular system (C-1)
4. Define cardiac output (C-1)
5. Identify and describe how the heart's pacemaking control, rate, and rhythm are
determined (C-2)
6. Identify and describe the components of the focused history as it relates to the patient with
cardiovascular compromise (C-1)
7. Describe the components of the OPQRST of chest pain assessment (C-1)
8. Describe the epidemiology, morbidity and mortality of Chest Pain, (C-1)
9. Identify the pathophysiology of Chest Pain (C-1)
10. List and describe the assessment parameters to be evaluated in a patient with Chest Pain
(C-1)
11. Describe the significant elements of the focused history in a patient with suspected Chest
Pain (C-1, C-2)
12. Identify what is meant by the OPQRST of chest pain assessment (C-1, C-3)
13. List other clinical conditions that may mimic signs and symptoms of coronary artery
disease and Chest Pain (C-1)
14. Differentiate the characteristics of the pain/discomfort occurring in angina pectoris and
acute myocardial infarction. (C-2)
15. Identify the responsibilities associated with management of patient with Chest Pain (C-2)
16. Based on the pathophysiology and clinical evaluation of the patient with chest pain, list the
anticipated clinical problems according to their life-threatening potential (C-2, C-3)
17. Describe the ILS and ILS/Airway medications (02, nitro, aspirin) used in the management
of chest pain and when ALS should be contacted for additional resources.(C-1, C-3)
18. Define the principle causes and terminology associated with heart failure (C-1)
19. Identify the factors that may precipitate or aggravate heart failure (C-1, C-3)
20. Describe the physiological effects of heart failure (C-2)
21. Define the term "acute pulmonary edema" and describe its relationship to left ventricular
failure (C-1, C-3)
22. List the interventions prescribed for the patient in acute congestive heart failure (C-1, C-2)
Section 3: Page 26
23. Define the term "cardiac tamponade" (C-1)

24. List the mechanisms by which cardiac tamponade may be produced by traumatic and
non-traumatic events. (C-1, C-2)
25. Identify the EMT-Intermediate responsibilities associated with management of a patient
with cardiac tamponade in conjunction with Advanced life support and air ambulance
transport (C-2)
26. Describe the incidence, morbidity and mortality of hypertensive crisis (C-1)
27. Define the term "hypertensive crisis" (C-1)
28. Identify the characteristics of patient population at risk for developing hypertensive crisis
(C-1)
29. Identify the progressive vascular changes associate with sustained hypertension(C-1)
30. Describe the clinical features of the patient in hypertensive crisis (C-2, C-3)
31. Rank the clinical problems of patients in hypertensive crisis according to their sense of
urgency (C-3)
32. From the priority of clinical problems identified, state the management responsibilities for
the patient with hypertensive crisis (C-2)
33. Correlate abnormal findings with clinical interpretation of the patient with hypertensive
crisis (C-2, C-3)
34. List the interventions prescribed for the patient in cardiogenic shock (C-1, C-2)
35. Describe the pathophysiology of vascular disorders (C-1)
36. List the traumatic and non-traumatic causes of vascular disorders (C-1)
37. Define the terms "aneurysm" (C-1)
38. Identify the peripheral arteries most commonly affected by occlusive disease (C-1)
39. Identify the major factors involved in the pathophysiology of aortic aneurysm (C-1)
40. Recognize the usual order of signs and symptoms that develop following peripheral artery
occlusion (C-2, C-3)
41. Describe the clinical significance of unequal arterial blood pressure readings in the arms
(C-3)
42. Recognize and describe the signs and symptoms of dissecting thoracic or abdominal
aneurysm (C-2, C-3)
43. Describe the significant elements of the patient history in a patient with vascular disease
(C-1, C-2)
44. Identify the hemodynamic effects of vascular disorders (C-1)
45. Identify the complications of vascular disorders (C-1)
46. Identify the responsibilities associated with management of patient with vascular disorders
(C-2)
47. Value the sense of urgency for initial assessment and intervention in the patient with
cardiac compromise (A-3)
48. Based on the pathophysiology and clinical evaluation of the patient with chest pain,
characterize the clinical problems according to their life-threatening potential (A-3)
49. Defend the urgency based on the rank the clinical problems of patients in hypertensive
crisis (A-3)
Section 3: Page 27
50. From the priority of clinical problems identified, state the management responsibilities for
the patient with hypertensive crisis (A-3)
51. Based on the pathophysiology and clinical evaluation of the patient with vascular
disorders, characterize the clinical problems according to their life-threatening potential
(A-3)
52. Value and defend the sense of urgency in identifying peripheral vascular occlusion (A-3)
53. Value and defend the sense of urgency in identifying aortic aneurysm (A-3)
54. Perform, document and communicate a cardiovascular assessment (P-1)
55. Perform, document and communicate a focused history (P-1)
56. Distinguish between normal and abnormal heart sounds. P-2
59. Given a list of signs and elements of a patient's history, identify those significant for Chest
Pain (P-2, P-3)
60. Given a list of signs and elements of a patient's history, identify those representative of
heart failure (P-2, P-3)
61. Given the model of a patient with signs and symptoms of heart failure, position the patient
to afford comfort and relief (P-1, P-2)
62. Given a list of signs of cardiac compromise, identify those representative of cardiac
tamponade (P-2, P-3)
63. Given a list of signs of cardiac compromise, identify those representative of hypertensive
crisis (P-2, P-3)
64. Given a list of signs of cardiac compromise, identify those representative of cardiogenic
shock (P-2, P-3)
65. Demonstrate how to evaluate major peripheral arterial pulses (P-1)
66. Given a list of signs and elements of a patient's history, identify those representative of
vascular disorders (P-1, P-2, P-3)
Section 3: Page 28
INTEGRATION
67. Apply knowledge of the epidemiology of cardiovascular disease to develop prevention
strategies. (C-3)
68. Integrate the pathophysiological principles into the assessment of a patient with
cardiovascular disease. (C-3)
69. Integrate the pathophysiological principles to the assessment of a patient with chest pain
(C-3)
70. Synthesize patient history, assessment findings to form a field impression for the patient
with Chest Pain (C-2, C-3)
patient with chest pain. (C-2, C-3)
72. Integrate the pathophysiological principles to the assessment of the patient with heart
failure (C-2, C-3)
73. Synthesize assessment findings and patient history information to form a field impression
of the patient with heart failure (C-3)
74. Develop, execute, and evaluate a treatment plan for based on the field impression for the
heart failure patient. (C-2, C-3)
75. Integrate the pathophysiological principles to the assessment of a patient with cardiac
tamponade. (C-3)
of the patient with cardiac tamponade (C-2, C-3)
patient with cardiac tamponade (C-2, C-3)
78. Integrate the pathophysiological principles to the assessment of the patient with
hypertensive crisis (C-2, C-3)
for of the patient with hypertensive crisis (C-2, C-3)
patient with hypertensive crisis (C-2, C-3)
cardiogenic shock (C-2, C-3)
of the patient with cardiogenic shock (C-2, C-3)
83. Develop, execute, and evaluate a treatment plan based on the field impression for the
patient with cardiogenic shock (C-2, C-3)
84. Integrate the pathophysiological principles to the assessment of a patient with vascular
disorders (C-3)
85. Synthesize assessment findings and patient history to form a field impression for the
patient with vascular disorders (C-3)
patient with vascular disorders (C-2, C-3)
Section 3: Page 29
PRESENTATION
DECLARATIVE
I. Introduction
A. Cardiovascular Anatomy and Physiology
1. Anatomy of the heart
a) Location
b) Chambers
(1) Atria
(2) Ventricles
2. Cardiac output
3. Vascular system
a) Aorta
(1) Ascending
(2) Thoracic
(3) Abdominal
b) Arteries
(1) Pulmonary artery
c) Capillaries
d) Venule
e) Veins
f) Vena cava
(1) Superior
(2) Inferior
g) Venous return
h) Resistance and capacitance
i) Pulmonary veins
4. Electrophysiology
a) Conduction system overview
(1) Characteristics of myocardial cells
(a) Automaticity
(b) Excitability
(c) Conductivity
(d) Contractility
II. Focused History
A. SAMPLE
1. Chief complaint
2. Pain
a) OPQRST
(1) Onset
Section 3: Page 30
(2) Provocation
(a) Exertional
(b) Non-exertional
(3) Quality
(a) Patient's narrative description
(b) For example, sharp, tearing, pressure, heaviness
(4) Region/radiation
(a) For example, arms, neck, back
(5) Severity
(a) "1-10" scale
(6) Timing
(a) Duration
(b) Worsening or improving
(c) Continuous or intermittent
(d) At rest or with activity
3. Dyspnea
a) Continuous or intermittent
b) Exertional
c) Non-exertional
d) Orthopneic
4. Cough
a) Dry
b) Productive
5. Related signs and symptoms
a) Unconsciousness
b) Altered level of consciousness
c) Restlessness
d) Anxiety
e) Syncope
f) Palpitations
g) Fatigue
h) Nausea
i) Vomiting
j) Headache
k) Behavioral change
l) Activity limitations
m) Trauma
n) Edema
(1) Extremities
(2) Sacral
o) Feeling of impending doom
Section 3: Page 31
p) Anguished facial expression

q) Diaphoresis
6. Past medical history
a) Coronary artery disease (CAD)
b) Atherosclerotic heart disease
(1) Angina
(2) Previous MI
(3) Hypertension
(4) Congestive heart failure (CHF)
c) Valvular disease
d) Aneurysm
e) Pulmonary disease
f) Diabetes
g) Renal disease
h) Vascular disease
i) Inflammatory cardiac disease
j) Previous cardiac surgery
k) Congenital anomalies
l) Current/past medications
(1) Prescribed
(a) Compliance
(b) Non compliance
(2) Borrowed
(3) Over-the-counter
(4) Recreational
m) Allergies
n) Family history
(1) Stroke, heart disease, diabetes, hypertension
(2) Age at death
o) Known cholesterol levels
III. Chest Pain
A. Epidemiology
1. Precipitating causes
a) Atherosclerosis
b) Vasospastic (Printzmetal's)
B. Morbidity/mortality
1. Not a self-limiting disease
2. Chest pain may dissipate, but myocardial ischemia and injury can continue
3. A single anginal episode may be a precursor to myocardial infarction
4. May not be cardiac in origin
5. Must be diagnosed by a physician
Section 3: Page 32
6. Related Terminology
a) Defined as a brief discomfort, has predictable characteristics and is relieved
promptly; no change in this pattern
b) Stable
(1) Occurs at a relative fixed frequency
(2) Usually relieved by rest and/or medication
c) Unstable
(1) Occurs without fixed frequency
d) Initial; first episode
e) Progressive; accelerating in frequency and duration
f) Preinfarction angina
(1) Pain at rest
(2) Sitting or lying down
7. Differentials
a) Acute viral pericarditis or any other inflammatory cardiac disease
b) Hiatus hernia
c) Gastric reflux
d) Respiratory infections
e) Pneumothorax
f) Chest wall trauma
C. Initial Assessment Findings
1. Airway/breathing
a) Labored breathing may or may not be present
2. Circulation
a) Peripheral pulses
(1) Quality
(2) Rhythm
b) Skin
(1) Changes in
(a) Color
(b) Temperature
(c) Moisture
D. Focused History
1. Chief complaint
a) Typical: Angina - sudden onset of discomfort, usually of brief duration,
lasting three to five minutes, maybe five to 15 minutes, usually relieved by
rest and/or medication
b) Atypical: Duration of 30 minutes to two hours suggests AMI
2. Denial
3. Contributing history
a) Initial recognized event
Section 3: Page 33
b) Recurrent event
c) Increasing frequency and/or duration of event
E. Detailed Physical Exam
1. Airway
2. Breathing
a) May or may not be labored
(1) Sounds
(a) May be clear to auscultation
(b) May be congested in the bases
3. Circulation
a) Alterations in heart rate and rhythm may occur
b) Peripheral pulses are usually not affected
c) Blood pressure may be elevated during the episode and normalize
afterwards
d) ECG findings - Arrhythmias and ectopy may not be present
F. Management
1. When paramedic service is available, ILS personnel shall contact medical
direction/control as soon as possible for advice about rendezvous with
paramedics.
2. Position of comfort
3. Pharmacological - Medications only to be administered by ILS or ILS/AW Techs
following approval by on-line or off-line medical direction/control.
a) Oxygen
b) Nitroglycerin
(1) Dosage - one dose (0.4 mg), repeated in 3-5 minutes if no relief; BP
greater than 100, and authorized by medical direction/control. Up to a
maximum of three doses.
c) Administration of IV and when to administer based on local MPD protocols
d) Aspirin (administer if chest pain appears to be of cardiac origin) and dosage
based on local MPD protocols
(1) Initial:
(a) 160 or 325 mg; may use chewable children’s aspirin which tastes
better
e) Contact ALS for additional resources
4. Non-phamacological
a) Monitor vitals
b) Monitor EKG
c) Pulse oximetry
5. Transport
a) Indications for rapid transport
(1) Sense of urgency for reperfusion
(2) No relief with medications
Section 3: Page 34
(3) Hypotension/hypoperfusion
G. Support and communications strategies
1. Explanation for patient, family, significant others
2. Communications and transfer of data to the physician
IV. Heart Failure
A. Precipitating causes
1. Left sided failure
2. Right sided failure
3. Myocardial infarction
4. Pulmonary embolism
5. Hypertension
B. Related terminology
1. Congestive heart failure
a) Loss of contractile ability which results in fluid overload
2. Chronic Vs acute
a) First time event
b) Multiple events
C. Initial Assessment
1. Airway/breathing
2. Circulation
(1) Quality
(2) Rhythm
b) Skin
(1) Changes in
(a) Color
(b) Temperature
(c) Moisture
D. Focused history
1. Chief complaint
a) Progressive or acute SOB
b) Progressive accumulation of edema
c) Weight gain over short period of time
d) Episodes of paroxysmal nocturnal dyspnea
e) Medication history
(1) Prescribed
(a) Compliance
(b) Non-compliance
(2) Borrowed
(3) Over-the-counter
Section 3: Page 35
f) Home oxygen use

E. Detailed physical exam
1. Level of consciousness
a) Unconscious
b) Altered levels of consciousness
2. Airway
a) Dyspnea
b) Productive cough
c) Labored breathing
(1) Most common, often with activity
(2) Paroxysmal nocturnal dyspnea (PND)
(3) Tripod position
(4) Adventitious sounds
(5) Retraction
3. Circulation
a) Heart rate/rhythm
(1) Any tachycardia
(2) Any bradycardia
b) Skin; changes in
(1) Color
(2) Temperature
(3) Moisture
c) Peripheral pulses
(1) Quality
(2) Rhythm
F. Complications
1. Pulmonary edema
a) Signs and symptoms
(1) Tachypnea
(2) Wheezing
(3) Rales at both bases
(4) Elevated jugular venous pressure
(5) Rapid "thready" pulse
(6) Abnormalities of apical pulse
(a) Due to displaced cardiac apex
(b) Abnormal bulges
(7) Cyanosis in advanced stages
(8) Frothy sputum
Section 3: Page 36
G. Management
paramedics.
a) Oxygen
b) Nitroglycerin
d) Contact ALS for additional resources
4. Non-phamacological
a) Monitor vitals
b) Monitor EKG
c) Pulse oximetry
5. Transport
H. Support and communications strategies
V. Cardiac Tamponade
A. Pathophysiology
1. Defined as impaired diastolic filling of the heart caused by increased
intrapericardiac pressure
a) Gradual onset with neoplasm or infection
b) Acute onset with infarction
c) Trauma
(1) Can occur with CPR
(2) Penetrating
1. Death if not relieved
1. Airway/breathing
2. Circulation
(1) Quality
(2) Rhythm
Section 3: Page 37
b) Skin
(1) Changes in
(a) Color
(b) Temperature
(c) Moisture
D. Focused History (as in precipitating causes)
E. Detailed physical examination
1. Airway
a) Dyspnea
b) Orthopnea
2. Circulation
a) Pulse rate and rhythm
b) Chest pain
c) Elevated venous pressures (early sign)
d) Decreased systolic pressure (early sign)
e) Narrowing pulse pressure (early sign)
f) Heart sounds normal early on, progressively faint or muffled
F. Management
paramedics.
2. Airway management and ventilation
3. Circulation
a) Oxygen
b) Contact ALS for Additional resources
5. Non-pharmacological
6. Rapid transport for pericardiocentesis in conjunction with Advanced Life
Support and air ambulance transport.
VI. Hypertensive Crisis
A. Epidemiology
a) History of hypertension
b) Non compliance with medication or any other treatment
c) Toxemia of pregnancy
1. Hypertensive encephalopathy
2. Stroke
Section 3: Page 38
1. Airway/breathing
2. Circulation
(1) Quality
(2) Rhythm
b) Skin
(1) Changes in
(2) Color
(3) Temperature
(4) Moisture
D. Focused history
1. Chief complaint
a) As in Precipitating Causes above
2. Medication history
a) Prescribed
(1) Compliance
(2) Non compliance with medication or treatment
b) Borrowed
c) Over-the-counter
3. Home oxygen use
E. Detailed physical examination
1. Airway
2. Breath Sounds
3. Circulation
a) Pulse
b) Vital signs
(1) Blood pressure
(a) Systolic greater than 160 mm/hg
(b) Diastolic greater than 94 mm/hg
4. Diagnostic signs/symptoms
a) General appearance
b) Level of consciousness
(1) Unconscious
(2) Altered level of consciousness
(3) Responsive
c) Skin color
(1) Can be pallor, flushed, or normal
d) Skin hydration
(1) Can be dry or moist
Section 3: Page 39
e) Skin temperature
(1) Can be warm or cool
f) Peripheral pulses
(1) Can be strong
g) Edema
(1) Pitting Vs non-pitting
h) Paroxysmal nocturnal dyspnea
i) Labored breathing (SOB)
j) Orthopnea
k) Vertigo
l) Epistaxis
m) Tinnitus
n) Changes in visual acuity
o) Nausea/vomiting
p) Seizures
q) Lateralizing signs
F. Management
paramedics.
a) Position of comfort
b) Airway and ventilation
a) Oxygen
b) Administration of IV and when to administer based on local MPD protocols
c) Contact ALS for Additional resources
4. Rapid transport
a) Refusal
b) No other indications for no transport
Section 3: Page 40
VII. Cardiogenic shock

A. Epidemiology
1. Differential from hypovolemic shock by one or more of the following:
a) Chief complaint (chest pain, dyspnea, tachycardia
b) Heart rate (bradycardia or excessive tachycardia)
c) Signs and symptoms of congestive heart failure
d) Arrhythmias
B. Initial assessment
1. Chief complaint
a) Chest pain
b) Dizziness
c) Syncopal episodes
C. Detailed physical exam
a) Altered levels of consciousness
b) Unresponsive
2. Airway
a) Dyspnea
b) Productive cough
c) Labored breathing
(1) Paroxysmal nocturnal dyspnea (PND)
(2) Tripod position
(3) Adventitious sounds
(4) Retractions
3. Skin condition
4. Edema
a) Pedal pulses may be obliterated
b) Pretibial
c) Sacral
d) Other anatomical locations
5. Circulation
(1) Bradycardia
(2) Tachycardia
(3) Weak/ “thready”
D. Management
paramedics.
a) May prefer sitting upright with legs in dependent position
a) Oxygen
Section 3: Page 41
b) Administration of Nitroglycerin based on local MPD protocols

d) Contact ALS for Additional resources
E. Transport
F. Support and communication of treatment strategies
2. Communication and transfer of data to the physician
VIII.Vascular Disorders
A. Epidemiology
1. Trauma
2. Non-traumatic
a) Precipitating causes
(1) Atherosclerosis
(2) Aneurysm
(a) Atherosclerotic
(b) Dissecting
(c) Infections
(d) Congenital
(3) Inflammation
(a) Arterial
(b) Peripheral arterial atherosclerotic disease
(4) Occlusive disease
(a) Trauma
(b) Thrombosis
(c) Tumor
(d) Embolus
(e) Idiopathic
(5) Venous thrombosis
(a) Phlebitis
(b) Varicose veins
B. Initial Assessment Findings
1. Airway/breathing
a) Usually not affected
2. Circulation (distal to or over the affected area)
a) Pain
b) Pallor
c) Pulselessness
d) Paralysis
e) Paresthesia
Section 3: Page 42
3. Skin
a) Pallor or mottled distal to or over the affected area
b) Skin temperature may vary
C. Focused History
1. Chief complaint
a) Sudden or gradual onset of discomfort
b) May be localized
c) Pain
(1) Chest, abdominal or involved extremity
(a) Sudden or gradual
(b) Radiating or localized
(2) Relief with rest or not
2. Contributing history
a) Initial recognized event
b) Recurrent event
c) Increasing frequency and/or duration of event
D. Detailed Physical Exam
1. Airway
2. Breath sounds
a) May be clear to auscultation
3. Circulation
a) Alterations in heart rate and rhythm may occur
b) Peripheral pulses absent or diminished over the affected extremity
c) Blood pressure
(1) Unequal pressure in the arms
(a) May indicate high thoracic aneurysm
d) Skin
(1) May be cool reflecting diminished circulation to the affected area or
extremity
(2) May be moist or dry reflecting diminished circulation to the affected
area or extremity
4. Management
a) When paramedic service is available, ILS personnel shall contact
medical direction/control as soon as possible for advice about
rendezvous with paramedics.
b) Position of comfort
c) Transport
(1) Indications for rapid transport
(a) No relief with medications
(b) Hypotension/hypoperfusion
d) Support and communications strategies
(1) Explanation for patient, family, significant others
(2) Communications and transfer of data to the physician
Section 3: Page 43
IX. Medical/legal considerations

X. Integration
A. Apply pathophysiological principles to the assessment of a patient with
cardiovascular disease.
B. Formulation of field impression; decisions based on:
1. Initial assessment
2. Focused history
3. Detailed physical examination
C. Develop and execute a patient management plan based on field impression
1. Initial management
a) Airway support
b) Ventilation support
c) Circulation support
d) Non-pharmacological
e) Pharmacological - Medications only to be administered by ILS or ILS/AW
Techs following approval by on-line or off-line medical direction/control.
f) Contact ALS for Additional resources
g) Electrical
2. Ongoing assessment
3. Transport criteria
a) Appropriate mode
b) Appropriate facility
4. Non-transport criteria
5. Advocacy
6. Communications
7. Prevention
8. Documentation
9. Quality assurance
NOTES:
Section 3: Page 44
Lesson 3-3: Medical

Section 3 - Pharmacology and Emergency Care/Lesson 3-3: Medical
OBJECTIVES LEGEND
1=Knowledge
2=Application

findings to formulate a field impression and implement the treatment plan for the patient with
respiratory, neurological, endocrine, anaphylactic or toxicological emergencies.
Upon completing this module, the EMT-Intermediate will be able to:
1. Review the function of the structures located in the upper and lower airway. (C-1)
2. Review the physiology of ventilation and respiration. (C-1)
3. Review common pathological events that effect the pulmonary system. (C-1)
4. Review abnormal assessment findings associated with pulmonary diseases and
conditions. (C-1)
5. Review various airway and ventilation techniques used in the management of pulmonary
diseases. (C-1)
6. Review the pharmacological preparations that EMT-Intermediates use for management of
respiratory diseases and conditions. (C-1)
7. Review the use of equipment used during the physical examination of patients with
complaints associated with respiratory diseases and conditions. (C-1)
8. Identify the epidemiology, anatomy, physiology, assessment findings, and management
for the following respiratory diseases and conditions: (C-1)
• COPD
• Bronchial Asthma
• Chronic Bronchitis
• Emphysema
• Pneumonia
• Non Cardiogenic Pulmonary Edema
• Pulmonary Thromboembolism
• Upper Respiratory Infections
• Epiglottitis
• Hyperventilation Syndrome
• Spontaneous pneumothorax
Section 3: Page 46
The following underlined material is for ILS/Airway Technicians (receiving training and
certification in both ILS and Airway Technician) ONLY
1. Discuss the pathophysiology lung injuries - NOTE: Instruction in the performance of
chest decompression is limited to ILS/Airway Technicians (receiving training and
certification in both ILS and Airway Technician) ONLY. (C-1)
• Tension pneumothorax
• Simple pneumothorax
• Open pneumothorax
• Hemothorax
• Hemopneumothorax
• Pulmonary contusion
2. Discuss the assessment findings associated with lung injuries. . (C-1)
3. Discuss the management of lung injuries. . (C-1)
4. Identify the need for rapid intervention and transport of the patient with lung injuries. (C-1)
5. Discuss the pathophysiology of non-traumatic neurologic emergencies. (C-1)
6. Discuss the assessment findings associated with non-traumatic neurologic emergencies.
(C-1)
7. Identify the need for rapid intervention and the transport of the patient with non-traumatic
emergencies. (C-1)
8. Discuss the management of non-traumatic emergencies. (C-1)
9. Discuss the pathophysiology of coma and altered mental status. (C-1)
10. Discuss the assessment findings associated with coma and altered mental status. (C-1)
11. Discuss the management/treatment plan of coma and altered mental status. (C-1)
12. Describe the ILS and ILS/Airway medications (Naloxone, Dextrose, oral glucose) used in
the management of coma and altered mental status and when ALS should be contacted.
(C-1)
13. Define coma. (C-1)
14. Define altered mental status. (C-1)
15. Discuss the pathophysiology of syncope. (C-1)
16. Discuss the assessment findings associated with syncope. (C-1)
17. Discuss the management/treatment plan of syncope. (C-1)
18. Discuss the pathophysiology of seizures. (C-1)
19. Discuss the assessment findings associated with seizures. (C-1)
20. Discuss the management/treatment plan of a patient presenting with seizures (C-1)
21. Discuss the pathophysiology of CVA. (C-1)
22. Describe the types of CVA (C-1)
23. Discuss the assessment findings associated with CVA. (C-1)
24. Discuss the management/treatment plan of CVA. (C-1)
25. Discuss the pathophysiology of transient ischemic attack (C-1)
26. Discuss the assessment findings associated with transient ischemic attack (C-1)
27. Discuss the management/treatment plan of transient ischemic attack (C-1)
28. Identify the assessment findings of a patient with a diabetic emergency.
29. Discuss the management of diabetic emergencies.
30. Identify the assessment findings of a hypoglycemia patient (C-1)
Section 3: Page 47
31. Recognize the signs and symptoms of the patient with hypoglycemia. (C-1)
32. Describe the management of a responsive hypoglycemia patient. (C-1)
33. Describe the management of an unresponsive hypoglycemia patient. (C-1)
34. Correlate abnormal findings in assessment with clinical significance in the patient with
hypoglycemia. (C-2, C-3)
35. Describe the ILS and ILS/Airway medications (Naloxone, Dextrose, oral glucose) used in
the management of hypoglycemia and when ALS should be contacted. (C-1)
36. Identify the assessment findings of a hyperglycemic patient. C-1)
37. Recognize the signs and symptoms of the patient with hyperglycemia. C-1)
38. Describe the management of hyperglycemia. C-1)
39. Define allergic reaction. (C-1)
40. Define anaphylaxis. (C-1)
41. Discuss the anatomy and physiology of the organs and structures related to anaphylaxis.
(C-1)
42. Discuss the pathophysiology of allergy and anaphylaxis. (C-1)
43. Describe the common methods of entry of substances into the body. (C-1)
44. Define natural and acquired immunity. (C-1)
45. Define antigens and antibodies. (C-1)
46. List common antigens most frequently associated with anaphylaxis. (C-1)
47. Discuss the formation of antibodies in the body. (C-1)
48. Describe physical manifestations in anaphylaxis. (C-1)
49. Differentiate manifestations of an allergic reaction from anaphylaxis. (C-3)
50. Recognize the signs and symptoms related to anaphylaxis. (C-1)
51. Differentiate among the various treatment and pharmacological interventions used in the
management of anaphylaxis. (C-3)
52. Describe the ILS and ILS/Airway medications (epinephrine 1:1000 by a commercially pre-
loaded measured dose device) used in the management of anaphylaxis and when ALS
should be contacted. (C-1)
53. Recognize and differentiate between adult and pediatric doses of epinephrine 1:1000, for
the management of anaphylaxis (mg/kg), when using a commercially pre-loaded
measured dose device. (C-1)
54. Review the incidence, morbidity and mortality of toxic emergencies. (C-1)
55. Review the risk factors most predisposing to toxic emergencies. (C-1)
56. Review the anatomy and physiology of the organs and structures related to toxic
emergencies. (C-1)
57. Review the routes of entry of toxic substances into the body. (C-1)
58. Review the role of the Poison Control Center in the United States and in Washington
State. (C-1)
59. Review the toxic substances that are specific to regions. (C-1)
60. Discuss the incidence of drug abuse in the United States. (C-1)
• Substance or drug abuse
• Substance or drug dependence
• Tolerance
Section 3: Page 48
• Withdrawal
• Addiction
62. Review the pathophysiology of the entry of toxic substances into the body. (C-1)
63. Review the assessment findings associated with toxic substances. (C-1)
64. Review the need for rapid intervention and the transport of the patient with a toxic
substance emergency. (C-1)
65. Review the management of toxic substances. (C-1)
66. Review poisoning by ingestion. (C-1)
67. Review the most common poisoning by ingestion. (C-1)
68. Review the signs and symptoms related to the most common poisoning by ingestion. (C-1)
69. Review the abnormal findings in assessment with the clinical significance in the patient
with the most common poisoning by ingestion. (C-1)
70. Review among the various treatments and pharmacological interventions in the
management of the most common poisoning by ingestion. (C-1)
71. Review the factors affecting the decision to induce vomiting in a patient with ingested
poison. (C-1)
72. Apply the assessment findings to formulate a field impression and implement a treatment
plan for the patient with the most common poisoning by ingestion. (C-2)
73. Review poisoning by inhalation. (C-1)
74. Review the most commonly poisoning by inhalation. (C-1)
75. Review the signs and symptoms related to the most common poisoning by inhalation. (C-1)
with the most common poisoning by inhalation. (C-1)
77. Review the various treatments and pharmacological interventions in the management of
the most common poisoning by inhalation. (C-1)
plan for the patient with the most common poisoning by inhalation. (C-2)
79. Review poisoning by injection. (C-1)
80. Review the most commonly poisoning by injection. (C-1)
81. Review the signs and symptoms related to the most common poisoning by injection. (C-1)
with the most common poisoning by injection. (C-1)
the most common poisoning by injection. (C-1)
plan for the patient with the most common poisoning by injection. (C-2)
85. Review poisoning by surface absorption. (C-1)
86. Review the most commonly poisoning by surface absorption. (C-1)
87. Review the signs and symptoms related to the most common poisoning by surface
absorption. (C-1)
with the most common poisoning by surface absorption. (C-1)
the most common poisoning by surface absorption. (C-1)
Section 3: Page 49
90. Apply the assessment findings to formulate a field impression and implement a treatment plan for
the patient with the most common poisoning by surface absorption. (C-2)
91. List the most commonly abused drugs (by both chemical name and street names). (C-1)
92. Recognize the signs and symptoms related to the most common drug abuse. (C-1)
93. Correlate the abnormal findings in assessment with the clinical significance in the patient
with the most common drug abuse. (C-3)
94. Differentiate among the various treatments and pharmacological interventions in the
management of the most common drug abuse. (C-3)
plan for the patient with the most common drug abuse. (C-2)
96. Recognize and value the assessment and treatment of patients with respiratory diseases
97. Indicate appreciation for the critical nature of accurate field impressions of patients with
respiratory diseases and conditions
98. Characterize the feelings of a patient who regains consciousness among strangers. (A-2)
99. Formulate means of conveying empathy to patients whose ability to communicate is
limited by their condition. (A-3)
100.Demonstrate and record pertinent assessment findings associated with pulmonary
diseases and conditions
101.Demonstrate chest decompression techniques for the management of lung injuries: -
NOTE: Instruction in the performance of chest decompression is limited to
ILS/Airway Technicians (receiving training and certification in both ILS and Airway
Technician) ONLY:
102.Review proper use of airway and ventilation devices
103.Conduct a simulated history and patient assessment, record the findings, and report
appropriate management of patients with pulmonary diseases and conditions
104.Perform an appropriate assessment of a patient with coma or altered mental status. (P-2,3)
105.Appropriately manage a patient with coma or altered mental status, including the administration
of oxygen oral glucose, dextrose 50%, dextrose 25% and naloxone. (P-3)
106.Perform an appropriate assessment of a patient with syncope. (P-2,3)
107.Appropriately manage a patient with syncope. (P-3)
108.Perform an appropriate assessment of a patient with seizures. (P-2,3)
109.Appropriately manage a patient with seizures. (P-3)
110.Perform an appropriate assessment of a patient with CVA or TIA. (P-2,3)
111.Appropriately manage a patient with CVA or TIA. (P-3)
Section 3: Page 50
INTEGRATION
112.Differentiate between neurological emergencies based on assessment findings.
113.Correlate abnormal assessment findings with the clinical significance in the patient with
neurological complaints
114.Develop a patient management plan based on field impression in the patient with
neurological emergencies.
115.Differentiate between endocrine emergencies based on assessment and history.
116.Correlate abnormal findings in the assessment with clinical significance in the patient with
endocrinologic emergencies.
endocrinologic emergency.
118.Integrate the pathophysiological principles of the patient with anaphylaxis
119.Correlate abnormal findings in assessment with the clinical significance in the patient with
anaphylaxis
120.Develop a treatment plan based on field impression in the patient with allergic reaction
and anaphylaxis
121.Correlate abnormal findings in the assessment with the clinical significance in the patient
exposed to a toxic substance (C-2)
122.Develop a patient management plan based on field impression in the patient exposed to a
toxic substance
NOTES:
Section 3: Page 51
PRESENTATION
DECLARATIVE
I. Pulmonology
A. Introduction
1. Anatomy and Physiology Review
a) Global physiology of the pulmonary system
(1) Function
(a) The respiratory system functions as a gas exchange system.
(b) 10,000 liters of air are filtered, warmed, humidified, and exchanged
daily in adults
(c) Oxygen is diffused into the bloodstream for use in cellular
metabolism by the body’s 100 trillion cells
(d) Wastes, including carbon dioxide, are excreted from the body via the
respiratory system
(2) Physiology
(a) Ventilation
(i) Ventilation refers to the process of air movement in and out of
the lungs
(ii) In order for ventilation to occur, the following functions must be
intact:
(a) Neurologic control (brainstem) needs to initiate inspiration
(b) Nerves between the brainstem and the muscles of
respiration (diaphragm & intercostal) need to be intact and
undamaged
(c) Diaphragm and intercostal must be functional and non-
traumatized
(d) Upper airways must be intact and patent
(e) Lower airways must be intact and patent
(f) The alveoli must be intact and non-collapsed
(iii) Emergent intervention for ventilation problems includes:
(a) Opening the upper and lower airways
(b) Providing assisted ventilation
(b) Perfusion
(i) Perfusion refers to the process of circulating blood through the
pulmonary capillary bed
(ii) In order for perfusion to occur, the following functions must be
intact:
(a) There must be adequate blood volume (and adequate
hemoglobin within the blood)
(b) The pulmonary capillaries must be intact and not occluded
(c) The left heart must be functioning properly to assure a
smooth flow of blood through the pulmonary capillary bed
(iii) Emergent intervention for perfusion problems includes:
Section 3: Page 52
(a) Ensuring adequate circulating volume and hemoglobin levels

(b) Optimizing left heart function as necessary
(3) Rationale behind learning physiology
(a) There are many, many different pulmonary diseases. Many act in a
variety of different ways on a number of body systems.
(b) Learning the pathophysiology of every respiratory disease is
impossible at the EMT-Intermediate level, and is not a useful
exercise because of the dynamic nature of newly developing or
identified pulmonary pathologies.
(c) However, all respiratory problems-- old or new-- can be categorized
as impacting ventilation, diffusion, and perfusion.
(d) Treatment can be initiated rapidly and effectively once the problem
has been identified as ventilation, diffusion, perfusion, or a
combination.
b) Anatomy of the pulmonary system
(1) The upper airway
(a) Functions
(i) Conduit for air
(ii) Filtration
(iii) Warming
(iv) Humidification
(v) Protection of lower airway
(b) Structures
(i) Nose
(ii) Pharynx
(iii) Larynx
(2) The lower airway
(a) Functions
(i) Conduit for air
(ii) Filtration
(iii) Warming
(iv) Humidification
(v) Removal of foreign particles
(b) Structures
(i) Trachea
(ii) Bronchi
(iii) Bronchioles
(iv) Cilia
(3) The gas exchange interface
(a) Functions
(i) Facilitate gas exchange
(ii) Transfer gases
(b) Structures
Section 3: Page 53
(i) Alveoli
(ii) Interstitial space
(iii) Pulmonary capillary bed
(4) The chest wall
(a) Functions
(i) Ventilation
(ii) Protection of lungs and airways
(iii) Mechanism and normals
(a) The process of inspiration and expiration
(b) Normal respiratory volumes (total lung capacity; tidal
volume)
(b) Structures
(i) Diaphragm is the major muscle of respiration
(ii) Intercostal muscles
(iii) Accessory muscles
(iv) Pleural space
B. General System Pathophysiology, Assessment and Management
1. Pathophysiology
a) A variety of problems can impact the pulmonary system’s ability to achieve its
goal of gas exchange to provide for cellular needs and excretion of wastes
b) Understanding these problems globally can enable the EMT-Intermediate to
quickly and effectively pinpoint probably causes and necessary interventions
c) Specific pathophysiologies
(1) Ventilation
(a) Upper airway obstruction
(i) Trauma
(ii) Epiglottitis
(iii) Foreign body obstruction
(iv) Inflammation of the tonsils
(b) Lower airway obstruction
(i) Trauma
(ii) Obstructive lung disease
(iii) Mucous accumulation
(iv) Smooth muscle spasm
(v) Airway edema
(c) Chest wall impairment
(i) Trauma
(ii) Hemothorax
(iii) Pneumothorax
(iv) Empyema
(v) Pleural inflammation
(vi) Neuromuscular diseases (such as multiple sclerosis or muscular
dystrophy)
Section 3: Page 54
(d) Problems in neurologic control

(i) Brainstem malfunction
(a) CNS depressant drugs
(b) CVA or other medical neurologic condition
(c) Trauma
(ii) Phrenic/spinal nerve dysfunction
(a) Trauma
(b) Neuromuscular diseases
2. Assessment Findings
a) Scene size up
(1) Pulmonary complaints may be associated with exposure to a wide variety
of toxins, including carbon monoxide, toxic products of combustion, or
environments that have deficient ambient oxygen (such as silos,
enclosed storage spaces etc.).
(2) It is critical to assure a safe environment for all EMS personnel before
initiating patient contact.
(3) If necessary, individuals with specialized training and equipment should
be utilized to remove the patient from a hazardous environment.
b) Initial assessment
(1) A major focus of the initial assessment is the recognition of life-threat.
There are a variety of pulmonary conditions, which may offer a very real
risk for patient death.
(2) Recognition of life threat and the initiation of resuscitation takes priority
over detailed assessment.
(3) Signs of life-threatening respiratory distress in adults, listed from most
ominous to least severe:
(a) Alterations in mental status
(b) Severe cyanosis
(c) Absent breath sounds
(d) Audible stridor
(e) 1-2 word dyspnea
(f) Tachycardia greater than 130 beats/minute
(g) Pallor and diaphoresis
(h) The presence of retractions/use of the accessory muscles
c) Focused history and physical examination
(1) Chief complaint
(a) Dyspnea
(b) Chest pain
(c) Cough
(i) Productive
(ii) Non-productive
(iii) Hemoptysis
(d) Wheezing
Section 3: Page 55
(e) Signs of infection

(i) Fever/chills
(ii) Increased sputum production
(2) History
(a) Previous experiences with similar/identical symptoms
(i) The patient’s subjective description of acuity is an accurate
indicator of the acuity of this episode if the pathology is chronic.
(ii) Asking the patient “what happened the last time you had an
attack this bad” is an extremely useful predictor of this episode’s
course.
(b) Known pulmonary diagnosis
(i) If the diagnosis is not known to the EMT-Intermediate, an effort
should be made to learn whether it is primarily related to
ventilation, diffusion, perfusion, or a combination.
(c) History of previous intubation is an accurate indicator of severe
pulmonary disease, and suggests that intubation may be required
again
(d) Medication history
(i) Current medications
(ii) Medication allergies
(iii) Pulmonary medications
(a) Sympathomimetic
(i) Inhaled
(ii) Oral
(iii) Parenteral
(b) Corticosteroid
(i) The presence of corticosteroid in the patient’s home
regimen strongly suggests severe, chronic disease
(ii) Inhaled
(iii) Oral (daily vs. during exacerbations only)
(c) Chromolyn sodium
(d) Methylxanthines (theophylline preparations)
(e) Antibiotics
(iv) Cardiac-related drugs
(e) History of the present episode
(f) Exposure/smoking history
(3) Physical exam
(a) General impression
(i) Position
(a) Sitting
(b) “tripod” position
(c) Feet dangling
Section 3: Page 56
(ii) Mentation
(a) Confusion is a sign of hypoxemia or hypercarbia
(b) Restlessness and irritability may be signs of fear and
hypoxemia
(c) Severe lethargy or coma is a sign of hypercarbia
(iii) Ability to speak
(a) 1-2 word dyspnea vs. Ability to speak freely
(b) Rapid, rambling speech as a sign of anxiety and fear
(iv) Respiratory effort
(a) Hard work indicates obstruction
(b) Retractions
(c) Use of accessory muscles
(v) Color
(a) Pallor
(b) Diaphoresis
(c) Cyanosis
(i) Central vs. Peripheral
(b) Vital signs
(i) Pulse
(a) Tachycardia is a sign of hypoxemia and the use of
sympathomimetic medications
(b) In the face of a pulmonary etiology, bradycardia is an
ominous sign of severe hypoxemia and imminent cardiac
arrest
(ii) Blood pressure
(a) Hypertension may be associated with sympathomimetic
medication use
(iii) Respiratory rate
(a) The respiratory rate is not a very accurate indicator of
respiratory status unless it is very slow
(b) Trends are essential in evaluating the chronic patient.
Slowing rate in the face of an unimproved condition suggests
exhaustion and impending respiratory insufficiency
(iv) Respiratory patterns
(a) Normal breathing
(b) Tachypnea
(c) Cheyne-Stokes
(d) Central neurogenic hyperventilation
(e) Kussmaul
(f) Apneustic
(g) Apnea
Section 3: Page 57
(c) Head/neck
(i) Pursed lip breathing
(ii) Use of accessory muscles
(iii) Sputum
(a) Increasing amounts suggests infection
(b) Thick, green or brown sputum suggests infection and/or
pneumonia
(c) Yellow or pale gray sputum may be related to allergic or
inflammatory etiologies
(d) Frank hemoptysis often accompanies severe tuberculosis or
carcinomas
(e) Pink, frothy sputum is associated with severe, late stages of
pulmonary edema
(iv) Jugular venous distention (JVD) may accompany right sided
heart failure, which may be caused by severe pulmonary
obstruction
(d) Chest
(i) Signs of trauma
(ii) Barrel chest demonstrates the presence of long-standing chronic
obstructive lung disease
(iii) Retractions
(iv) Symmetry
(v) Breath sounds
(a) Normal
(i) Bronchial
(ii) Bronchovesicular
(iii) Vesicular
(b) Abnormal
(i) Stridor
(ii) Wheezing
(iii) Rhonchi (low wheezes)
(iv) Rales (crackles)
(v) Pleural friction rub
(e) Extremities
(i) Peripheral cyanosis
(ii) Clubbing is indicative of long-standing chronic hypoxemia
(iii) Carpopedal spasm may be associated with hypocapnia resulting
from periods of rapid, deep respiration
(4) Diagnostic testing
(a) Pulse oximetry
(i) Used to evaluate or confirm the adequacy of oxygen saturation
Section 3: Page 58
(ii) May be inaccurate in the presence of conditions which

abnormally bind hemoglobin, including carbon monoxide
poisoning or methemoglobinemia
(b) Peak flow
(i) Provides a baseline assessment of airflow for patients with
obstructive lung disease
(c) Capnometry
(i) Provides ongoing assessment of endotracheal tube position.
End-tidal CO2 drops immediately when the tube is displaced from
the trachea
(ii) Quantitative vs. Qualitative
3. Management
b) Airway and Ventilation
(1) Head Tilt/Chin Lift
(2) Trauma Chin Lift
(3) Head Tilt/Jaw Thrust
(4) Oropharyngeal airway
(5) Nasopharyngeal airway
(6) Nasal Cannula
(7) Simple oxygen mask
(8) Non-rebreather mask
(9) HEPA mask
(10) Multi-Lumen Airways
(a) Pharyngeal Tracheal Double-Lumen Airway
(b) Pharyngeal Tracheal Lumen Airway
(11) Bag-valve-mask
(12) Bag-valve-mask with PEEP
(13) Suctioning
(14) Oral cavity
(15) Endotracheal intubation
(16) Oxygen Powered Manually Triggered Ventilators
(17) Automatic Transport Ventilator
c) Circulation
d) Pharmacological - Medications only to be administered by ILS or ILS/AW
(1) Oxygen
Section 3: Page 59
(2) Albuterol
(a) Dosage - based upon order from medical direction/control.
(i) Adult:
(a) Solution: 2.5 mg; dilute 0.5 ml of the 0.5% solution for
inhalation with 2-4 ml normal saline in nebulizer over 5-15
min
(b) Metered dose inhaler: 1-2 inhalations (90 µg each). May be
repeated every 15 min as needed.
(ii) Pediatric:
(a) Age younger than 12 yrs: Solution: 0.03 ml/kg of a 0.5%
solution up to 1 ml over 5-10 min
(b) Age 12 and over: Use full adult dose
(3) Contact ALS for additional resources
e) Non-pharmacological
(1) Positioning - sitting up
(2) Back blows
f) Monitoring and devices used in Pulmonology
(1) Pulse Oximetry
(2) Peak flow
(3) Capnometry
g) Transport Considerations
(1) Appropriate mode
(2) Appropriate facility
C. Specific Illness
1. Obstructive Airway Diseases
a) A spectrum of diseases which affect a substantial number of individuals
worldwide
b) Diseases include asthma, COPD (which includes emphysema and chronic
bronchitis)
c) Epidemiology
(1) Morbidity/mortality
(a) Overall
(b) Asthma: 4-5% of US population
(c) 20% of adult males have chronic bronchitis
(2) Causative factors
(a) Cigarette smoking
(b) Exposure to environmental toxins
(c) Genetic predisposition
(3) Factors which may exacerbate underlying conditions
(a) Intrinsic
(i) Stress is a significant exacerbating factor, particularly in adults
(ii) Upper respiratory infection
Section 3: Page 60
(iii) Exercise
(b) Extrinsic
(i) Tobacco smoke
(ii) Allergens (including foods, animal danders, dusts, molds,
pollens)
(iii) Drugs
(iv) Occupational hazards
(4) Prevention strategies
(a) Smoking prevention, particularly for youth
(b) Stop-smoking for existing smokers
(c) Control of air pollution
(d) Provision of smoke-free workplaces and public locations
d) Pathophysiology review
(1) Ventilation disorders
(2) Obstruction occurs in the bronchioles, and may be the result of:
(a) Smooth muscle spasm
(i) Beta receptors
(b) Mucous
(i) Goblet cells
(ii) Cilia
(c) Inflammation
(3) Obstruction may be reversible or irreversible
(4) Obstruction causes air trapping through the following mechanism:
(a) Bronchioles dilate naturally on inspiration
(b) Dilation enables air to enter the alveoli despite the presence of
obstruction
(c) Bronchioles naturally constrict on expiration
(d) Air becomes trapped distal to obstruction on exhalation
e) Pathophysiology varies slightly by disease
(1) Asthma
(a) Reversible obstruction
(b) Obstruction caused by a combination of smooth muscle spasm, thick
mucous, and edema
(c) Exacerbating factors tend to be extrinsic in children, intrinsic in adults
(d) Status Asthmaticus
(i) Prolonged exacerbation which doesn't respond to therapy
(2) Chronic bronchitis
(a) Reversible and irreversible obstruction
(b) Characterized by hyperplasia and hypertrophy of mucous-producing
glands
(c) Clinical definition: productive cough for at least 3 months/year for 2 or
more consecutive years
Section 3: Page 61
(d) Typically associated with cigarette smoking, but may also occur in
non-smokers
(3) Emphysema
(a) Irreversible airway obstruction
(b) Diffusion defect also exists because of the presence of blebs
(c) Because blebs have extremely thin walls, they are prone to collapse.
To prevent collapse, the patient often exhales through pursed lips,
effectively maintaining a positive airway pressure.
(d) Almost always associated with cigarette smoking or significant
exposure to environmental toxins.
f) Assessment Findings
(1) Signs of severe respiratory impairment
(a) Altered mentation
(b) 1-2 word dyspnea
(c) Absent breath sounds
(2) Chief complaint
(a) Dyspnea
(b) Cough
(c) Nocturnal awakening with dyspnea and wheezing
(3) History
(a) Personal or family history of asthma and/or allergies
(b) History of acute exposure to pulmonary irritant
(c) History of prior similar episodes
(4) Physical findings
(a) Wheezing may be present in ALL types of obstructive lung disease
(b) Retractions and/or use of accessory muscles
(5) Diagnostic testing
(a) Pulse oximeter to document degree of hypoxemia and response to
therapy
(b) Peak flow to establish baseline airflow
g) Management
(1) When paramedic service is available, ILS personnel shall contact
(2) Airway and Ventilation
(a) Intubation as required
(b) Assisted ventilation may be necessary
(c) High flow oxygen
(3) Circulation
(a) Intravenous therapy may be necessary to:
(i) Improve hydration
(ii) Thin and loosen mucous
Section 3: Page 62
(4) Pharmacological - Medications only to be administered by ILS or ILS/AW

(a) Albuterol by inhalation
(i) Dosage - based upon order from medical direction/control.
(a) Adult:
(i) Solution: 2.5 mg; dilute 0.5 ml of the 0.5% solution for
inhalation with 2-4 ml normal saline in nebulizer over 5-
15 min
(ii) Metered dose inhaler: 1-2 inhalations (90 µg each). May
be repeated every 15 min as needed.
(b) Pediatric:
(i) Age younger than 12 yrs: Solution: 0.03 ml/kg of a
0.5% solution up to 1 ml over 5-10 min
(ii) Age 12 and over: Use full adult dose
(b) Contact ALS for additional resources
(5) Supportive care
(6) Transport Considerations
(a) Appropriate mode
(b) Appropriate facility
(7) Continue monitoring
(8) Contact medical direction/control
(9) Psychological support/communication strategies
2. Pneumonia
a) Epidemiology
(1) Incidence
(a) Fifth leading cause of death in the US
(b) Not a single disease, but a group of specific infections
(c) Risk factors
(i) Cigarette smoking
(ii) Alcoholism
(iii) Exposure to cold
(iv) Extremes of age (old or young)
(2) Anatomy and Physiology review
(a) Cilia
(b) Causes and process of mucous production
b) Pathophysiology
(1) Ventilation disorder.
(2) Infection of lung parenchyma
(a) Most commonly bacterial
(b) May also be viral or fungal
(3) May cause alveolar collapse (atelectasis)
Section 3: Page 63
(4) Localized inflammation/infection may become systemic, leading to sepsis

and septic shock
(5) Community acquired vs. Hospital acquired
c) Assessment Findings
(1) Typical pneumonia
(a) Acute onset of fever and chills
(b) Cough productive of purulent sputum
(c) Pleuritic chest pain (in some cases)
(d) Pulmonary consolidation on auscultation
(e) Location of bronchial breath sounds
(f) Rales
(g) Egophony
(2) Atypical pneumonia
(a) Non-productive cough
(b) Extra- pulmonary symptoms
(c) Headache
(d) Myalgia
(e) Fatigue
(f) Sore throat
(g) Nausea, vomiting, diarrhea
(h) Fever and chills
d) Management
(2) Airway and ventilation
(a) Intubation may be required
(b) Assisted ventilation as necessary
(3) Circulation
(a) Intravenous access
(b) Administration of IV fluids
(i) Improve hydration
(ii) Thin and mobilize mucous
(a) Albuterol may be required if airway obstruction is severe or if the
patient has accompanying obstructive lung disease
(i) Dosage - based upon order from medical direction/control.
(a) Adult:
15 min
Section 3: Page 64
(ii) Metered dose inhaler: 1-2 inhalations (90 µg each). May

be repeated every 15 min as needed.
(b) Pediatric:
(5) Non-pharmacological
(a) Cool if high fever
(a) Elderly, over 65 years
(i) Significant co-morbidity
(ii) Inability to take oral medications
(iii) Support complications
(iv) Appropriate facility
3. Pulmonary edema
a) Not a disease but a pathophysiological condition
(1) High pressure (cardiogenic)
(2) High permeability (non-cardiogenic)
b) Epidemiology
(1) Risk factors vary based on type:
(a) High pressure (cardiogenic)
(i) Acute myocardial infarction
(ii) Chronic hypertension
(iii) Myocarditis
(b) High permeability (non-cardiogenic)
(i) Acute hypoxemia
(ii) Near-drowning
(iii) Post-cardiac arrest
(iv) Post shock
(v) High altitude exposure
(vi) Inhalation of pulmonary irritants
c) Assessment Findings
(1) History of associated factors:
(a) Hypoxic episode
(b) Shock (hypovolemic, septic, or neurogenic)
(c) Chest trauma
(d) Recent acute inhalation of toxic gases or particles
(e) Recent ascent to high altitude without climatizing
(2) Dyspnea
(3) Orthopnea
Section 3: Page 65
(4)Fatigue
(5)Reduced exercise capacity
(6)Pulmonary rales, particularly in severe cases
(7)Diagnostic testing
(a) Pulse oximetry
d) Management
(2) High pressure (cardiogenic)
(a) Refer to cardiology
(3) High permeability (non-cardiogenic)
(a) Airway and ventilation
(i) Intubation as necessary
(ii) Assisted ventilation may be required
(iii) High flow oxygen
(4) Circulation
(a) Avoid fluid excess; monitor IV flow rates carefully
(a) Oxygen
(a) Position the patient in an upright position with legs dangling
(b) Rapid removal from any environmental toxins
(c) Rapid descent in altitude if high altitude pulmonary edema (HAPE) is
suspected
(7) Transport decisions
4. Pulmonary Thromboembolism
a) Epidemiology
(1) Responsible for 50,000 death annually
(2) 5% of sudden deaths
(3) Less than 10% of pulmonary emboli result in death
(4) Risk Factors
(a) Recent surgery
(b) Pregnancy
(c) Oral contraceptives
(d) Long bone fractures
(e) Prolonged inactivity
(f) Bedridden patients
Section 3: Page 66
(5) Emboli come from clots in:

(a) Leg veins
(b) Pelvic veins
(c) Fat emboli from long bone fractures
b) Assessment Findings - depend on size of the clot
(1) Evidence of significant life-threatening embolus in a proximal location
(a) Altered mentation
(b) Severe cyanosis - Hypoxia does not correct with oxygen
(c) Profound hypotension
(d) Cardiac arrest
(2) Chief complaint
(a) Chest pain
(b) Dyspnea
(c) Cough (typically non-productive
(3) History
(a) Sudden onset
(b) Identification of risk factors
(a) Normal breath sounds or, in some cases, rales or wheezes
(b) Pleural fiction rub
(c) Tachycardia
(d) Clinical evidence of thrombophlebitis (found in less than 50%)
(e) Tachypnea
(f) Hemoptysis (fairly rare)
(g) Petechiae on upper thorax and arms
(h) Above findings during spontaneous childbirth
c) Management
(2) Depends on the size of the embolism
(a) Intubation if necessary
(b) Positive pressure ventilation if required
(4) Circulation
(a) CPR if required
(b) IV therapy; hydration based on clinical symptoms
(a) Oxygen
(6) Non-pharmacological therapy
Section 3: Page 67
(a) Support body systems

(b) Most severe cases will be managed as a cardiac arrest of unknown
origin
(a) Rapid transport
(b) Appropriate mode
(c) Appropriate facility
5. Upper Respiratory Infection
a) Epidemiology
(1) Incidence
(a) 80 million cases in 1975
(2) Morbidity/Mortality
(a) Rarely life threatening
(b) Often exacerbates underlying pulmonary conditions
(c) Often become significant infections in patients with suppressed
immune function (such as HIV)
(3) Risk factors
(a) Avoidance of exposure is nearly impossible because of the
prevalence of causative agents
(b) Severity increases in patients with underlying pulmonary conditions
(4) Prevention strategies
(a) Handwashing and covering the mouth during sneezing and coughing
are essential in preventing spread
b) Anatomy and Physiology review
(1) Nasopharynx
(2) Oropharynx
(3) Paranasal sinus
(4) Inner ear
(5) Middle ear
(6) Outer ear
(7) Eustachian tubes
(8) Epiglottis
(9) Respiratory epithelium
(10) Lymphatic system
(11) Secretory antibody immunoglobulin gamma A (IgA)
c) Pathophysiology
(1) A variety of bacteria and virus cause upper respiratory infections (URI)
(2) 20-30% are Group A streptococci
(3) 50% of pharyngitis cases have no demonstrated bacterial or viral cause
(4) Most are self-limiting diseases
d) Assessment findings
(1) Chief complaints
Section 3: Page 68
(a) Sore throat

(b) Fever
(c) Chills
(d) Headache
(e) Difficulty /painful swallowing
(f) Sense of anxiety/doom
(g) Drooling
(a) Cervical adenopathy
(b) Erythematous pharynx
(c) Positive throat culture
e) Management
(a) Typically no intervention required
(b) Oxygen administration may be appropriate in patients with underlying
pulmonary conditions. Administer based on symptoms and pulse
oximetry
(a) Prehospital care is symptomatic, and based in part on the presence
of underlying pulmonary conditions. Bronchodilation may be
appropriate
(b) Oxygen
(c) Contact ALS for additional resources
(4) Non-Pharmacological
(a) Collected throat cultures require family notification of results and
follow-up care
6. Epiglottitis
a) Pathophysiology
(1) An inflammation of the epiglottis which most often occurs in children, but
can also occur in adults
(2) Caused by bacteria which directly invade tissues above the glottis,
causing swelling of the epiglottis and surrounding soft tissue
(3) The spread of bacteria into the blood stream is common
(4) The progression of tissue swelling and inflammation is rapid, and upper
airway obstruction can occur suddenly
Section 3: Page 69
b) Assessment Findings
(1) Classic presentation is that of a child with:
(a) High fever
(b) An ill appearance
(c) Difficult and very painful swallowing
(d) Drooling
(e) Their mouth open and the tongue protruding
(f) Severe respiratory distress
(g) Preference to sit upright, leaning slightly forward on their hands with
the neck extended forward (tripod position)
(h) Muffled voice and stridor, depending on the degree of obstruction
(i) In severe cases, hypoxia
(2) Presentation may be more subtle
(3) Many children will have history of upper respiratory tract infection, a low
grade temperature and even a croup like cough
(4) Older children and adults may describe only a sore throat and subtle
voice changes
(5) Patient complaints and physical findings are limited to the respiratory
system
(a) Lung examination is normal
(b) Respiratory muscle retractions are evident
c) Severity
(1) It is a true emergency because the patient can progress to complete
airway obstruction and respiratory arrest if the epiglottis swells over the
opening of the trachea
d) Management
(2) The prehospital management of epiglottitis in children and adults is
primarily supportive
(a) Airway and Ventilation
(i) Maintain patent airway
(ii) High flow, high concentration, cool mist oxygen
(a) Administered by non-rebreather mask, using the blow-by
technique
(b) Should be offered but not forced on the patient, particularly
the young child
(iii) DO NOT PLACE ANYTHING IN THE PATIENT’S MOUTH
(iv) NEVER ATTEMPT TO VISUALIZE THE AIRWAY
(v) If airway becomes obstructed, maintain ventilation and
oxygenation with a BVM
(b) Circulation
(i) DO NOT attempt IV access
Section 3: Page 70
(c) Pharmacological - Medications only to be administered by ILS or

ILS/AW Techs following approval by on-line or off-line medical
direction/control.
(i) Oxygen
(ii) Contact ALS for Additional resources
(d) Non-pharmacological
(i) DO NOT upset the patient
(ii) DO NOT FORCE THE PATIENT TO DO ANYTHING
(iii) Allow the patient to assume position of comfort and a child
should remain with a calm parent/guardian
(e) Transport considerations
(i) Notify hospital of patient status early
(ii) Transport to the hospital quickly, but quietly
(f) Psychological support/communication strategies
(3) Assessment
(a) Monitor vital signs for improvement or decompensation
(b) Gently transport to the hospital
(d) Adult bag-valve-mask-device (BVM)
7. Hyperventilation Syndrome
a) Multiple causes
(1) Hypoxia
(2) High altitude
(3) Pulmonary disease
(4) Pulmonary disorders
(5) Pneumonia
(6) Interstitial pneumonitis, fibrosis, edema
(7) Pulmonary emboli, vascular disease
(8) Bronchial asthma
(9) Cardiovascular disorders
(10) Congestive heart failure
(11) Hypotension
(12) Metabolic disorders
(13) Acidosis
(14) Hepatic failure
(15) Neurologic disorders
(16) Psychogenic or anxiety hypertension
(17) Central nervous system infection, tumors
(18) Drug-induced
(19) Salicylate
(20) Methylxanthine derivatives
(21) Beta-adrenergic agonists
(22) Progesterone
Section 3: Page 71
(23) Fever, sepsis

(24) Pain
(25) Pregnancy
b) Assessment Findings
(1) Chief complaint
(a) Dyspnea
(b) Chest pain
(c) Other symptoms based on etiology
(d) Carpopedal spasm
(a) Rapid breath with high minute volume
(b) Varying depending on cause of syndrome
(c) Carpopedal spasms
c) Pathophysiology
(1) Depends on cause of syndrome
d) Management
(1) Depends on cause of syndrome, discussed elsewhere
(a) Airway and Ventilation
(i) Oxygen, rate of administration based on symptoms and pulse
oximetry
(b) If anxiety hyperventilation is confirmed (especially based on patient’s
prior history) coached ventilation might be considered
(2) Circulation
(a) Intervention rarely required
(a) Oxygen
(b) Contact ALS for Additional resources
(a) Intervention rarely required
(b) Patients with anxiety hyperventilation will require psychological
approaches to calm them
(c) Have them mimic your respiratory rate and volume
(d) Do not place bag over mouth and nose
(a) Depends on cause of hyperventilation
Section 3: Page 72
8. Spontaneous Pneumothorax
a) Epidemiology
(1) Incidence
(a) 18 per 100,000
(a) 15-20 % partial pneumothorax may be well tolerated
(3) Risk factors
(a) Males
(b) Younger age
(c) Thin body mass
(d) History of COPD (secondary spontaneous pneumothorax)
b) Assessment findings
(1) Chief complaint
(a) Shortness of breath
(b) Chest pain
(c) Sudden onset
(a) Typically minor
(i) Pallor
(ii) Diaphoresis
(iii) Tachypnea
(b) Severe
(i) Altered mentation
(ii) Cyanosis
(iii) Tachycardia
(iv) Decreased breath sounds
(v) Local hyperresonance to percussion
(vi) Subcutaneous emphysema
c) Management
(a) Intubation as required
(b) Assisted ventilation if necessary
(c) Oxygen, administration levels based on symptoms and pulse
oximetry
(3) Circulation
(a) IV initiation if severe symptoms present
(a) Not typically necessary. Treat symptomatically
Section 3: Page 73

(a) Position of comfort/best ventilation
II. Lung Injuries - NOTE: Instruction in the performance of chest decompression is
limited to ILS/Airway Technicians (receiving training and certification in both ILS
and Airway Technician) ONLY:
A. Anatomy and Physiology Review of the Thorax
1. Anatomy
a) Skin
b) Bones
(1) Thoracic cage
(2) Sternum
(3) Thoracic spine
c) Muscles
(1) Intercostal
(2) Trapezius
(3) Latissimus dorsi
(4) Rhomboids
(5) Pectoralis major
(6) Diaphragm
(7) Sternocleidomastoid
d) Trachea
e) Bronchi
f) Lungs
(1) Parenchyma
(2) Alveoli
(3) Alveolar - capillary interface
(4) Pleura
(a) Visceral
(b) Parietal
(c) Serous fluid
(5) Lobes
g) Vessels
(1) Arteries
(a) Aorta
(b) Carotid
Section 3: Page 74
(c) Subclavian
(d) Intracostal arteries
(e) Innominate
(f) Internal mammary
(2) Veins
(a) Superior vena cava
(b) Inferior vena cava
(c) Subclavian
(d) Internal jugular
(3) Pulmonary
(a) Arteries
(b) Veins
h) Heart
(1) Ventricles
(2) Atrium
(3) Valves
(4) Pericardium
i) Esophagus
(1) Thoracic inlet
(2) Course through chest
(3) Esophageal foramen through diaphragm
j) Mediastinum
(1) Structures located in mediastinum
(a) Heart
(b) Trachea
(c) Vena cava
(d) Aorta
(e) Esophagus
2. Physiology
a) Ventilation
(1) Expansion and contraction of thoracic cage
(a) Bellows system
(b) Musculoskeletal structure
(c) Intercostal muscles
(d) Diaphragm
(e) Accessory muscles
(f) Changes in intrathoracic pressure
b) Respiration
(1) Neurochemical control
(2) Gas exchange
(a) Alveolar-capillary interface
(b) Capillary-cellular interface
Section 3: Page 75
(c) Pulmonary circulation

(d) Cardiac circulation
(e) Acid-base balance
(i) Respiratory alkalosis
(ii) Respiratory acidosis
(iii) Compensation for metabolic acidosis and alkalosis
B. Injuries to the Lung
1. Tension pneumothorax - NOTE: Instruction in the performance of chest
decompression is limited to ILS/Airway Technicians (receiving training and
certification in both ILS and Airway Technician) ONLY:
a) Epidemiology
(1) Incidence
(a) Penetrating trauma
(b) Blunt trauma
(a) Profound hypoventilation could result
(b) Death related to delayed management
(c) Immediate life-threatening chest injury
b) Pathophysiology
(1) Defect in airway allowing communication with pleural space
(2) Blunt trauma:
(a) Penetration by rib fracture
(b) Sudden increase in intrapulmonary pressure
(c) Bronchial disruption from shear forces
(3) Air trapped in pleural space with build up of pressure
(4) Lung collapse on affected side with mediastinal shift to contralateral side
(5) Lung collapse leads to right-to-left intrapulmonary shunting and hypoxia
(6) Reduction in cardiac output
(a) Increased intrathoracic pressure
(b) Deformation of vena cava reducing preload (decreased venous
return to heart)
c) Assessment findings
(1) The initial signs of tension pneumothorax may be subtle, such as
restlessness. However, these patients have an extremely rapid downhill
course over a period of just a few minutes
(a) Restlessness and agitation/extreme anxiety
(b) Increased airway resistance on ventilating patient
(c) Neck vein distention
(d) Respiratory distress
(i) Severe dyspnea
(ii) Tachypnea
(iii) Air hunger in the conscious patient
Section 3: Page 76
(e) Unilateral decreased or absent breath sounds

(f) Hyperresonance to percussion on affected side
(g) Hypotension
(h) Cyanosis
(i) Tracheal deviation toward unaffected side
(j) Bulging of intercostal muscles
(k) Tachycardia
(l) Narrow pulse pressure
(m) Subcutaneous emphysema
(n) Respiratory arrest
(2) A high index of suspicion and repeated assessment n patients with
clinical profiles at risk for tension pneumothorax are extremely important
d) Indications - Thoracic decompression is indicated in patients with clinical
signs and symptoms consistent with tension pneumothorax
e) Contraindications - There are no contraindications for performing a needle
decompression for patients meeting the above criteria, however, medical
direction/control may be required before executing this procedure
f) Management
(a) Positive pressure ventilation if necessary
(2) Circulation
(a) Relieve tension pneumothorax to improve cardiac output
(a) Occlude open wound
(b) Needle decompression
(i) Equipment
(a) Large-bore over the needle catheter (14 gauge or larger)
(b) 10 cc syringe
(c) Povidone-iodine preps
(d) Finger cut from a sterile glove for flutter valve (alternatively,
a Heimlich flutter valve may be used)
(e) Sterile dressing
(f) Sterile gloves
(g) McSwain Dart is used in some systems
(ii) Procedure
(a) Observe body substance isolation precautions (gloves and
eye protection)
(b) locate the landmark for decompression on the affected side
and cleanse the chest with povidone-iodine solution
(c) Attach a 10 cc syringe to a 14 gauge (or larger) over the
needle catheter
Section 3: Page 77
(d) Puncture the skin perpendicularly just superior to the third rib
(second intercostal space) in the midclavicular line
(approximately in line with the nipple) until the thoracic cavity
is entered
(i) The fifth intercostal space in the mid-axillary line is an
alternate site
(e) On entering the thoracic cavity with a tension pneumothorax,
you should feel a pop, and then, depending on the level of
ambient noise, you may hear a “hiss” as air is decompressed
(i) Alternately, you may see the plunger of the syringe push
outward
(f) Advance the catheter and remove the needle
(g) A Heimlich valve or the finger cut from a surgical glove may
be used to create a one-way valve allowing air to escape,
but not enter, the chest
(i) Place a finger from a surgical glove over the catheter
hub
(ii) Cut a small hole in the end of the finger to make a one-
way or flutter valve
(iii) Secure the glove finger to the catheter, using tape or a
rubber band
(iv) The flutter valve collapses during inspiration and opens
during expiration
(v) In some EMS systems, a Heimlich valve is used in place
of the surgical glove finger.
(h) Secure the catheter to the chest wall with a dressing and
tape
(iii) Assess the need for a second or third needle insertion
(4) Transport consideration
2. Simple pneumothorax
a) Epidemiology
(1) Incidence
(a) 10-30% in blunt chest trauma
(b) Almost 100% with penetrating chest trauma
(a) Extent of atelectasis
(b) Associated injuries
b) Pathophysiology
(1) Lung 1-3 cm away from the chest wall
(2) May have stable amount of accumulation of air
(3) Pulmonary function may be good
Section 3: Page 78
(4)
Internal wound allows air to enter the pleural space
(5)
Small tears self-seal, larger one may progress
(6)
Paper bag syndrome
(7)
If standing air will accumulate in the apexes, check there first for
diminished breath sounds otherwise, if supine it accumulates in the
anterior chest
(8) Trachea may tug towards the effected side
(9) Ventilation/perfusion mismatch
(1) Tachypnea
(2) Tachycardia
(3) Respiratory distress
(4) Absent or decreased breath sounds on affected side
(5) Hyperresonance
(6) Decreased chest wall movement
(7) Dyspnea
(8) Chest pain referred to shoulder or arm on affected side
(9) Slight pleuritic chest pain
d) Management
(b) Monitor for development of tension pneumothorax
(2) Non-pharmacologic
(a) Needle decompression if tension pneumothorax develops - NOTE:
Instruction in the performance of chest decompression is
limited to ILS/Airway Technicians (receiving training and
certification in both ILS and Airway Technician) ONLY:
(i) Equipment
(ii) Procedure
e) Psychological support/communication strategies
3. Open pneumothorax
a) Epidemiology
(1) Incidence
(a) Penetrating trauma
(a) Profound hypoventilation could result
(b) Death related to delayed management
b) Pathophysiology
(1) Open defect in the chest wall
Section 3: Page 79
(a) Allows communication between pleural space and atmosphere

(b) Prevents development of negative intrapleural pressure
(c) Produces collapse of ipsilateral lung
(d) Inability to ventilate affected lung
(e) Ventilation/perfusion mismatch
(i) Shunting
(ii) Hypoventilation
(iii) Hypoxia
(iv) Large functional dead space
(2) Air will enter pleural space during inspiratory phase
(3) Air may exit during exhalation phase
(4) Resistance to air flow through respiratory tract may be greater than
through open wound resulting in ineffective respiratory effort
(5) One way flap valve may let air in but not out resulting in built up pressure
in pleural space
(6) Direct lung injury may be present
(7) Vena cava kinked from swaying of mediastinum
(8) Preload decreased from knifing of inferior vena cava
(1) To and fro air motion out of defect
(2) Defect in the chest wall
(3) Penetrating injury to the chest which does not seal itself
(4) Sucking sound on inhalation
(5) Tachycardia
(6) Tachypnea
(8) Subcutaneous emphysema
(9) Decreases breath sounds on affected side
d) Management
(b) Monitor for development of tension pneumothorax
(2) Non-pharmacologic
(a) Occlude open wound
(b) Needle decompression - NOTE: Instruction in the performance of
chest decompression is limited to ILS/Airway Technicians
(receiving training and certification in both ILS and Airway
Technician) ONLY:
(i) Equipment
(ii) Procedure
Section 3: Page 80

e) Psychological support/communication strategies
4. Hemothorax
a) Epidemiology
(1) Incidence
(a) Associated with pneumothorax
(b) Blunt or penetrating trauma
(c) Rib fractures are frequent cause
(a) Life threatening injury that frequently requires urgent chest tube
and/or surgery
(b) Hemothorax associated with great vessel or cardiac injury
(i) 50% will die immediately
(ii) 25% live five to ten minutes
(iii) 25% may live 30 minutes or longer
b) Pathophysiology
(1) Accumulation of blood in the pleural space
(2) Bleeding from:
(a) Penetrating or blunt lung injury
(b) Chest wall vessels
(c) Intercostal vessels
(d) Myocardium
(3) Pulmonary parenchyma is low-pressure vascular system
(4) Bleeding from pulmonary contusion generally causes 1000 to 1500 cc
blood loss
(5) Massive hemothorax indicates great vessel or cardiac injury
(6) Collapse of ipsilateral lung
(7) Respiratory insufficiency dependent on amount of blood
(8) Hypoxia
(9) Hypotension and inadequate perfusion may result from blood loss
(10) Chest cavity can hold 2,000 to 3,000 ml of blood
(11) Classified by amount of blood loss
(12) Tissue pressure effects of legs, arms and abdomen vs thorax
(a) La Place law
(b) Extraluminal pressure in legs
(c) Extraluminal pressure in thorax
(13) An intercostal artery can easily bleed 50 cc’s per minute
(14) Intrapulmonary hemorrhage
(a) Bronchus
(b) Parenchyma
Section 3: Page 81
(1) Tachypnea
(2) Tachycardia
(3) Dyspnea
(5) Hypotension
(7) Pleuritic chest pain
(8) Pale, cool, moist skin
(9) Dullness on percussion
(10) Decreased breath sounds
d) Management
(2) Circulation
(a) Re-expand the affected lung to reduce bleeding
(a) Needle decompression - NOTE: Instruction in the performance of
Technician) ONLY:
(i) Equipment
(ii) Procedure
5. Hemopneumothorax
a) Pathophysiology
(1) Pneumothorax with bleeding in pleural space
(1) Tachypnea
(2) Tachycardia
(3) Dyspnea
(5) Hypotension
(7) Pleuritic chest pain
(8) Pale, cool, moist skin
(9) Dullness on percussion
(10) Decreased breath sounds
Section 3: Page 82
c) Management
(2) Circulation
(a) Re-expand the affected lung to reduce bleeding
(a) Needle decompression - NOTE: Instruction in the performance of
Technician) ONLY:
(i) Equipment
(ii) Procedure
6. Pulmonary contusion
a) Epidemiology
(1) Incidence
(a) Blunt trauma to chest
(i) Most common injury from blunt thoracic trauma
(ii) 30-75% with blunt trauma have pulmonary contusion
(b) Associated commonly with rib fracture
(c) High energy shock waves from explosion
(d) High velocity missile wounds
(e) Rapid deceleration
(f) High incidence of extrathoracic injuries
(g) Low velocity - ice pick
(a) Missed due to high incidence of other associated injuries
(b) Mortality between 14-20%
b) Pathophysiology
(1) Three physical mechanisms:
(a) Implosion effect
(i) Overexpansion of air in lungs secondary to positive-pressure
concussive wave
(ii) Rapid excessive stretching and tearing of alveoli
(b) Inertial effect
(i) Strips alveoli from heavier bronchial structures when accelerated
at varying rates by concussive wave
(c) Spalding effect
(i) Liquid-gas interface is disrupted by shock-wave
Section 3: Page 83
(ii) Wave releases energy

(iii) Differential transmission of energy causes disruption of tissue
(2) Alveolar and capillary damage with interstitial and intra-alveolar
extravasation of blood
(3) Interstitial edema
(4) Increased capillary membrane permeability
(5) Gas exchange disturbances
(6) Hypoxemia and carbon dioxide retention
(7) Hypoxia causes reflex thickening of mucous secretions
(a) Bronchiolar obstruction
(b) Atelectasis
(8) Blood is shunted away from unventilated alveoli leading to further
hypoxemia
(1) Tachypnea
(2) Tachycardia
(3) Cough
(4) Hemoptysis
(5) Apprehension
(7) Dyspnea
(8) Evidence of blunt chest trauma
(9) Cyanosis
d) Management
(2) Circulation
(a) Restrict intravenous fluids (use caution restricting fluids in
hypovolemic patients)
III. Neurology
A. General system pathophysiology, assessment and management
1. Physiology
a) Alterations in cognitive systems
b) Alterations in cerebral homeostasis
c) Alterations in motor control
d) Central nervous system disorders
(1) Trauma
(2) Cerebrovascular disorders
(3) Tumors
Section 3: Page 84
(4) Infection
(5) Inflammation
(6) Degenerative diseases
(7) Hydrocephalus
e) Peripheral nervous system disorders
f) Neuromuscular junction disorders
2. Assessment findings
a) History
(1) General health
(2) Previous medical conditions
(3) Medications
(4) Previous experience with complaint
(5) Time of onset
(6) Seizure activity
b) Physical
(1) General appearance
(2) Assess for level of consciousness
(3) Speech
(4) Mood
(5) Thought
(6) Perceptions
(7) Judgment
(8) Memory and attention
(9) Skin
(10) Posture and gait
(11) Odors on breath
(12) Facial expression
(13) Vital signs
(a) Hypertension
(b) Hypotension
(c) Heart rate / fast or slow
(d) Ventilation/ rate/ quality
(14) Fever
(15) Head
(16) Neck
(17) Eyes
(18) Nose
(19) Mouth
(20) Thorax and lungs
(a) Auscultate
(21) Cardiovascular
(a) Heart rate
Section 3: Page 85
(b) Rhythm
(c) Jugular vein pressure
(d) Auscultation
(e) ECG monitoring
(22) Abdomen
(23) Nervous
(a) Motor system
(i) How are these assessed in relation to movement?
(ii) Muscle tone
(iii) Muscle strength
(iv) Flexion
(v) Extension
(vi) Grip
(vii) Coordination
(24) Assessment tools
(a) Pulse oximetry
(b) Blood glucose
c) Ongoing assessment
3. Management
b) Airway and ventilatory support
(1) Oxygen
(2) Positioning
(3) Assisted ventilation
(4) Suction
(5) Advanced airway device
c) Circulatory support
(1) Venous access
(2) Blood glucose
(1) Positioning
(2) Spinal precautions
(1) Oxygen
(2) Dextrose
(a) Adult dosage: 25-50 g IV bolus (50-100 ml of a 50% solution)
(b) Pediatric Dosage 25 % dextrose at 0.5-1.0g/kg IV bolus. A 50 %
(3) Naloxone
(a) Dosage
Section 3: Page 86
(i) Adult:
(a) Initial dose of 2 mg IV
(b) If necessary, dose may be repeated in 2 to 3 minute
(ii) Pediatric:
(a) If less than or equal to 5 years of age or less than or equal to
20 kg: 0.1 mg/kg
f) Psychological support
g) Transport considerations
B. Specific injuries/illnesses
1. Coma and altered mental status
a) Anatomy and physiology review
(1) Pathophysiology
(a) Metabolic
(i) Chemical
(a) Hypoglycemia
(b) Diabetic ketoacidosis
(c) Uremia
(d) Hepatic failure
(e) Hypothyroidism
(f) Hypercapnia
(g) Hypoxia
(i) Insufficient cardiac output
(ii) Obstruction to blood flow
(iii) Respiratory insufficiency
(iv) Oxygen-poor atmosphere
(h) Drugs
(i) Ethyl or methyl alcohol
(ii) Barbiturates
(iii) Narcotics
(i) Infection
(i) Meningitis
(ii) Encephalitis
(ii) Environmental
(a) Hyperthermia
(i) Fever
(ii) Heat stoke
(b) Cold
Section 3: Page 87
(b) Structural
(i) Intracranial hemorrhage
(a) Epidural hematoma
(b) Subdural hematoma
(ii) Skull trauma
(iii) Brain tumor
(iv) Brain abscess
(c) Psychiatric
(i) Hysteria
(ii) Catatonia
(1) History
(a) General health
(b) Previous medical conditions
(c) Medications
(d) Previous experience with complaint
(e) Time of onset
(f) Seizure activity
(2) Physical
(a) General appearance
(b) Assess for level of consciousness
(c) Speech
(d) Mood
(e) Thought
(f) Perceptions
(g) Judgment
(h) Memory and attention
(i) Skin
(j) Posture and gait
(k) Odors on breath
(l) Facial expression
(m) Vital signs
(i) Hypertension
(ii) Hypotension
(iii) Heart rate / fast or slow
(iv) Ventilation/ rate/ quality
(n) Fever
(o) Head
(p) Neck
(q) Eyes
(r) Nose
(s) Mouth
Section 3: Page 88
(t) Thorax and lungs

(i) Auscultate
(u) Cardiovascular
(i) Heart rate
(ii) Rhythm
(iii) Amplitude
(iv) Jugular vein pressure
(v) Auscultation
(vi) ECG monitoring
(v) Abdomen
(w) Nervous
(i) Motor system
(a) Muscle tone
(b) Muscle strength
(c) Flexion
(d) Extension
(e) Grip
(f) Coordination
(x) Assessment tools
(i) Pulse oximetry
(ii) Blood glucose
(3) Ongoing assessment
c) Management
(2) Airway and ventilatory support
(a) Oxygen
(b) Positioning
(c) Assisted ventilation
(d) Suction
(e) Advanced airway device
(3) Circulatory support
(a) Venous access
(b) Blood glucose
(a) Positioning
(b) Spinal precautions
(a) Oxygen
(b) Dextrose
Section 3: Page 89
(ii) Pediatric Dosage 25 % dextrose at 0.5-1.0 g/kg IV bolus. A 50

% solution may be diluted 1:1 with normal saline or sterile water
(c) Naloxone
(i) Dosage
(a) Adult:
(i) Initial dose of 2 mg IV
(ii) If necessary, dose may be repeated in 2 to 3 minute
(b) Pediatric:
(i) If less than or equal to 5 years of age or less than or
equal to 20 kg: 0.1 mg/kg
(ii) If greater than 5 years of age or greater than 20 kg: 2.0
mg
(d) Contact ALS for additional resources
(6) Psychological support
2. Syncope
(1) Pathophysiology
(a) Metabolic
(i) Chemical
(a) Hypoglycemia
(b) Diabetic ketoacidosis
(c) Uremia
(d) Hepatic failure
(e) Hypothyroidism
(f) Hypercapnia
(g) Hypoxia
(i) Insufficient cardiac output
(ii) Obstruction to blood flow
(iii) Respiratory insufficiency
(iv) Oxygen-poor atmosphere
(h) Poisons and toxins
(i) Drugs
(i) Ethyl or methyl alcohol
(ii) Barbiturates
(iii) Narcotics
Section 3: Page 90
(j) Infection
(i) Meningitis
(ii) Encephalitis
(ii) Environmental
(a) Hyperthermia
(i) Fever
(ii) Heat stoke
(b) Cold
(iii) Structural
(a) Intracranial hemorrhage
(i) Epidural hematoma
(ii) Subdural hematoma
(b) Skull trauma
(c) Brain tumor
(d) Brain abscess
(iv) Psychiatric
(a) Hysteria
(b) Catatonia
(1) History
(a) General health
(c) Medications
(e) Time of onset
(2) Physical
(c) Speech
(d) Mood
(e) Thought
(f) Perceptions
(g) Judgment
(h) Memory and attention
(i) Skin
(j) Posture and gait
(k) Odors on breath
(l) Facial expression
(m) Vital signs
(i) Hypertension
(ii) Hypotension
Section 3: Page 91
(iii) Heart rate / fast or slow

(iv) Ventilation/ rate/ quality
(n) Fever
(o) Head
(p) Neck
(q) Eyes
(r) Nose
(s) Mouth
(t) Thorax and lungs
(i) Auscultate
(u) Cardiovascular
(i) Heart rate
(ii) Rhythm
(iii) Amplitude
(iv) Jugular vein pressure
(v) Auscultation
(a) ECG monitoring
(v) Abdomen
(w) Nervous
(i) Motor system
(a) Muscle tone
(b) Muscle strength
(c) Flexion
(d) Extension
(e) Grip
(f) Coordination
(x) Assessment tools
(i) Pulse oximetry
(ii) Blood glucose
c) Management
(a) Oxygen
(b) Positioning
(d) Suction
(a) Venous access
Section 3: Page 92
(b) Blood glucose

(a) Positioning
(a) Oxygen
(b) Dextrose
(ii) Pediatric Dosage 25 % dextrose at 0.5-1.0g/kg IV bolus. A 50 %
3. Seizures
b) Pathophysiology
(1) Unexpected electrical discharge of neurons in brain
(2) Types
(a) Generalized
(i) Grand mal (tonic-clonic)
(ii) Petit mal
(b) Partial
(i) Simple partial, e.g., Jacksonian
(ii) Complex partial, e.g., Psychomotor or temporal lobe
(c) Status epilepticus
(3) Causes
(a) Idiopathic
(b) Fever
(c) Neoplasms
(d) Infection
(e) Metabolic
(f) Drug intoxication
(g) Drug withdrawal
(h) Head trauma
(i) Eclampsia
(j) Cerebral degenerative diseases
(1) History
(a) General health
(c) Medications
(e) Time of onset
Section 3: Page 93

(i) Duration
(ii) Number of events
(iii) Consciousness between
(2) Physical
(c) Speech
(d) Cognitive functions
(e) Memory and attention
(f) Skin
(g) Posture and gait
(h) Odors on breath
(i) Tongue laceration(s)
(j) Facial expression
(k) Vital signs
(i) Blood pressure
(ii) Pulse
(iii) Respirations
(l) Fever
(m) Head
(i) Hemorrhage
(ii) Wounds
(n) Neck
(o) Eyes
(p) Nose
(q) Mouth
(r) Thorax and lungs
(i) Auscultate
(s) Cardiovascular
(i) Heart rate
(ii) Rhythm
(iii) Jugular vein pressure (JVD)
(iv) ECG monitoring
(t) Abdomen and Pelvis
(i) Incontinence of bladder
(ii) Incontinence of bowel
(u) Nervous
(i) Motor system
(a) Muscle tone
(b) Muscle strength
(c) flexion
(d) extension
(e) grip
(f) coordination
(v) Additional assessment tools
(i) Pulse oximetry
(ii) Blood glucose
Section 3: Page 94

d) Management
(a) Oxygen
(b) Positioning
(d) Suction
(a) Venous access
(b) Blood glucose
(4) Non-pharmacological interventions
(a) Protection from injury
(b) Positioning
(c) Spinal precautions
(5) Pharmacological interventions - There are no phamacological
interventions approved at this time.
(a) Oxygen
(a) appropriate mode
(b) appropriate facility
4. CVA
b) Hemorrhagic
(1) subarachnoid
(2) intracerebral
(1) History
(a) General health
(c) Medications
(e) Time of onset
(g) Headache
(h) Nose bleed
(2) Physical
(c) Speech / slurred / aphasia
(e) Skin
(f) Posture and gait
Section 3: Page 95
(g) Odors on breath

(h) Facial expression
(i) Vital signs
(i) Hypertension
(ii) Heart rate / fast or slow / irregular
(iii) Ventilation/ rate/ quality
(j) Fever
(k) Head
(l) Neck
(m) Eyes
(n) Nose
(o) Mouth
(p) Thorax and lungs
(i) Auscultate
(q) Cardiovascular
(i) Heart rate
(ii) Rhythm
(iii) Jugular vein pressure
(iv) ECG monitoring
(r) Abdomen
(s) Nervous
(i) Motor system
(a) Reflexes
(b) Muscle tone
(c) Muscle strength
(d) flexion
(e) extension
(f) grip
(g) coordination
(t) Additional assessment tools
(i) Pulse oximetry
(ii) Blood glucose
d) Management
(a) Oxygen
(b) Positioning
(d) Suction
(a) Venous access
(b) Blood glucose
(a) Positioning
Section 3: Page 96

(a) Oxygen
5. Transient ischemic attack
b) Pathophysiology
(1) Transient neurological deficits
(2) Partial disruptions of blood flow
(a) hemorrhagic
(b) vasospasm
(c) subarachnoid
(d) intracerebral
(i) Partially occlusive
(e) emboli
(f) thrombi
(1) History
(a) General health
(c) Medications
(e) Time of onset
(f) Seizures
(g) Headache
(h) Nosebleed
(2) Physical
(c) Speech / slurred / aphasia
(e) Skin
(f) Posture and gait
(g) Odors on breath
(h) Facial expression
(i) Vital signs
(i) Hypertension
(ii) Heart rate / fast or slow / irregular
(iii) Ventilation/ rate/ quality
(j) Fever
(k) Head
(l) Neck
(m) Eyes
Section 3: Page 97
(n) Nose
(o) Mouth
(p) Thorax and lungs
(i) Auscultate
(q) Cardiovascular
(i) Heart rate
(ii) Rhythm
(iii) Jugular vein pressure
(iv) ECG monitoring
(r) Abdomen
(s) Nervous
(i) Motor system
(a) Reflexes
(b) Muscle tone
(c) Muscle strength
(d) flexion
(e) extension
(f) grip
(g) coordination
(t) Assessment tools
(i) Pulse oximetry
(ii) Blood glucose
d) Management
(a) Oxygen
(b) Positioning
(d) Suction
(a) Venous access
(b) Blood glucose
(a) Positioning
(a) Oxygen
C. Integration
Section 3: Page 98
IV. Endocrinology
A. Specific illnesses
1. Diabetes Mellitus
a) Pathophysiology
(1) Pancreas cannot secrete at all or not enough insulin to control blood
glucose levels
(2) Diabetes Mellitus Type I (insulin dependent)
(a) Diabetes: Occurs anytime after birth
(b) Juvenile may suffer more severe consequences/effects, i.e.,
deteriorates eyesight; shortens life span
(3) Diabetes Mellitus Type II (non insulin dependent)
(a) Normally occurs in adults
(b) May control with diet
(c) May be some insulin production by pancreas
(4) Normal insulin metabolism
(a) produced by beta cells in the islets of Langerhans
(b) continuously released into the bloodstream
(i) the level of plasma insulin rises after a meal
(ii) the fall of plasma insulin levels during normal overnight fasting
facilitates the release of
(a) stored glucose from the liver
(b) protein from muscle tissue
(c) fat from adipose tissue
(c) activity of released insulin
(i) lowers blood glucose levels
(ii) facilitates a stable, glucose range
(a) Normal blood sugar range - 70 to 120 mg/dl
(b) Abnormal blood sugar ranges:
(i) 65 and lower
(ii) 180 and higher
(5) Effects of diabetes
(a) Osmotic diuresis
(i) Glucose filtered in urine
(ii) High blood glucose levels cause high glucose concentration in
urine
(iii) Secretion of glucose molecules leads to increased urine output
and eventual dehydration
b) Ketone formation
(1) When insulin supply is insufficient, glucose cannot be used for cellular
energy
(2) Fat breakdown increases to provide alternate energy source for cells
that can no longer use glucose
(3) Fat breakdown products are called ketoacids/ketone bodies
Section 3: Page 99
(4) Response to cellular starvation

(5) Excess ketones upset the pH balance and acidosis develops
c) Renal excretion of ketoacids
(1) When more ketoacids are produced than the kidneys can excrete, they
accumulate and produce metabolic acidosis (ketoacidosis)
d) Assessment Findings
(1) Known History of:
(a) Has insulin dosage changed recently?
(b) Has the patient had a recent infection?
(c) Has the patient suffered any psychological stress?
(2) Signs and Symptoms:
(a) Altered mental status
(b) Abnormal respiratory pattern (Kussmaul's breathing)
(c) Tachycardia
(d) Sweating, shaking and faintness
(e) Hypotension
(f) Breath has a distinct fruity odor
(g) Polydipsia
(h) Polyuria
(i) Polyphagia
(j) Warm dry skin
(k) Weight loss
(l) Weakness
(m) Dehydration
e) Management
(3) Circulation
(4) Pharmacological - Medications only to be administered by ILS or
direction/control.
(a) Oxygen
(7) Psychological support / communication strategies
Section 3: Page 100

2. Hypoglycemia
a) Pathophysiology
(1) Blood glucose levels fall below that required for normal body functioning
(a) Insulin lowers serum glucose by enhancing transfer into cells and
by stimulating deposit of glycogen.
(b) Epinephrine and glycogen tend to cause hypoglycemia by
stimulating the breakdown of glycogen; interfering with the
utilization of glucose at the cell level
(c) Hypoglycemia can occur with excess insulin or lack of hormones
that maintain critical levels
(d) Glucose cannot enter muscle and fat cells
(e) Glucose accumulates in blood
(f) Increases blood osmotic pressure
(g) Kidneys - increased urine output
(2) Precipitating factors
(a) Hypoglycemia can occur after fasting or after food intake
(b) Chronic alcoholism
(c) Tumor of pancreas; overdose of insulin
(3) Onset of hypoglycemia
(a) Develops rapidly
(b) Onset of diabetic ketoacidosis; progresses slowly over 12 to 24
hours
b) Assessment
(1) Known history of:
(a) Diabetes
(b) Prolonged fasting
(c) Alcoholism
(2) Signs and Symptoms
(a) Hunger
(b) Anxiety
(c) Weakness
(d) Tremors
(e) Diaphoresis
(f) Palpitations
(g) Tachycardia
(h) Weak, rapid pulse
(i) Pale, cool skin
(j) Irritable, nervous or bizarre behavior
(k) Altered mental status due to low levels of blood glucose reaching
the brain
(i) Confusion
(ii) Stupor
(iii) Seizures
Section 3: Page 101
(iv) May appear intoxicated

(l) Coma in severe cases
(3) Compensatory mechanism in hypoglycemic patient: normal/shallow
respirations
c) Management
(3) Circulation
direction/control.
(a) Oxygen
(b) Blood glucose monitoring
(c) Oral glucose
(d) IV KVO
(i) Draw blood prior to:
(a) Any fluids
(b) Dextrose
(i) Adult dosage: 25-50 g IV bolus (50-100 ml of a 50%
solution)
(ii) Pediatric Dosage 25 % dextrose at 0.5-1.0 g/kg IV bolus.
A 50 % solution may be diluted 1:1 with normal saline or
sterile water
(e) Contact ALS for additional resources
3. Hyperglycemia/Ketoacidosis
a) Pathophysiology of Diabetic ketoacidosis
(1) Occurs when the blood sugar level becomes too high
(2) Insulin dose too small
(3) Patient has not taken insulin dose
(4) When insulin level is low, glucose cannot enter the cell - accumulates in
the blood
(5) Ketoacidosis
b) Precipitation of diabetic ketoacidosis:
(1) May be triggered by stress on patient metabolism by:
(a) Infection
(b) Excess alcohol
Section 3: Page 102

(c) Pregnancy
(d) Trauma
c) Onset of hyperglycemia; progresses slowly over 12 to 24 hours
(1) Occurs in patients with diabetes who are able to produce enough
insulin to prevent DKA but not enough to prevent severe
hyperglycemia, osmotic diuresis and extracellular fluid depletion
(2) Increasing blood glucose levels causes a fluid shift from intracellular to
extracellular spaces
d) Assessment
(1) Known History of:
(a) Diabetes
(b) Inadequate fluid intake
(2) Signs and Symptoms:
(a) Polydipsia, Polyuria, Polyphagia
(b) Nausea/vomiting
(c) Dehydration
(d) Tachycardia
(e) Deep rapid respirations
(f) Fruit odor on breath
(g) Warm dry skin
(h) Sometimes:
(i) Fever
(ii) Abdominal pain
(iii) Falling blood pressure
(i) Neurologic abnormalities
(i) Increasing mental depression
(ii) Decreased level of consciousness
(iii) Somnolence
(iv) Hemiparesis
(v) Aphasia
(vi) Seizures
(vii) Coma
(3) Compensatory mechanism in the ketoacidotic patient: Deep/rapid
respirations in an attempt to blow off excess CO2 (Kussmaul breathing)
e) Management
(3) Circulation
(a) Pharmacological interventions - Medications only to be
administered by ILS or ILS/AW Techs following approval by on-line
or off-line medical direction/control.
Section 3: Page 103

B. Integration
V. Anaphylaxis
A. Introduction
1. Epidemiology
a) Incidence
b) Morbidity/mortality
c) Risk factors
d) Prevention
2. Anatomy
a) Review of cardiovascular system
b) Review of respiratory system
c) Review of nervous system
d) Review of gastrointestinal system
3. Physiology
a) Antigens
b) Antibodies
B. Pathophysiology
1. Allergen
2. Routes of entry
a) Oral ingestion
b) Injected/envenomation
c) Inhaled
d) Topical
3. Common Allergens
a) Drugs
b) Insects
c) Foods
d) Animals
e) Latex
f) Other
4. Allergic Response
a) Histamine or histamine-like substance release
b) Immunity
c) Sensitivity
d) Hypersensitivity
5. Urticaria
a) Redness of skin
Section 3: Page 104

6. Angioneurotic
a) Swelling / Edema of the skin
7. Anaphylactic Shock
a) Cardiovascular system
b) Respiratory system
c) Gastrointestinal system
d) Nervous system
C. Assessment findings
1. Not all signs and symptoms are present in every case
2. History
a) Previous exposure
b) Previous experience to exposure
c) Onset on symptoms
d) Dyspnea
a) Unable to speak
b) Restless
c) Decreased level of consciousness
d) Unresponsive
4. Upper airway
a) Hoarseness
b) Stridor
c) Pharyngeal edema / spasm
5. Lower Airway
a) Tachypnea
b) Hypoventilation
c) Labored-Accessory muscle use
d) Abnormal retractions
e) Prolonged expirations
f) Wheezes
g) Diminished lung sounds
6. Skin
a) Redness
b) Rashes
c) Edema
d) Moisture
e) Itching
f) Urticaria
g) Pallor
h) Cyanotic
7. Vital Signs
a) Tachycardia
Section 3: Page 105

b) Hypotension
8. Gastrointestinal
a) Abnormal cramping
b) Nausea/vomiting
c) Diarrhea
9. Assessment Tools
a) Cardiac monitor
b) Oximetry low
c) End Tidal CO2 high
D. Management of Anaphylaxis
paramedics.
2. Remove offending agent (i.e. Stinger)
3. Airway and ventilation
a) Positioning
b) Oxygen
c) Assist ventilation
d) Advanced airway
4. Circulation
a) Venous access
b) Fluid resuscitation
a) Oxygen
b) Epinephrine 1:1000, by a commercially pre-loaded measured dose device
(1) Dosage
(a) Adult:
(i) Intramuscular - one adult auto-injector (0.3 mg)
(ii) Subcutaneous - one adult measured dose device (0.1 to 0.5 mg
1:1000 SQ)
(b) Infant and child:
(i) Intramuscular - one pediatric auto-injector (0.15 mg)
(ii) Subcutaneous - one infant/child measured dose devise (0.01 to
.03 mg/kg 1:1000 SQ)
c) Contact ALS for additional resources
6. Psychological support
Section 3: Page 106

E. Management of Allergic Reaction

paramedics.
2. Oxygen
3. Epinephrine 1:1000, by a commercially pre-loaded measured dose device,
ONLY if permission is given by on-line or off-line medical direction/control
a) Dosage
(1) Adult:
(b) Subcutaneous - one adult measured dose device (0.1 to 0.5 mg
1:1000 SQ)
(2) Infant and child:
(b) Subcutaneous - one infant/child measured dose devise (0.01 to .03
mg/kg 1:1000 SQ)
4. Contact ALS for additional resources
F. Integration
VI. Toxicology
A. Introduction
1. Accidental poisoning
a) Role of the Poison Control Center in the United States and Washington State.
b) Epidemiology
(1) Incidence
(2) Mortality/Morbidity
(3) Risk Factors
(4) Prevention Strategies
2. Drug abuse
a) Epidemiology
(1) Incidence
(2) Mortality/Morbidity
(3) Risk Factors
(4) Prevention Strategies
b) Concepts of drug abuse
(1) Substance or drug abuse
(2) Substance or drug dependence
(3) Tolerance
(4) Addiction
(5) Withdrawal
3. Anatomy and Physiology review
Section 3: Page 107

B. General pathophysiology, assessment and management

1. Pathophysiology
a) Assessment Findings
2. Management
b) Airway and Ventilation
c) Circulation
(1) Oxygen
e) Non-Pharmacological
f) Transport Considerations
g) Psychological / Communication strategies
3. Route of Entry
a) Poisoning by Ingestion
(1) Assessment Findings
(2) Management
(a) When paramedic service is available, ILS personnel shall
contact medical direction/control as soon as possible for
advice about rendezvous with paramedics.
(b) Airway and Ventilation
(c) Circulation
(d) Pharmacological - Medications only to be administered by ILS or
direction/control.
(i) Ipecac
(ii) Activated Charcoal
(iii) Contact ALS for additional resources
(e) Non-Pharmacological
(f) Transport Considerations
(i) Appropriate mode
(ii) Appropriate facility
(g) Psychological / Communication strategies
b) Poisoning by Inhalation
Section 3: Page 108

(2) Management
(c) Circulation
direction/control.
(i) Oxygen
(ii) Contact ALS for additional resources
c) Poisoning by Injection
(2) Management
(c) Circulation
direction/control.
(i) Oxygen
(ii) When resulting in anaphylaxis, Epinephrine 1:1000, by a
commercially pre-loaded measured dose device, ONLY if
permission is given by on-line or off-line medical
control/direction
(a) Dosage: - Adult:
(ii) Subcutaneous - one adult measured dose device (0.1 to
0.5 mg 1:1000 SQ)
(b) Dosage: - Infant and child:
(ii) Subcutaneous - one infant/child measured dose devise
(0.01 to .03 mg/kg 1:1000 SQ)
Section 3: Page 109

d) Poisoning by surface absorption
(2) Management
(c) Circulation
direction/control.
(i) Oxygen
(ii) Contact ALS for additional resources
C. Specific pathophysiology, assessment and management
1. Carbon Monoxide
(1) Epidemiology
(2) Incidence
(4) Risk factors
(5) Prevention
b) Anatomy and physiology review
c) Etiology/Pathophysiology
(1) Cellular anoxia
(a) Affinity for hemoglobin
(b) Carboxyhemoglobin
(2) Neurological changes due to hypoxia
e) Management
(3) Circulation
Section 3: Page 110
(a) Oxygen
(7) Psychological / Communication strategies
2. Snake bites
a) Epidemiology
(1) Incidence
(3) Risk factors
(4) Prevention
e) Management
(3) Circulation
(a) Oxygen
3. Organophosphate and Carbamate insecticides
a) Epidemiology
(1) Incidence
(3) Risk factors
(4) Prevention
e) Management
Section 3: Page 111


(3) Circulation
(a) Oxygen
4. Hallucinogens
a) Epidemiology
(1) Incidence
(3) Risk factors
(4) Prevention
e) Management
(3) Circulation
(a) Oxygen
5. Cocaine
a) Epidemiology
(1) Incidence
(3) Risk Factors
Section 3: Page 112
(4) Prevention
b) Anatomy and Physiology Review
c) Etiology / Pathophysiology
e) Management
(3) Circulation
(a) Oxygen
6. Ethanol
a) Epidemiology
(1) Incidence
(3) Risk Factors
(4) Prevention
e) Management
(3) Circulation
(a) Oxygen
Section 3: Page 113
7. Narcotics
a) Epidemiology
(1) Incidence
(3) Risk Factors
(4) Prevention
e) Management
(3) Circulation
(a) Oxygen
(b) Naloxone
(i) Dosage
(a) Adult:
(i) Initial dose of 2 mg IV
(ii) If necessary, dose may be repeated in 2 to 3 minute
(b) Pediatric:
(i) If less than or equal to 5 years of age or less than or
equal to 20 kg: 0.1 mg/kg
(ii) If greater than 5 years of age or greater than 20 kg: 2.0
mg
8. Marijuana and Cannabis Compounds
a) Epidemiology
(1) Incidence
(3) Risk Factors
(4) Prevention
Section 3: Page 114

e) Management
(3) Circulation
(a) Oxygen
D. Integration
VII. Medical/legal considerations
Section 3: Page 115

NOTES:
Section 3: Page 116


Section 4 - Special Considerations/Lesson 4-1: Pediatrics
OBJECTIVES LEGEND
1=Knowledge
2=Application
LESSON TERMINAL INSTRUCTIONAL OBJECTIVE.

findings to formulate a field impression and implement the treatment plan for the pediatric
emergency patient.
1. Identify the growth and development characteristics of infants and children. (C-1)
2. Identify anatomy and physiology characteristics of infants and children. (C-1)
3. Describe techniques for successful evaluation of infants and children. (C-1)
4. Describe techniques for successful treatment of infants and children. (C-1)
5. Identify the common responses of families to acute illness and injury of an infant or child.
(C-1)
6. Describe techniques for successful interaction with families of acutely ill or injured infants
and children. (C-1)
7. Describe how infant and child anatomical and physiological features affect patient
management. (C-1)
8. Discuss pediatric patient assessment. (C-1) PLEASE REFERENCE THE PEDIATRIC
ASSESSMENT INFORMATION PROVIDED AT THE END OF THIS LESSON.
9. Determine appropriate airway adjuncts for infants and children. (C-1)
10. Discuss complications of improper utilization of airway adjuncts with infants and children.
(C-1)
11. Discuss appropriate ventilation devices for infants and children. (C-1)
12. Discuss complications of improper utilization of ventilation devices with infants and
children. (C-1)
13. Define respiratory distress. (C-1)
14. Define respiratory failure. (C-1)
15. Differentiate between upper and lower airway obstruction. (C-3)
16. Discuss the common causes of hypoperfusion in infants and children. (C-1)
17. Evaluate the severity of hypoperfusion in infants and children. (C-1)
18. Describe the primary etiologies of altered level of consciousness in infants and children.
(C-1)
19. Discuss the primary etiologies of cardiopulmonary arrest in infants and children. (C-1)
20. Discuss age appropriate vascular access sites for infants and children. (C-1)
21. Discuss the appropriate equipment for vascular access in infants and children. (C-1)
22. Identify complications of vascular access for infants and children. (C-1)
23. Discuss anatomical features of children that predispose or protect them from certain
injuries. (C-1)
Section 4: Page 2
24. Discuss fluid management and shock treatment for infant and child trauma patient. (C-1)
25. Describe why critical incident stress debriefing plays a vital role for EMT-Intermediate’s.
(C-1)
26. Discuss the pathophysiology of respiratory distress/failure in infants and children(C-1)
27. Discuss the assessment findings associated with respiratory distress/failure in infants and
children. (C-1)
28. Discuss the management/treatment plan for respiratory distress/failure in infants and
children. (C-1)
29. Discuss the pathophysiology of hypoperfusion in infants and children. (C-1)
30. Discuss the assessment findings associated with hypoperfusion in infants and children.
(C-1)
31. Discuss the management/treatment plan for hypoperfusion in infants and children. (C-1)
32. Discuss the assessment findings associated with seizures in infants and children(C-1)
33. Discuss the management/treatment plan for seizures in infants and children. (C-1)
34. Discuss the assessment findings associated with hypoglycemia in infants and children.
(C-1)
35. Discuss the management/treatment plan for hypoglycemia in infants and children. (C-1)
38. Discuss the anatomy and physiology of the organs and structures related to
anaphylaxis. (C-1)
48. Differentiate among the various treatment and pharmacological interventions used in
the management of anaphylaxis. (C-3)
49. Describe the ILS and ILS/Airway medications (epinephrine 1:1000 by a commercially
pre-loaded measured dose device,) used in the management of anaphylaxis and when
ALS should be contacted. (C-1)
50. Recognize and differentiate between adult and pediatric doses of epinephrine 1:1000,
for the management of anaphylaxis(mg/kg), when using a commercially pre-loaded
measured dose device. (C-1)
51. Discuss the assessment findings associated with head injury in infants and children. (C-1)
52. Discuss the management/treatment plan for head injury in infants and children. (C-1)
53. Discuss the pathophysiology of burns in infants and children. (C-1)
54. Discuss the assessment findings associated with burns in infants and children. (C-1)
55. Discuss the management/treatment plan for burns in infants and children. (C-1)
Section 4: Page 3
56. Describe the epidemiology, including the incident, morbidity/mortality, risk factors and
prevention strategies for abuse and neglect in infants and children. (C-1)
57. Discuss the pathophysiology of abuse and neglect in infants and children. (C-1)
58. Discuss the assessment findings associated with abuse and neglect in infants and
children. (C-1)
59. Discuss the management/treatment plan for abuse and neglect in infants and children. (C-
1)
60. Discuss the assessment findings associated with SIDS infants. (C-1)
61. Discuss the management/treatment plan for SIDS in infants. (C-1)
62. Demonstrate the appropriate approach for treating infants and children.
63. Demonstrate appropriate intervention techniques with families of acutely ill or injured
infants and children.
64. Demonstrate an appropriate assessment for different developmental age groups.
65. Evaluate the severity of respiratory distress/failure in infants and children.
66. Demonstrate the techniques/procedures for treating infants and children with respiratory
distress.
67. Demonstrate appropriate technique for insertion of peripheral intravenous catheters for
68. Demonstrate appropriate treatment of infants and children requiring advanced airway and
breathing control.
69. Demonstrate appropriate treatment of infants and children with burns.
70. Demonstrate appropriate parent/care giver interviewing techniques for infant and child
death situations.
INTEGRATION
71. Integrate the pathophysiological principles of the patient with anaphylaxis
72. Correlate abnormal findings in assessment with the clinical significance in the patient
with anaphylaxis
73. Develop a treatment plan based on field impression in the patient with allergic reaction
and anaphylaxis
Section 4: Page 4
Presentation
DECLARATIVE
I. Definition
A. Infant
1. First month after birth to approximately 12 months of age
a) Neonatal period (first 28 days of life) may be included
b) Some extend the period to 24 months of age
B. Toddler
1. A child between 12 and 36 months of age
C. Preschool
1. A child between three and five years of age
D. School age
1. The child between 6 and 12 years of age
E. Adolescent
1. The child between 13 and 18 years of age
2. The period between the onset of puberty and adulthood
II. Anatomy and physiology
A. Head
1. Proportionally larger and heavier
2. Large occipital region
3. Fontanelles
a) Posterior - closes at approximately 2 months
b) Anterior - close at 12 - 18 months
4. Face is small in comparison to size of head
5. Nasal bridge is flat and flexible
6. EMT-Intermediate implications
a) Higher proportion of blunt trauma involves the head
b) Different airway positioning techniques
(1) Place thin layer of padding under back if seriously injured child < 3
years of age to obtain neutral position
(2) Place folded sheet under occiput of medically ill child < 3 years of age
to obtain sniffing position
c) Examine fontanelle in infants
(1) Bulging fontanelle suggests increased intracranial pressure
(2) Sunken fontanelle suggests dehydration
B. Airway
1. Nasal passages
a) Small and easily obstructed
b) Infants are obligate nose breathers
2. Tongue is larger in comparison to size of mouth
3. Muscles controlling jaw are immature
4. Larynx is higher (C 3-4) and more anterior
Section 4: Page 5
5. Cricoid ring is the narrowest part of the airway until approximately 8 years of age
6. Tracheal cartilage more elastic
a) Hyperextension or flexion can cause crimping of the airway
7. Trachea smaller in both length and diameter
a) Easily obstructed with blood, mucus or foreign body
8. Epiglottis
a) Omega shaped in infants
b) Extends at a 45 degree angle into airway
c) Epiglottic folds are more elastic and cause it to be more floppy
a) Keep nares clear in infants < 6 months of age
b) Narrower upper airways are more easily obstructed
(1) Flexion or hyperextension
(2) Particulate matter
(3) Soft tissue injury
c) Difference in intubation technique (Airway and ILS/AW Technicians only)
(1) Gentler touch
(2) Straight blade
(3) Lift epiglottis
(4) Uncuffed tube
(5) Precise placement
C. Chest and lungs
1. Ribs are positioned horizontally
a) Allows for less chest expansion
b) Rib cage is more elastic and flexible
(1) Rib fractures are uncommon
(2) Offer less protection to abdominal organs
(3) Greater energy transmitted to underlying organs
2. Chest muscle immature
a) Fatigue easily
b) Accessory muscles are the chest muscles in young children
c) Diaphragm is the major muscle of breathing
d) Infants and children are abdominal breathers
3. Lung tissue is fragile
a) Pulmonary contusions are very common
b) Prone to pneumothorax
4. Mobile mediastinum
a) Greater shift with pneumothorax or tension pneumothorax
5. Thin chest wall allows for easily transmitted breath sounds
Section 4: Page 6
a) Watch abdominal movement as well as chest movement; do not restrict
abdominal movement
b) Rib fractures are less frequent but not uncommon in child abuse and
trauma
c) Greater energy transmitted to underlying organs following trauma,
therefore, significant internal injury can be present without external signs
d) Chest muscle use becomes more prominent as the work of breathing
increases
e) Pulmonary contusions are more common in major trauma
f) Lung tissue is more fragile
g) Lungs prone to pneumothorax
h) Mediastinum has greater shift with pneumothorax or tension pneumothorax
i) Thin chest wall allows for easily transmitted breath sounds, therefore,
making it easy to miss a pneumothorax or misplaced intubation
D. Abdomen
1. Immature abdominal muscles offer less protection
2. Abdominal organs are closer together
3. Liver and spleen proportionately larger and more vascular
a) Liver and spleen more frequently injured
b) Multiple organ injuries more common
E. Extremities
1. Bones are softer and more porous until adolescence
a) Greenstick and buckle fractures are common
b) Injuries to the growth plates may disrupt bone growth
a) Immobilize any “sprain” or “strain” as it is likely a fracture
b) Avoid piercing growth plate during intraosseous needle insertion
c) Injuries to growth plates may disrupt bone growth
F. Skin and body surface area (BSA)
1. Thinner and more elastic
a) Thermal exposure results in deeper burn
2. Less subcutaneous fat
a) Less insulation
3. Larger surface area to body mass
a) Head of infants account for 20% of BSA
b) Larger BSA increases heat loss
a) More easily and deeply burned
b) Larger losses of fluid and heat
Section 4: Page 7
G. Respiratory system
1. Tidal volume equal 7 ml/kg
2. Metabolic oxygen requirements are greater
a) Infants/children: 6 - 8 L/kg/min
b) Older adolescent/adult: 3 -4 L/kg/min
3. Limited oxygen reserve
a) Hypoxia develops rapidly
a) Hypoxia develops rapidly because of increased oxygen requirements and
decreased oxygen reserves
H. Cardiovascular system
1. Fixed stroke volume until approximately 2 years of age
a) Pulse pressure is proportional to stroke volume
2. Greater cardiac reserve
a) Can sustain tachycardia longer
b) Very effective vascular control
c) Quality and pulse pressure are more important than rate
3. Bradycardia is a response to hypoxia
4. Can maintain blood pressure longer than an adult
a) Approximately 40 % blood volume loss before a change in blood pressure
5. Circulating blood volume is proportionally larger than in an adult
6. Absolute volume is smaller than in an adult
a) Smaller absolute volume of fluid/blood loss needed to cause shock
b) Larger proportional volume of fluid/blood loss needed to cause shock
c) Hypotension is a late sign of shock, therefore, shock assessment is based
upon clinical signs of tissue perfusion
d) A child may be in shock despite normal blood pressure
e) Carefully assess for shock if tachycardia is present
f) Monitor carefully for development of hypotension
I. Nervous system
1. Develops throughout childhood
2. Infants are unable to localize pain
3. Newborns and neonates are unable to shiver to maintain body temperature
4. Motor development occurs from head to toes
a) Brain injuries are more devastating in young children
b) Greater force transmitted to underlying brain of young children
c) Spinal cord injury can occur without spinal cord injury
J. Metabolic differences
1. Infants and children have a limited glycogen and glucose stores
2. Significant volume loss can result from vomiting and diarrhea
Section 4: Page 8
3. Prone to hypothermia due to increased body surface area

4. Newborns and neonates are unable to shiver to maintain body temperature
a) Keep child warm during treatment and transport
b) Cover the head to minimize heat loss
III. Infant and child assessment - PLEASE REFERENCE THE PEDIATRIC ASSESSMENT
INFORMATION PROVIDED AT THE END OF THIS LESSON
A. General considerations
1. Many components of the initial patient evaluation can be done without touching
the patient
2. Utilize the parents/guardian to assist in making the infant or child more
comfortable
3. Interacting with parents and family
a) Normal responses to acute illness and injury
(1) May feel responsible for illness or injury (guilt)
(2) May blame you for slow response (anger)
(3) Disbelief of illness/injury
b) Parent/guardian and child interaction
c) Intervention techniques
(1) Use the infant/child's name when discussing the patient with the family
(2) Briefly explain treatment and transport at the earliest possible moment
(3) Do not give false hopes (everything will be OK)
(4) If appropriate, reassure the family that the illness/injury was not their fault
(5) Involve them if appropriate in the comfort, evaluation and care of the
infant or child
B. Physical Exam
1. Scene survey
a) Observe the scene for hazards or potential hazards
b) Observe the scene for mechanism of injury/illness
(1) Ingestion
(a) Pills, medicine bottles, household chemicals, etc.
(2) Child abuse
(a) Injury and history do not coincide, bruises not where they should be
for mechanism of injury, etc.
(3) Broken glass
(4) Position patient found
c) Observe the parent/child interaction
(1) Do they act appropriately
(2) Is there concern
(3) Is parent/guardian angry
(4) Is parent/guardian indifferent
2. Initial assessment
a) The general impression
(1) Get a general impression of environment
(2) General impression of parent/guardian and child interaction
Section 4: Page 9
(3) The Pediatric Assessment Triangle

(a) A structure for assessing the pediatric patient
(b) Focuses on the most valuable information for pediatric patients
(c) Used to ascertain if any life threatening condition exists
(d) Appearance
(i) Mental status
(a) Appropriate for age
(b) Alert
(c) Curious
(d) Quiet
(e) Uninterested
(f) Unresponsive
(g) Recognize parents
(ii) Muscle tone
(a) Spontaneous, purposeful movement
(b) Symmetrical movements
(c) Limp
(iii) Respiration
(a) Present
(i) Rate
(ii) Quiet/noisy
(iii) Audible wheezing
(b) Respiratory effort
(i) Use of accessory muscles
(ii) Nasal flaring
(iii) Retractions
(iv) Grunting
(c) Position of child
(e) Circulation
(i) Skin signs
(ii) Skin color
(a) Pale
(b) Flushed
(c) Cyanotic
(d) Mottled
(iii) Hydration
(a) Skin turgor
(b) Sunken or flat fontanelles for and infant
(c) Presence of tears and saliva
b) Vital functions
(1) Initial triage decisions
(a) Urgent - proceed with rapid ABC assessment, treatment and
transport
Section 4: Page 10
(b) Non urgent - proceed with focused history, detailed physical exam,
and initial assessment
(2) Determine level of consciousness
(a) AVPU
(i) Alert
(a) Infant - curious, recognizes parents
(b) Child - alert
(ii) Responds to Verbal stimuli
(a) Infant - irritable cry
(b) Child - opens eyes
(iii) Responds to Painful stimuli
(a) Infant - cries to pain
(b) Child - withdraws
(iv) Unresponsive
(a) Infant - no response
(b) Child - no response
(b) Modified Glasgow Coma Scale
(c) Signs of inadequate oxygenation
(3) Airway
(a) Does the child need to be positioned
(b) Is the airway open
(c) Will it remain patent
(4) Breathing
(a) Respiration
(i) Should be counted for one minute
(ii) Note depth of respiration
(iii) Adequate chest rise and fall
(iv) Is motion symmetrical
(v) Does abdomen rise and fall with breathing
(b) Use of accessory muscles
(c) Nasal flaring
(d) Tachypnea
(e) Bradypnea
(f) Irregular breathing pattern
(g) Head bobbing
(h) Signs of inadequate oxygenation
(i) Agitation
(ii) Lethargy
(iii) Altered level of consciousness
(iv) Cyanosis
(i) Any abnormal sounds
(i) Upper airway
(a) Stridor
Section 4: Page 11
(b) Slurring
(c) Gurgling
(ii) Lower airway
(a) Prolonged expiration
(b) Wheezes
(c) Rales
(d) Rhonchi
(e) Absent breath sounds
(f) Grunting
(j) Breath sounds equal
(5) Circulation
(a) Pulse - palpate for one minute
(i) Central
(a) Infant - brachial, femoral
(b) Child - carotid, femoral or brachial
(ii) Peripheral
(a) Infant - pedal, radial
(b) Child - pedal, radial
(c) Compare to central pulse to determine level of perfusion
(iii) Quality of pulse
(a) Present Vs absent
(b) Strong Vs weak
(c) Difference between central and peripheral pulses
(iv) Capillary refill
(a) Normal refill is two seconds or less
(b) Valuable to assess on patients less than six years of age
(c) Consider environmental issues - less reliable in cold
environment
(d) Blanch nail bed, base of the thumb, sole of feet, forehead,
sternum, or gums of the mouth
(b) Blood pressure
(i) Measuring blood pressure not necessary in children < 3 years
of age
(ii) If possible utilize the upper extremity
(iii) Emotional upset, pain and anxiety will increase systolic pressure
(c) Skin color
(i) Normal - pink, warm and dry
(ii) Hypoxic - cyanotic
(iii) Hypoperfusion - pale, mottled, cool, moist
(a) Note: Major symptoms to indicate a need for
intervention with IV/IO (six years old or less) fluids
would include:
Section 4: Page 12
(i) “Quiet” tachycardia (rate over 170)

(ii) Altered level of consciousness
(iii) Decreased perfusion
(d) Control any active hemorrhage
(6) Vital signs - PLEASE REFERENCE THE PEDIATRIC ASSESSMENT
INFORMATION PROVIDED AT THE END OF THIS LESSON
(a) Infant
(b) Toddler
(c) Preschool
(d) School aged
(e) (Adolescent
3. Transition phase
a) Utilized to allow the infant or child to become familiar with you and your
equipment
b) Use of transition phase depends on the seriousness of the patient's condition
c) For the conscious, non-acutely ill child
(1) Project a calm, friendly manner
(2) Use age appropriate language
(a) For infants and young toddlers, smile, speak in a quiet tone and use
a slow, deliberate approach
(3) Use toys or equipment as distracters
(a) Stethoscope
(b) Blood pressure cuff bulb
(c) Blow penlight out as a candle
(4) Get down to the patient's eye level
(5) Avoid separating the infant/child from parents/guardian unless absolutely
necessary
(6) Use the parent/guardian as a model for demonstration
(7) Treat the child with respect, especially if school aged
(8) Ask the child questions if possible
(a) What happened
(b) How do you feel
(c) Can you point with one finger to where it hurts
(9) If the child is uncooperative, do not delay treatment or transport with this
phase
d) For the unconscious, non-acutely ill child do not perform the transition
phase and proceed to the physical examination
C. Focused history
1. Approach
a) For infant, toddler and preschool aged patients, obtain from parent/guardian
b) For school aged and younger adolescent, most information may be obtained
from the patient
Section 4: Page 13
c) For adolescents, you should question them in private regarding sexual

activity, pregnancy, illicit drug and alcohol use
2. Content
a) Nature of illness/injury
b) How long has the patient been sick/injured
c) Presence of fever
d) Effects on behavior
e) Bowel/urine habits
f) Vomiting/diarrhea
g) Frequency of urination
3. Past medical history
a) Infant or child under the care of a physician
b) Chronic illnesses
(a) Diabetes
(b) Asthma
(c) Seizures
(d) Heart disease
(e) Sickle cell
(f) Transplant
(g) Other
(2) Medications
(a) Routine medicine for chronic illness
(b) Medications given today
(i) Aspirin, acetaminophen, cold medicine, etc.
c) Allergies
D. Detailed physical exam (some or all of the following may be appropriate, depending
on the situation)
1. Examine all body regions
a) Head to toe in older child
b) Toe to head in younger child
c) Maintain normal body temperature throughout examination
2. Pupils
a) Size
b) Symmetry
c) Reaction to light
3. Capillary refill
a) Normal - two seconds or less
b) Valuable to assess on patients less than six years of age
c) Less reliable in cold environment
d) Blanch nailbed, base of the thumb, sole of the feet
4. Hydration
a) Skin turgor
b) Sunken or flat fontanelle for an infant
c) Presence of tears and saliva
(1) Not normally present in infant <six weeks of age
Section 4: Page 14
d) Sunken orbits
5. Pulse-oximetry
a) Should be utilized on any moderately injured or ill infant or child
b) Place pediatric probe on finger or toe
c) Hypothermia and shock can alter reading
6. Cardiac monitor
E. Ongoing Exam
1. Continually monitor the following
a) Respiratory effort
b) Color
c) Mental status
d) Pulse oximetry
e) Vital signs
f) Patient temperature
F. General management
paramedics.
2. Airway management in pediatric patients
a) Basic airway management
(1) Manual positioning
(a) Allow medical patients to assume position of comfort
(b) Support under the torso for trauma patients less than 3 year old
(c) Occipital elevation for supine medical patients 3 years of age or
older
(2) Foreign body airway obstruction -basic clearing methods
(a) Back blows
(b) Chest thrusts
(3) Suction
(a) Avoid hypoxia
(b) Avoid upper airway stimulation
(c) Decrease suction negative pressure (£100 mm/Hg) in infants and
neonates
(4) Oxygenation
(a) Non-rebreather mask
(b) Blow by oxygen
(i) Used if mask is not tolerated
(c) Utilize the parent or guardian to deliver oxygen if patient condition
warrants
(d) Maintain proper head position
(5) Oropharyngeal airway
(a) Sizing
(b) Preferred method of insertion uses the tongue blade to depress the
tongue and jaw
(6) Nasopharyngeal airway
(a) Sizing
(b) No major differences in sizing or use compared to adults
Section 4: Page 15
(7) Ventilation
(a) Bag size
(b) Proper mask fit
(c) Proper mask position and seal
(d) Ventilate at age appropriate rate
(e) Obtain chest rise with each breath
(f) Allow adequate time for exhalation
(g) Assess BVM ventilation
(h) Apply cricoid pressure to minimize gastric inflation and passive
regurgitation
b) Advanced airway management (AIRWAY AND ILS/AW TECHNICIANS
ONLY)
(1) Foreign body airway obstruction - advanced clearing method
(a) Direct laryngoscopy with Magill forceps
(2) Endotracheal intubation in pediatric patients
(a) Laryngoscope and size appropriate blades
(i) Length based resuscitation tapes
(ii) Straight blades are preferred
(iii) General guidelines
(b) Sizing the endotracheal tube/stylette
(c) Technique for pediatric intubation
(d) Depth of insertion
(e) Endotracheal tube securing device
3. Circulation
a) Vascular access
b) Fluid resuscitation
(1) 20 ml/kg of lactated Ringer’s or normal saline bolus as needed
4. Pharmacological - Medications only to be administered by ILS or ILS/AW
Technicians following approval by on-line or off-line medical direction/control.
a) Contact ALS for additional resources
a) C-spine immobilization for traumatic cause
b) Keep the patient warm
a) Appropriate mode
(1) Transport should not be delayed to perform procedures that can be
done in route
(2) Proper BLS care must be performed prior to any ALS interventions
b) Appropriate facility
(1) The availability of a receiving hospital with expertise in pediatric care
affect the patient’s outcome
7. Psychological support / communication strategies
a) Utilize the parent/guardian to assist in making the infant or child more
comfortable, NOT TO "control" patient (holding child still to start an IV)
b) Encourage parents to help calm the child during painful procedures
c) Infants, toddlers, preschool and school aged patients do not like to be
separated from parent/guardian
Section 4: Page 16
d) Infants and children have a natural fear of strangers; for stable patients,
allow them to become accustomed to you before your hands-on
assessment
e) When possible and practical, physically position your face at the same level
as the patient’s face to facilitate communication and minimize fear
f) Use age-appropriate vocabulary
g) Children are naturally curious about what you are going to do; alleviate fears
with age appropriate information
h) Use non-threatening vocabulary (measure blood pressure, not take blood
pressure)
i) Give some control of what is going to happen to the patient (which arm to
have their IV)
j) Allow the older child to assist in their care if possible
k) Cover wounds quickly to avoid sight of blood for younger children
l) Keep patient warm
m) Allow child to take their favorite toy/blanket if possible
n) Keep equipment to a minimum
o) Warm your hands and stethoscope prior to placing them on the patient
p) Minimize bright light if possible
q) Avoid sudden movements if possible
r) Respect the child's concern for modesty
s) Permit the child to express their feelings (e.g., fear, pain, crying,)
t) Let the child know that physical actions (e.g., hitting, biting, spitting) is not
permitted
IV. Specific pathophysiologies, assessment and management

A. Anatomy and physiology review
1. Upper airway
a) Extends from the oropharynx to the carina
2. Lower airway
a) Extends from the carina to the alveoli
b) Upper airway obstruction
c) Lower airway disease
B. Respiratory Compromise
1. Pathophysiology
a) Respiratory illnesses cause respiratory compromise in airway/lung
(1) Severity of respiratory compromise depends on extent of respiratory
illness
(2) Approach to treatment depends on severity of respiratory compromise
b) Severity
(1) Respiratory distress (mild)
(a) Increased work of breathing
(b) Carbon dioxide tension in the blood initially decreases, then
increases as condition deteriorates
(c) If uncorrected respiratory distress leads to respiratory failure
Section 4: Page 17
(2) Respiratory failure (moderate)

(a) Inadequate ventilation or oxygenation
(b) Respiratory and circulatory systems are unable to exchange
enough oxygen and carbon dioxide
(c) Carbon dioxide tension in the blood increases, leading to metabolic
acidosis
(d) Very ominous condition; patient is on the verge of respiratory arrest
(3) Respiratory arrest (severe)
(a) Cessation of breathing
(b) Failure to intervene will result in cardiopulmonary arrest
(c) Good outcomes can be expected with early intervention that
prevents cardiopulmonary arrest
c) Assessment
(1) Chief complaint
(2) History
(a) Signs and symptoms of respiratory distress
(i) Tachypnea
(ii) Retractions
(iii) Tachycardia
(iv) Irritability
(v) Anxiety
(b) Signs and symptoms of respiratory failure- all those of respiratory
distress, plus any of the following:
(i) Marked retractions
(ii) Agitation
(iii) Lethargy
(iv) Central cyanosis
(v) Pulse oximetry reading of less than 92 on supplemental oxygen
in absence of cyanotic congenital heart disease
(vi) Bradypnea
(vii) Bradycardia
(viii)Head bobbing
(ix) Grunting
(c) Signs and symptoms of respiratory arrest
(i) Apnea
(4) Ongoing assessment - improvement indicated by increasing oxygen
saturation, respiratory and circulatory systems returning to normal,
increased level of consciousness
d) Management
(2) Graded approach to treatment
(3) Consider separating parent and child
(4) Airway
(a) Manage upper airway obstructions as needed
Section 4: Page 18
(b) Insert airway adjunct if needed

(i) The proper size nasopharyngeal airways may not be available
(ii) Small endotracheal tubes may be used for small infants and kids
(5) Ventilation and oxygenation
(a) Respiratory distress/early respiratory failure
(i) Administer high flow oxygen
(a) Blow-by
(b) Simple mask
(c) Non-rebreather mask
(b) Late respiratory failure/respiratory arrest
(i) Bag-Valve-Mask (BVM)
(a) Ventilate patient with 100% oxygen via age appropriate
sized bag
(ii) Airway and ILS/AW technicians only:
(a) Intubate patient if positive pressure ventilation does not
rapidly improve patient condition
(6) Circulation
(a) Consider IV or IO (six years old or less)
(7) Supportive care
(a) Utilize the parents or guardian to deliver oxygen
2. Anaphylaxis
a) Introduction
(1) Epidemiology
(a) Incidence
(b) Morbidity/mortality
(c) Risk factors
(d) Prevention
(2) Anatomy
(a) Review of cardiovascular system
(b) Review of respiratory system
(c) Review of nervous system
(d) Review of gastrointestinal system
(3) Physiology
(a) Antigens
(b) Antibodies
b) Pathophysiology
(1) Allergen
(2) Routes of entry
(a) Oral ingestion
Section 4: Page 19
(b) Injected/envenomation
(c) Inhaled
(d) Topical
(3) Common Allergens
(a) Drugs
(b) Insects
(c) Foods
(d) Animals
(e) Latex
(f) Other
(4) Allergic Response
(a) Histamine or histamine-like substance release
(b) Immunity
(c) Sensitivity
(d) Hypersensitivity
(5) Urticaria
(a) Redness of skin
(6) Angioneurotic
(a) Swelling / Edema of the skin
(7) Anaphylactic Shock
(a) Cardiovascular system
(b) Respiratory system
(c) Gastrointestinal system
(d) Nervous system
(1) Not all signs and symptoms are present in every case
(2) History
(a) Previous exposure
(b) Previous experience to exposure
(c) Onset on symptoms
(d) Dyspnea
(3) Level of consciousness
(a) Unable to speak
(b) Restless
(c) Decreased level of consciousness
(d) Unresponsive
(4) Upper airway
(a) Hoarseness
(b) Stridor
(c) Pharyngeal edema / spasm
(5) Lower Airway
Section 4: Page 20
(a) Tachypnea
(b) Hypoventilation
(c) Labored-Accessory muscle use
(d) Abnormal retractions
(e) Prolonged expirations
(f) Wheezes
(g) Diminished lung sounds
(6) Skin
(a) Redness
(b) Rashes
(c) Edema
(d) Moisture
(e) Itching
(f) Urticaria
(g) Pallor
(h) Cyanotic
(7) Vital Signs
(a) Tachycardia
(b) Hypotension
(8) Gastrointestinal
(a) Abnormal cramping
(b) Nausea/vomiting
(c) Diarrhea
(9) Assessment Tools
(a) Cardiac monitor
(b) Oximetry low
(c) End Tidal CO2 high
d) Management of Anaphylaxis
(2) Remove offending agent (i.e. Stinger)
(a) Positioning
(b) Oxygen
(c) Assist ventilation
(d) Advanced airway
(4) Circulation
(a) Venous access
(b) Fluid resuscitation
Section 4: Page 21

direction/control.
(a) Oxygen
(b) Epinephrine 1:1000, by a commercially pre-loaded measured dose
device
(i) Dosage
(a) Adult:
(ii) Subcutaneous - one adult measured dose device (0.1
to 0.5 mg 1:1000 SQ)
(b) Infant and child:
(ii) Subcutaneous - one infant/child measured dose devise
(0.01 to .03 mg/kg 1:1000 SQ)
e) Management of Allergic Reaction
(2) Oxygen
(3) Epinephrine 1:1000, by a commercially pre-loaded measured dose
device, ONLY if permission is given by on-line or off-line medical
direction/control
(a) Dosage
(i) Adult:
(b) Subcutaneous - one adult measured dose device (0.1 to
0.5 mg 1:1000 SQ)
(ii) Infant and child:
(b) Subcutaneous - one infant/child measured dose devise
(0.01 to .03 mg/kg 1:1000 SQ)
f) Integration
Section 4: Page 22
3. Upper airway obstruction

a) Croup
(1) Pathophysiology
(a) An inflammatory process of the upper respiratory tract involving the
subglottic region
(b) Most commonly seen in infants and children between 6 months and
4 years of age
(c) Another form is spasmodic croup, occurring mostly in the middle of
the night, usually without prior upper respiratory infection
(d) Usually occurs during late fall and early winter
(2) Assessment
(a) Signs of respiratory distress or failure, depending on severity, plus
(i) History of upper respiratory infection (classic croup) for 1 - 2
days
(ii) Respiratory stridor - due to subglottic edema
(iii) Wheezing may be heard if lower airways are involved
(iv) Characteristic “barking” (seal or dog-like) or brassy cough - due
to edema of the vocal chords
(v) Hoarseness
(vi) Fever (+/-)
(vii) Most children show signs of respiratory distress
(viii)Infant or child appears sick, but not toxic
(3) Management
(b) Airway and ventilation
(i) Humidified or nebulized oxygen
(ii) High flow, high concentration, cool mist oxygen administered by
non-rebreather mask, using the blow-by technique
(c) Circulation
(d) Pharmacological interventions - There are no phamacological
(i) Contact ALS for additional resources
(e) Non-pharmacological
(i) Keep child in position of comfort
(ii) Maintain patent airway
(iii) If airway becomes obstructed, perform two rescuer technique to
ventilate with BVM
(f) Transport considerations
(i) Monitor vital signs for improvement or decompensation
(ii) Gently transport to the hospital
(iii) Notify hospital of patient status early
(iv) Transport to the hospital quickly, but quietly
Section 4: Page 23
(g) Psychological support communication strategies

(i) DO NOT upset the infant or child
(ii) DO NOT FORCE THE CHILD TO DO ANYTHING
(iii) NEVER ATTEMPT TO VISUALIZE THE AIRWAY
(iv) Keep the parent/guardian with the infant or child
(v) Allow the patient to assume position of comfort
(vi) Allow the parent to administer oxygen
b) Foreign body aspiration
(1) Pathophysiology
(a) Partial or complete blockage of the upper airway by a foreign body
(b) (Most common in toddlers and preschool (1-4 years of age) but can
occur at any age
(c) Objects are usually food (hard candy, nuts, seeds, hot dog) or small
objects (coins, balloons)
(d) Partial
(i) Most children show signs of mild distress
(ii) Appears anxious, but not toxic
(iii) Interventions other than oxygen and transport may precipitate
complete obstruction
(e) Complete
(i) Most children show signs of severe distress
(ii) Appears agitated, but not toxic
(iii) If no interventions, respiratory arrest ensues, followed by
cardiopulmonary arrest
(2) Assessment
(a) Partial obstruction - signs of respiratory distress or failure depend
on severity, plus:
(i) Inspiratory stridor
(ii) Retractions
(iii) Nasal flaring
(iv) Muffled or hoarse voice
(v) Pain in throat
(vi) Drooling
(vii) Usually a history of choking if observed by adult
(b) Complete obstruction - signs of respiratory distress or failure
depend on severity, plus:
(i) Agonal or no respiratory effort
(ii) Altered mental status
(iii) Poor muscle tone
(iv) Cyanosis
(v) Bradycardia
(3) Management
Section 4: Page 24
(b) Partial
(i) Assure airway and ventilation
(ii) Place patient in sitting position
(iii) Deliver oxygen by non-rebreather mask or blow-by
(iv) Do not attempt to look in mouth
(c) Complete
(i) Assure airway and ventilation
(ii) Open airway and attempt to visualize the obstruction
(iii) Sweep visible obstructions with your finger (do NOT perform
blind finger sweeps)
(iv) Perform BLS foreign body airway obstruction (FBAO)
maneuvers
(v) Attempt BVM ventilations
(vi) Airway or ILS/Airway Technicians only:
(a) Perform laryngoscopy if BVM is unsuccessful
(b) Remove object if possible with pediatric Magill forceps
(c) Intubate if possible
(vii) Continue BLS FBAO maneuvers if ALS unsuccessful
(d) Circulation
(e) Pharmacological interventions - There are no phamacological
(i) Notify hospital of patient status
(ii) Transport expeditiously
(g) Psychological support/communication strategies
(i) Do not agitate patient
(ii) Keep care giver with child, if appropriate
c) Epiglottitis
(1) Pathophysiology
(a) Rapidly forming cellulitis of the epiglottis and its surrounding
structures
(b) Most common in children between 3 and 7 years of age but can
occur at any age
(c) Bacterial infection, usually Hemophilus influenza type B
(d) Increasingly uncommon due to the H-flu vaccine
(e) Child usually appears agitated, toxic, in respiratory distress or
failure
(f) It is a true emergency because the child can progress to complete
airway obstruction and respiratory arrest if the epiglottis swells over
the opening of the trachea
(2) Assessment
(a) Signs and symptoms - signs of respiratory distress or failure
depend on severity, plus the patient will:
(i) Look very ill
(ii) Be very quiet
Section 4: Page 25
(iii) Be doing everything possible just to keep breathing

(iv) Be sitting upright, leaning slightly forward on their hands with the
neck extended forward (tripod position)
(v) Usually have their mouth open with the tongue protruding
(drooling)
(vi) Show signs of respiratory distress
(vii) Have very painful swallowing
(viii)Have a fever
(ix) Muffled voice and stridor may be present
(x) Toxic appearance
(xi) In severe cases, be hypoxic
(b) History
(3) Management
(i) Maintain patent airway
(ii) High flow, high concentration, cool mist oxygen administered by
non-rebreather mask, using the blow-by technique
(iii) Never attempt to visualize the airway
(iv) Allow the parent to administer oxygen
(v) If airway becomes obstructed, perform two rescuer technique to
ventilate with BVM occluding the pressure limiting device if
necessary to provide adequate pressure
(vi) Airway and ILS/AW Technicians only
(a) If BVM is not effective, attempt intubation with stylet in
place
(b) Should not be attempted in settings with short transport
times
(c) Performing chest compression upon glottic visualization
during intubation may produce a bubble at the tracheal
opening
(c) Circulation
(d) Pharmacological interventions - There are no phamacological
(i) Allow the patient to assume position of comfort
(i) Allow patient to assume position of comfort
(ii) Notify hospital of patient status early
(iii) Gently transport to the hospital quickly, but quietly, keeping child
warm
Section 4: Page 26
(g) Psychological support communication strategies

(i) DO NOT upset the patient
(ii) DO NOT FORCE THE PATIENT TO DO ANYTHING
(iii) DO NOT PLACE ANYTHING IN THE PATIENT’S MOUTH
(iv) NEVER ATTEMPT TO VISUALIZE THE AIRWAY
(v) Keep the parent/guardian with the patient
d) Lower airway disease
(1) Asthma /bronchiolitis
(a) Pathophysiology
(i) Bronchospasm, excessive mucous production, inflammation of
the small airways;
(ii) Typically in child with known history of asthma
(iii) Triggered by upper respiratory infections, allergies, changes in
temperature, physical exercise and emotional response
(iv) Children that experience prolonged asthma attacks tire easily;
watch for signs of failure
(b) Severity
(i) Children that experience prolonged asthma attacks tire easily;
watch for signs of failure
(ii) A silent chest means danger
(c) Assessment
(i) Signs and symptoms - signs of respiratory distress or failure
depend on severity, plus:
(a) Expiratory wheezes
(b) Tachypnea with prolonged expiratory phase
(c) Supraclavicular retractions
(d) Intercostal retractions
(e) Subcostal retractions
(f) Nasal flaring
(g) Tachycardia
(h) Cough
(i) Cyanosis
(j) Diaphoresis
(k) Anxious
(l) Decreased mental status
(m) A silent chest means danger
(ii) History
(iii) Bronchiolitis and asthma may present very similarly, however,
albuterol will not improve bronchiolitis but it will also not harm
patient
(d) Management
(i) When paramedic service is available, ILS personnel shall
Section 4: Page 27
(ii) Airway and ventilation

(a) Allow patient to remain in position of comfort
(b) Oxygen by the most comfortable and effective method, 4 - 6
l/min via mask, cannula, tubing or blow-by
(c) BVM ventilations for respiratory failure/arrest (progressive
lethargy, poor muscle tone, shallow respiratory effort)
(d) Airway and ILS/AW Technicians only
(i) Endotracheal intubation for respiratory failure,
prolonged BVM ventilations, or inadequate response to
BVM ventilations
(iii) Circulation
(a) Obtain vascular access
(iv) Pharmacological - Medications only to be administered by ILS
or ILS/AW Technicians following approval by on-line or off-line
medical direction/control.
(a) IV/IO (six years old or less)
(b) Albuterol - Adult:
(i) Dosage - based upon order from medical
direction/control
(ii) Solution: 2.5 mg; dilute 0.5 ml of the 0.5% solution for
15 min
(iii) Metered dose inhaler: 1-2 inhalations (90 µg each).
May be repeated every 15 min as needed.
(c) Albuterol - Pediatric:
(i) Dosage - based upon order from medical
direction/control
(ii) Age younger than 12 yrs: Solution: 0.03 ml/kg of a
(iii) Age 12 and over: Use full adult dose
(d) Medication may be repeated if no initial effect
(e) Contact ALS for additional resources
(v) Transport considerations
(a) Allow patient to assume position of comfort
(b) Monitor vital signs for improvement or decompensation
(vi) Psychological support communication strategies
(a) Keep care giver with child
(2) Pneumonia
(a) Pathophysiology
(i) Infection of the lower airway and lung
(ii) Most common in infants, toddlers and preschoolers (1 - 5 years
of age)
(iii) Can occur in any age child
(iv) Very common disease process
Section 4: Page 28
(b) Assessment
(i) Signs and symptoms - signs of respiratory distress of failure
depend on the severity, plus:
(a) Fever
(b) Tachypnea
(c) Tachycardia
(d) Retractions
(e) Nasal flaring
(f) Pain in the chest
(g) Decreased breath sounds
(h) Rales
(i) Rhonchi (localized or diffuse)
(j) Evidence of respiratory distress
(k) Mild to moderate - child frequently appears alert, awake,
non-toxic in mild respiratory distress
(l) Severe - Child may appear agitated, toxic, cyanotic, severe
retractions in respiratory failure or arrest
(ii) Rarely progresses rapidly to respiratory failure or arrest
(iii) History
(c) Management
(a) High-flow oxygen
(b) Airway and ILS/AW Technicians
(i) Consider intubation if necessary
(iii) Circulation
(iv) Transport considerations
(v) Psychological support communication strategies
(3) Foreign body lower airway
(a) Pathophysiology
(i) Foreign body in the lower airway or lung
(ii) Rarely progresses rapidly to respiratory failure or arrest
(b) Assessment
(i) Signs and symptoms - signs of respiratory distress of failure
depend on the severity, plus:
(a) Tachypnea
(b) Retractions
(c) Nasal flaring
(d) Pain in the chest
(e) Decreased breath sounds
(f) Rales
(g) Rhonchi (localized or diffuse)
(ii) History
(a) History of choking during aspiration if witnessed event
Section 4: Page 29
(c) Management
(a) High-flow oxygen
(b) Airway and ILS/AW Technicians
(i) Consider intubation
(iii) Circulation
(iv) Transport considerations
(v) Psychological support communication strategies
(a) Allow patient to assume their position of comfort
C. Shock
1. Pathophysiology
a) An abnormal condition characterized by inadequate delivery of oxygen and
metabolic substrates to meet the metabolic demands of tissues
b) Severity
(1) Compensated
(a) Patient’s blood pressure is normal although signs of inadequate
tissue perfusion are present
(2) Decompensated
(a) Hypotension and signs of inadequate organ perfusion are present
c) Assessment
(1) Chief complaint
(2) History
(3) Physiological findings
(a) Signs and symptoms compensated (early) shock
(i) Anxiety or agitation
(ii) Tachycardia
(iii) Tachypnea
(iv) Peripheral pulses weaker than central pulses
(v) Delayed capillary refill
(b) Signs and symptoms of decompensated (late) shock
(i) Lethargy or coma
(ii) Marked tachycardia or bradycardia
(iii) Respiratory depression
(iv) Absent peripheral pulses
(v) Markedly delayed capillary refill
(vi) Cool, pale extremities
(vii) Hypotension
(viii)Decreased urinary output
Section 4: Page 30
2. Etiology
a) Hypovolemia - common
(1) Pathophysiology
(a) Dehydration
(i) Vomiting
(ii) Diarrhea
(iii) Fever, hyperventilation
(iv) Excessive perspiration
(v) Plasma losses (burns, surgical drains, fistulas, and open
wounds)
(vi) Internal losses (peritonitis, pancreatitis, or bowel obstruction)
(b) Blood loss
(i) Trauma
(ii) Child-abuse
(a) Other, e.g., GI bleed
(2) Signs and symptoms -assess for general compensated or
decompensated shock plus:
(a) Dehydration
(i) Poor skin turgor
(ii) Decreased saliva and or tears
(iii) Sunken fontanelle: infants
(iv) Dry mucosa
(v) Excessive thirst
(vi) Capillary refill less than 2 seconds
(vii) Increased pulse rate, decreased blood pressure
(b) Blood loss
(i) Signs and symptoms
(a) Thirst
(b) Tachypnea
(c) Tachycardia
(d) Pale skin
(e) Delayed capillary refill
(f) Hematomas
(g) Tender abdomen
(h) Rigid abdomen
(i) Obvious long bone fracture
(3) Management
(b) Compensated
(i) Oxygen
(c) Decompensated
(i) Airway and ventilation
(a) Administer high flow oxygen
Section 4: Page 31
(b) Airway and ILS/AW only

(ii) Circulation
(a) Initiate large bore IV or IO (six years old or less) Ringers
lactate or normal saline
(b) IV – Be Cautious About Over Hydration
(c) 20 ml/kg of LR or NS bolus as needed
(d) Do Not withhold an IV simply because the patient is pediatric
(iii) Pharmacological - Medications only to be administered by ILS
or ILS/AW Technicians following approval by on-line or off-line
(a) Dextrose
(i) Pediatric Dosage: 25% dextrose at 0.5-1.0g/kg IV
bolus. A 50% solution may be diluted 1:1 with normal
saline or sterile water
(iv) Non-pharmacological
(a) Control any external hemorrhage
(b) Splint any fracture
(v) Assessment
(a) Monitor vital signs for improvement or decompensation
(b) Administer additional fluid bolus if indicated
(vi) Transport considerations
(vii) Psychological support communication strategies
(d) C-spine immobilization for trauma
(4) Distributive - uncommon
(a) Etiology
(i) Sepsis
(ii) Neurogenic
(iii) Anaphylactic
(b) Pathophysiology
(i) Peripheral pooling due to loss of vasomotor tone
(ii) Shift of fluid from intravascular space to extravascular space
(c) Signs and symptoms - assess for general compensated or
decompensated shock plus:
(i) Sepsis
(a) Early - warm skin
(b) Late - cool skin
(ii) Neurogenic
(a) Warm skin
(b) Bradycardia
(iii) Anaphylactic
(a) Allergic rash
(b) Airway swelling
Section 4: Page 32
(d) Management
(ii) Compensated
(a) Oxygen
(iii) Decompensated
(a) Airway and ventilation
(b) High-flow oxygen
(c) Airway and ILS/Airway Technicians only
(iv) Circulation
(a) IV or IO (six years old or less)
(b) 20 ml/kg of LR or NS bolus as needed
(v) Transport considerations
(vi) Psychological support communication strategies
D. Seizure
1. Pathophysiology
a) Types
(1) Generalized (grand mal)
(2) Focal (petit mal)
2. Assessment
(1) Generalized (grand mal)
(a) Sudden jerking of the entire body followed by tenseness and
relaxation of the body
(b) Loss of consciousness
(2) Focal (petit mal)
(a) Sudden jerking of a part of the body (arm, leg)
(b) Lip smacking
(c) Eye blinking
(d) Staring
(e) (a
(f) Lethargy
b) History may or may not be contributory
3. Management
a) When paramedic service is available, ILS personnel shall contact medical
paramedics.
(1) Maintain patent airway
(2) Administer high-flow oxygen
c) Circulation
(1) Consider IV
(2) Consider IO (six years old or less)
Section 4: Page 33

Technicians following approval by on-line or off-line medical
direction/control.
(1) Dextrose
(a) Pediatric Dosage: 25% dextrose at 0.5-1.0g/kg IV bolus. A 50%
(1) Protect patient from further injury
(2) Protect head and cervical spine if injury has occurred
f) Transport considerations
g) Psychological support communication strategies
E. Head injury
1. Pathophysiology
a) Increased intracranial pressure
(1) Elevated blood pressure
(2) Bradycardia
(3) Slow, deep respirations alternating with rapid deep respirations
(Cheyne-Stokes)
b) Early recognition and aggressive management can reduce mortality and
morbidity
c) Severity
(1) Mild - Glasgow Coma Scale (GCS) is 13 to 15
(2) Moderate - GCS is 9 to 12
(3) Severe - GCS is less than or equal to 8
2. Assessment
(1) Decreased level of consciousness
(2) Irritable
(3) Clear or amber drainage from nose or ears
(4) Bruising behind ears
(5) Bruising around eyes
(6) Unequal pupils
(7) Abnormal lateral gaze
(8) Roving eye movements
(9) Local tissue swelling
(10)Bulging fontanelle (infant)
(11)Posturing
(12)Shock
b) History
3. Management
paramedics.
(1) Maintain patent airway
Section 4: Page 34
(2) High-flow oxygen

(3) Ventilate at normal breathing rate with 100% oxygen for severe head
injuries
(4) Airway and ILS/AW technicians only:
(a) Intubate severe head injured patient
(5) Hyperventilate only if
(a) Blown pupils are present
(b) Patient is actively seizing
(c) Patient is posturing
c) Circulation
(1) Consider IV or IO (six years old or less)
(2) (Administer fluid challenge if in decompensated shock
direction/control.
(1) Stabilize cervical spine
g) Psychological support communication strategies
F. Hypoglycemia
1. Pathophysiology
a) Children have limited glucose storage
b) In severe cases, if not treated promptly, can cause brain damage
2. Assessment
(1) Mild
(a) Hunger
(b) Weakness
(c) Tachypnea
(d) Tachycardia
(2) Moderate
(a) Sweating
(b) Tremors
(c) Irritability
(d) Vomiting
(e) Mood swings
(f) Blurred vision
(g) Stomach ache
(h) Headache
(i) Dizziness
(3) Severe
(a) Decreased level of consciousness
(b) Seizure
b) Measure blood glucose
c) History
Section 4: Page 35
3. Management
paramedics.
c) Circulation
direction/control.
(1) Dextrose
(a) Pediatric Dosage: 25% dextrose at 0.5-1.0g/kg IV bolus. A 50%
(2) Repeat blood glucose test 10-15 minutes after dextrose infusion
e) Transport considerations
f) Psychological support communication strategies
G. Hyperglycemia
1. Pathophysiology
a) In severe cases, if not treated promptly, can cause brain damage
2. Assessment
(1) Early
(a) Increased thirst
(b) Increased urination
(c) Weight loss
(2) Acute (dehydration and early ketoacidosis)
(a) Weakness
(b) Abdominal pain
(c) Generalized aches
(d) Loss of appetite
(e) Nausea
(f) Vomiting
(g) Signs of dehydration except decreased urinary output
(h) Fruity breath odor
(i) Tachypnea
(j) Hyperventilation
(k) Tachycardia
(3) Pre-comatose (ketoacidosis)
(a) Decreased level of consciousness
(b) Signs of moderate dehydration
(4) Comatose
(a) Deep and slow respirations (Kussmaul)
(b) Signs of severe dehydration
Section 4: Page 36
3. Management
paramedics.
c) Circulation
(1) IV or IO (six years old or less)
(2) Administer LR or NS if signs of dehydration are present per medical
direction
direction/control.
(1) Measure blood glucose
e) Transport considerations
f) Psychological support communication strategies
H. Poisoning and toxic exposure
1. Epidemiology
a) Morbidity / mortality
(1) Major cause of preventable death in children under five years of age
b) Incidence
(1) Children account for the majority of poisoning events
2. Pathophysiology
a) Attempt to identify the type of poison or toxin and the extent of exposure
(1) Common substances of pediatric poisonings
(2) Alcohol
(3) Barbiturates
(4) Sedatives
(5) (Amphetamines
(6) Cocaine
(7) Hallucinogens
(8) Anticholinergic
(9) Aspirin
(10)Corrosives
(11)Digitalis
(12)(Beta-blockers
(13)Hydrocarbons
(14)Narcotics
(15)Organic solvents (inhaled)
(16)Organophosphate
3. Assessment
a) Signs and symptoms - Will vary depending upon both the poisoning/toxic
substance and the time since the child was exposed
(1) Respiratory system depression
(2) Circulatory system depression
(3) Central nervous system stimulus or depression
Section 4: Page 37
(4) Mind-altering ability

(5) Gastrointestinal system irritation
b) History
4. Management
b) Contact Poison Control Center or Medical Command to obtain directions for
specific treatment
c) Airway and ventilation
(2) Airway and ILS/AW Technicians only:
(a) Consider intubation
d) Circulation
(1) Consider IV or IO (six years old or less)
direction/control.
f) Non-pharmacological
(1) Take pills, substances, containers and vomitus to the hospital
g) Transport considerations
h) Psychological support communication strategies
V. Pediatric Trauma
A. Pathophysiology
1. Blunt
a) Thinner body wall allows forces to be readily transmitted to body contents
b) Predominant cause of injury in children
2. Penetrating
a) Becoming an increasing problem in adolescents
b) Higher incidence in the inner city (mostly intentional), but significant
incidence in other areas (mostly unintentional)
B. Mechanism of injury (MOI)
1. Fall
a) Single most common cause of injury in children
b) Serious injury or death resulting from truly accidental falls is relatively
uncommon unless from a significant height
c) Factors to consider when determining MOI
d) Prevention strategies
2. Motor vehicle crash
a) Leading cause of permanent brain injury and new cases of epilepsy
b) Leading cause of death and serious injury in children
c) Factors to consider when determining MOI
3. Pedestrian vehicle crash
a) Particularly lethal form of trauma in children
b) Initial injury due to impact with vehicle (extremity/trunk)
Section 4: Page 38
c) Child is thrown from force of impact causing additional injury (head/spine)

upon impact with other objects (ground, another vehicle, light standard,
etc.)
d) Factors to consider when determining MOI
e) Prevention strategies
4. Near-drowning
a) Third leading cause of injury or death in children between birth and 4
b) Causes approximately 2000 deaths annually
c) Severe, permanent brain damage occurs in 5% to 20% of hospitalized
children for near drowning
5. Penetrating injuries
a) Risk of death from firearm injuries increase with age
b) Stab wounds and firearm injuries account for approximately 10-15% of all
pediatric trauma admissions
c) Visual inspection of external injuries can not evaluate the extent of internal
involvement
6. Burns
a) The leading cause of accidental death in the home for children under the
age of 14 years
b) Burn survival is a function of burn size and concomitant injuries
c) Modified “Rule of Nines” is utilized to determine percentage of surface area
involved
7. Physical abuse
a) Has been classified into four categories: physical abuse, sexual abuse,
emotional abuse and child neglect
b) Social phenomena such as increased poverty, domestic disturbance,
younger aged parents, substance abuse, and community violence have
been attributed to increase of abuse
c) Document all pertinent findings, treatments and interventions
C. Special considerations
1. Airway control
a) Maintain in-line stabilization in neutral, not sniffing position
b) Administer 100% oxygen to all trauma patients
c) Patent airway must be maintained via suctioning and jaw thrust
d) Be prepared to assist ineffective respirations
e) Airway and ILS/AW Technicians only:
(1) Intubation should be performed when the airway remains inadequate
2. Immobilization
a) Indications for stabilization and immobilization of cervical spine
b) Utilize appropriate sized pediatric immobilization equipment
(1) Rigid cervical collar
(2) Towel/blanket roll
(3) Child safety seat
Section 4: Page 39
(4) Pediatric immobilization device

(5) Vest-type/short wooden backboard
(6) Long backboard
(7) Straps, cravats
(8) Tape
(9) Padding
c) Maintain supine neutral in-line position for infants, toddlers, and pre-
schoolers by placing padding from the shoulders to the hips
3. Fluid management
a) Management of the airway and breathing take priority over circulatory
management because circulatory compromise is less common in children
than adults
b) Vascular access
(1) Large-bore intravenous catheter should be inserted into a large
peripheral vein
(2) Do not delay transport to gain access
(3) Intraosseous access
(4) Initial fluid bolus of 20 cc/kg of an isotonic crystalloid solution
(5) Reassess vital signs and re-bolus with 20 cc/kg if no improvement
(6) If improvement does not occur after the second bolus, there is likely to
be significant blood loss and the need for rapid surgical intervention
D. Specific injuries
1. Head and neck injury
a) Larger relative mass of the head and lack of neck muscle strength provides
increased momentum in acceleration-deceleration injuries and a greater
stress to the cervical spine region
b) Fulcrum of cervical mobility in the younger child is at the C2-C3 level
c) 60% to 70% of pediatric fractures occur in C1 or C2
d) Head injury is the most common cause of death in pediatric trauma victim
e) Diffuse injuries are common in children, focal injuries are rare
f) Soft tissues, skull and brain are more compliant in children than in adults
g) Due to open fontanelles and sutures, infants up to an average age of 16
months may be more tolerant to an increase of intracranial pressure and
can have delayed signs
h) Subdural bleeds in a infant can produce hypotension (extremely rare)
i) Significant blood loss can occur through scalp lacerations and should be
controlled immediately
j) The Modified Glasgow Coma Score should be utilized for infants and young
children
2. Chest injury
a) Chest injuries in children under 14 years of age are usually the result of
blunt trauma
b) Due to the compliancy of the chest wall, severe intrathoracic injury can be
present without signs of external injury
c) Tension pneumothorax is poorly tolerated and is an immediate threat to life
d) Flail segment is an uncommon injury in children; when noted without a
significant mechanism of injury, suspect child abuse
Section 4: Page 40
e) Many children with cardiac tamponade will have no physical signs of

tamponade other then hypotension
3. Abdominal injury
a) Musculature is minimal and poorly protects the viscera
b) Organs most commonly injured are spleen, liver, bowel mesentery and
kidney
c) Onset of symptoms may be rapid or gradual
d) Due to the small size of the abdomen, be certain to palpate only one
quadrant at a time
e) Any child who is hemodynamically unstable without evidence of obvious
source of blood loss should be considered as having an abdominal injury
until proven otherwise
4. Extremity
a) Relatively more common in children than adults
b) Growth plate injuries are common
c) Compartment syndrome is an emergency in children
d) Any sites of active bleeding must be controlled
e) Splinting should be performed to prevent further injury and blood loss
f) PASG may be useful in unstable pelvic fractures with hypotension
5. Burns
a) Thermal burns in children
b) Chemical burns in children
c) Electrical burns in children
d) Management priorities
(1) Prompt management of the airway is required as swelling can develop
rapidly
(2) Airway and ILS/AW Technicians only:
(a) If intubation is required, an endotracheal tube up to two sizes
smaller than what would normally be used may be required
(3) Thermally burned children are very susceptible to hypothermia;
maintain normal body temperature
(4) Suspect musculoskeletal injuries in electrical burn patients and perform
spine immobilization techniques
VI. Sudden Infant Death Syndrome (SIDS)
A. Epidemiology
1. Risk factors
a) Occurs most frequently in the fall and winter months
b) Minor illness (cold or upper respiratory infection) within two weeks prior to
the death
c) Premature and low birth-weight infants
d) Infants of young mothers
e) Infants of mothers who did not receive prenatal care
f) Infants of mothers who used cocaine, methadone or heroin during
pregnancy
2. Prevention strategies
Section 4: Page 41
B. Pathophysiology
1. Sudden and unexpected death of a seemingly healthy infant, which remains
unexplained even after a thorough postmortem examination
2. No prior symptoms of life-threatening illness
3. Death usually occurs during sleep
4. No definitive answer at this time
5. A small percentage is abuse related
6. Many victims of SIDS appear to have suffered from long-term under-ventilation
of the lungs, possibly due to poor control of breathing during sleep
7. Abnormalities in the brainstem
C. Assessment
1. Signs and symptoms
a) No external signs of injury
b) Lividity
c) Frothy blood-tinged drainage from nose/mouth
d) Rigor mortis
e) Evidence that the baby was very active just prior to the death (i.e. rumpled
bed clothes, unusual position or location in the bed)
2. History
D. Management
paramedics.
a) High-flow oxygen
b) Airway and ILS/AW Technicians only:
(1) Intubation
3. Circulation
a) CPR unless the infant is obviously dead (unquestionably dead to a lay
person)
b) IV or IO (six years old or less)
a) Contact ALS for additional resources
6. Psychological support communication strategies
a) Be prepared for the range of possible family emotional reactions
b) Parents/care giver should be allowed to accompany their baby in the
ambulance
c) Explain that certain information is required regarding the infant’s health is
necessary to determine the care to be given
d) Utilize the baby’s name
e) Questions should be phrased so blame is not implied
f) Debriefing
g) Resources for SIDS families
Section 4: Page 42
VII. Child abuse and neglect

A. Epidemiology
1. Second leading cause of death in infants less than 6 months of age
2. Between 2000 and 5000 children die each year due to abuse and neglect
B. Age considerations
1. Under 18 years of age
2. Physically or mentally handicapped person under 21 years of age
C. Abuse or neglect perpetrators
1. Parent, legal guardian, foster parent
2. Person, institution, agency or program having custody of the child
3. Person serving as a caretaker, i.e. baby-sitter
D. Abuse
1. Types
a) Physical
b) Emotional
c) Sexual
2. Abuse indicators
a) Historical
b) Psychosocial
c) Signs of physical abuse
d) Signs of emotional abuse
(1) Physical indicators
(2) Behavioral indicators
e) Signs of sexual abuse
E. Neglect
1. Types
a) Physical
b) Emotional
2. Neglect indicators
a) Behavioral
b) Physical
F. EMT-Intermediate role in treating abuse and neglect
1. Assess the injuries/neglect and render appropriate care
2. Look at the environment for condition and cleanliness
3. Look for evidence of anything out of the ordinary
4. Look and listen to family members
5. Assess whether the explanation fit the injury
6. Document all findings thoroughly
7. Report suspicion
a) Mandated reporter
b) Immunity from liability
G. Resources for abuse and neglect
1. State, regional and local Department of Public Welfare agency
2. Hospital social service department
VIII. Transport Considerations
A. Mode
B. Equipment
Section 4: Page 43
C. Personnel
D. Receiving facility
IX. Medical/legal considerations
NOTES:
Section 4: Page 44
All sizes and measurements are age/weight relative ESTIMATES
AGE WEIGHT PULSE RESP SYS BP

(kg) min min (mmHg)
PREMATURE 1-3 120-180 <60 50-60
TERM 3-4 95-145 35-45 60-70
6 MO 7 110-180 24-30 70-110
1 YEAR 10 110-120 22-30 80-120
2 12 110-120 22-30 90-130
3 14 100-110 20-26 90-130
4 16 95-105 20-24 90-130
5 18 95-105 20-24 90-130
6 20 90-100 20-24 95-130
7 24 90-100 18-22 95-130
8 25 90-100 18-22 95-130
9 30 90-100 18-22 100-130
12 40 85-95 16-22 100-140
16 >50 75-80 14-20 100-140
ADULT 50-100 60-100 12-20 90+AGE
This information was extracted from the Pediatric Emergency Management Guide provided by
the Mary Bridge Children’s Hospital and Health Center, Tacoma, Washington.
NOTES:
Section 4: Page 45
NOTES:
Section 4: Page 46

Section 4 - Special Considerations/Lesson 4-2: Geriatrics
OBJECTIVES LEGEND
1=Knowledge
2=Application

At the completion of this lesson, the EMT-Intermediate student will be able to utilize the
assessment findings to formulate and implement the treatment plan for the geriatric patient.
GENERAL
1. Discuss population demographics demonstrating the rise in elderly population in the
U.S. (C-1)
2. Discuss society's view of aging and the social, financial, and ethical issues facing the
elderly. (C-1)
3. Describe the various living environments of elderly patient. (C-1)
4. Assess the local resources available to assist the elderly and create strategies to refer
at risk patients to appropriate community services. (C-3)
5. Discuss issues facing society concerning the elderly. (C-1)
6. Describe local community resources available for referral to the elderly. (C-1)
7. Discuss the expected anatomical and physiological changes as well as common pathology
that accompany the aging process to include the following systems: (C-1)
• Skin
• Sensory
• Cardiovascular
• Respiratory
• Gastrointestinal
• Renal
• Musculoskeletal
• Urological
• Immunologic
8. Discuss common emotional and psychological reactions to aging to include causes and
manifestations. (C-1)
GENERAL PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT-Geriatrics

9. Apply the pathophysiology of multi-system failure to the assessment and management
of medical conditions in the elderly patient. (C-1)
10. Compare the pharmacokinetics of an elderly patient to that of a young adult. (C-2)
11. Discuss the problems with mobility in the elderly. (C-1)
Section 4: Page 48
12. Discuss the implications of problems with sensation, communication and patient
assessment. (C-2)
13. Discuss the problems with continence and elimination and develop communication
strategies to provide psychological support. (C-3)
14. Discuss factors that may complicate the assessment of the elderly patient. (C-1)
15. Describe principles that should be employed when assessing and communicating with
the elderly. (C-1)
16. Compare the assessment of a young patient with that of an elderly patient. (C-3)
17. Discuss common complaints of elderly patients. (C-1)
18. Discuss the impact of polypharmacy and medication non-compliance on patient
assessment and management. (C-1)
19. Discuss drug distribution, metabolism, and excretion in the elderly patient. (C-3)
20. Discuss medication issues of the elderly including polypharmacy, dosing errors and
increased drug sensitivity. (C-1)
21. Discuss the use and effects of commonly prescribed drugs for the elderly patient.
PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Pulmonology

1. Discuss the normal and abnormal changes with age of the pulmonary system. (C-1)
2. Discuss the assessment of the elderly patient with pulmonary complaints related to the
pulmonary complaints. (C-1)
3. Identify the need for intervention and transport of the elderly pulmonary patient. (C-1)
4. Develop and execute a treatment plan and management of the elderly pulmonary
patient. (C-3)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Pneumonia

5. Compare and contrast the pathophysiology of pneumonia in the elderly with that of a
younger adult. (C-3)
6. Discuss the assessment findings common in elderly patients with pneumonia. (C-1)
7. Discuss the management considerations when treating an elderly patient with
pneumonia. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Chronic

Obstructive Pulmonary Diseases
8. Compare and contrast the pathophysiology of chronic obstructive pulmonary diseases
in the elderly with that of a younger adult. (C-1)
9. Discuss the assessment findings common in elderly patients with chronic obstructive
pulmonary diseases. (C-1)
10. Discuss the management/ considerations when treating an elderly patient with chronic
obstructive pulmonary diseases. (C-1, C-3)
Section 4: Page 49
PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Cardiology

11. Discuss the normal and abnormal changes with age of the cardiovascular system. (C-1)
12. Discuss the assessment of the elderly patient with complaints related to the
cardiovascular system. (C-1)
13. Identify the need for intervention and transport of the elderly patient with cardiovascular
complaints. (C-1)
14. Develop and execute a treatment plan and management of the elderly patient with
cardiovascular complaints. (C-2, C-3)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Myocardial

infarction
15. Compare and contrast the pathophysiology of myocardial infarction in the elderly with
that of a younger adult. (C-3)
16. Discuss the assessment findings common in elderly patients with myocardial infarction.
(C-1)
17. Discuss the management/ considerations when treating an elderly patient with
myocardial infarction. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Heart Failure

18. Compare and contrast the pathophysiology of heart failure in the elderly with that of a
19. Discuss the assessment findings common in elderly patients with heart failure. (C-1)
20. Discuss the management/ considerations when treating an elderly patient with heart
failure. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Aneurysms

21. Compare and contrast the pathophysiology of aneurysms in the elderly with that of a
22. Discuss the assessment findings common in elderly patients with aneurysms. (C-1)
aneurysms. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Hypertension

24. Compare and contrast the pathophysiology of hypertension in the elderly with that of a
25. Discuss the assessment findings common in elderly patients with hypertension. (C-1)
hypertension. (C-1)
Section 4: Page 50
PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Neurology

27. Discuss the normal and abnormal changes with age of the nervous system. (C-1)
28. Discuss the assessment of the elderly patient with complaints related to the nervous
system. (C-1)
29. Identify the need for intervention and transport of the patient with complaint related to
the nervous system. (C-1, C-2)
complaints related to the nervous system. (C-2)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Delirium

31. Compare and contrast the pathophysiology of delirium in the elderly with that of a
32. Discuss the assessment findings common in elderly patients with delirium. (C-1)
33. Discuss the management/ considerations when treating an elderly patient with delirium.
(C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Altered Level of

Consciousness
34. Compare and contrast the pathophysiology of states of altered levels of consciousness
in the elderly with that of a younger adult. (C-3)
35. Discuss the assessment findings common in elderly patients with altered levels of
consciousness. (C-1)
36. Discuss the management/ considerations when treating an elderly patient with altered
levels of consciousness. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Alzheimer

Diseases
37. Compare and contrast the pathophysiology of Alzheimer disease in the elderly with that
of a younger adult.
38. Discuss the assessment findings common in elderly patients with Alzheimer disease.
Alzheimer disease.
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Parkinson

Disease
40. Compare and contrast the pathophysiology of Parkinson disease in the elderly with that
of a younger adult. (C-3)
41. Discuss the assessment findings common in elderly patients with Parkinson disease.
(C-1)
Parkinson disease. (C-1)
Section 4: Page 51
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Hypoglycemia

43. Compare and contrast the pathophysiology of hypoglycemia in the elderly with that of a
44. Discuss the assessment findings common in elderly patients with hypoglycemia. (C-1)
hypoglycemia. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Hypothermia

46. Compare and contrast the pathophysiology of Hypothermia in the elderly with that of a
47. Discuss the assessment findings common in elderly patients with Hypothermia. (C-1)
Hypothermia. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Stroke, CVA, TIA

49. Compare and contrast the pathophysiology of a stroke, CVA, TIA in the elderly with that
50. Discuss the assessment findings common in elderly patients with a stroke, CVA, TIA.
(C-1)
51. Discuss the management/ considerations when treating an elderly patient with a stoke,
CVA, TIA. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Dementia

52. Compare and contrast the pathophysiology of Dementia in the elderly with that of a
53. Discuss the assessment findings common in elderly patients with Dementia. (C-1)
Dementia. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Intracranial

Hemorrhage
55. Compare and contrast the pathophysiology of intracranial hemorrhage in the elderly
with that of a younger adult. (C-2, C-3)
56. Discuss the assessment findings common in elderly patients with intracranial
hemorrhage. (C-1)
intracranial hemorrhage. (C-1)
Section 4: Page 52
PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Endocrinology

58. Discuss the normal and abnormal changes with age of the endocrine system. (C-1)
59. Discuss the assessment of the elderly patient with complaints related to the endocrine
system. (C-1)
60. Identify the need for intervention and transport of the patient with endocrine problems.
(C-1, C-2)
endocrine problems. (C-2, C-3)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Diabetes

62. Compare and contrast the pathophysiology of diabetes in the elderly with that of a
younger adult. (C-2, C-3)
63. Discuss the assessment findings common in elderly patients with diabetes. (C-1)
diabetes. (C-1)
PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Gastroenterology

65. Discuss the normal and abnormal changes with age of the gastrointestinal system. (C-1)
gastrointestinal system. (C-1)
67. Identify the need for intervention and transport of the patient with gastrointestinal
complaints. (C-1, C-2)
gastrointestinal problems. (C-2, C-3)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - GI Hemorrhage

69. Compare and contrast the pathophysiology of GI hemorrhage in the elderly with that of
a younger adult. (C-2, C-3)
70. Discuss the assessment findings common in elderly patients with GI hemorrhage. (C-1)
71. Discuss the management/ considerations when treating an elderly patient with GI
hemorrhage. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Bowel

Obstruction
72. Compare and contrast the pathophysiology of bowel obstruction in the elderly with that
73. Discuss the assessment findings common in elderly patients with bowel obstruction.
(C-1)
74. Discuss the management/ considerations when treating an elderly patient with bowel
obstruction. (C-1)
Section 4: Page 53
PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Toxicology

75. Discuss the normal and abnormal changes with age of the toxicology. (C-1)
76. Discuss the assessment of the elderly patient with complaints related to toxicology. (C-1)
77. Identify the need for intervention and transport of the patient with toxicological
problems. (C-1, C-2)
toxicological problems. (C-2, C-3)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Drug toxicity

79. Compare and contrast the pathophysiology of drug toxicity in the elderly with that of a
80. Discuss the assessment findings common in elderly patients with drug toxicity. (C-1)
81. Discuss the management/ considerations when treating an elderly patient with drug
toxicity. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Drug and

alcohol abuse
82. Compare and contrast the pathophysiology of drug and alcohol abuse in the elderly
83. Discuss the assessment findings common in elderly patients with drug and alcohol
abuse. (C-1)
and alcohol abuse. (C-1)
PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Environmental

Considerations
85. Discuss the normal and abnormal changes with age of the thermoregulation. (C-1)
86. Discuss the assessment of the elderly patient with complaints related to
thermoregulation. (C-1)
87. Identify the need for intervention and transport of the patient with environmental
considerations. (C-1, C-2)
environmental considerations. (C-2, C-3)

89. Compare and contrast the pathophysiology of hypothermia in the elderly with that of a
90. Discuss the assessment findings common in elderly patients with hypothermia. (C-1)
hypothermia. (C-1)
Section 4: Page 54
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Hyperthermia

92. Compare and contrast the pathophysiology of hyperthermia in the elderly with that of a
93. Discuss the assessment findings common in elderly patients with hyperthermia. (C-1)
hyperthermia. (C-1)
PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Behavioral/ Psychiatric

Disorders
95. Discuss the normal and abnormal psychiatric changes of aging. (C-1)
96. Discuss the assessment of the elderly patient with psychiatric complaints. (C-1)
97. Identify the need for intervention and transport of the psychiatric patient. (C-1, C-2)
98. Develop and execute a treatment plan and management of the elderly psychiatric
patient. (C-2, C-3)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Depression

99. Compare and contrast the psychiatry of depression in the elderly with that of a younger
adult. (C-2, C-3)
100. Discuss the assessment findings common in depressed elderly patients. (C-1)
101. Discuss the management/ considerations when treating a depressed elderly patient.
(C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Suicide

102. Compare and contrast the psychiatry of suicide in the elderly with that of a younger
adult. (C-2, C-3)
103. Discuss the assessment findings common in suicidal elderly patients. (C-1)
104. Discuss the management/ considerations when treating a suicidal elderly patient. (C-1)
PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Musculoskeletal System

105. Discuss the normal and abnormal changes with age of the musculoskeletal system. (C-
1)
musculoskeletal system. (C-1)
107. Identify the need for intervention and transport of the patient with musculoskeletal
musculoskeletal complaints. (C-2, C-3)
Section 4: Page 55
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Trauma in the

elderly
109. Compare and contrast the pathophysiology of trauma in the elderly with that of a
110. Discuss the assessment findings common in elderly patients with traumatic injuries. (C-
1)
traumatic injures. (C-1)
PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Trauma in the elderly

112. Discuss the assessment of the elderly patient with traumatic injures. (C-1)
113. Identify the need for intervention and transport of the elderly patient with trauma. (C-1,
C-2)
trauma. (C-2, C-3)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Long bone

fractures
115. Compare and contrast the pathophysiology of long bone fractures in the elderly with
that of a younger adult. (C-2, C-3)
116. Discuss the assessment findings common in elderly patients with long bone fractures.
(C-1)
117. Discuss the management/ considerations when treating an elderly patient with long
bone fractures. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Hip fractures

118. Compare and contrast the pathophysiology of hip fractures in the elderly with that of a
119. Discuss the assessment findings common in elderly patients with hip fractures. (C-1)
120. Discuss the management/ considerations when treating an elderly patient with hip
fractures. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Head injuries

121. Compare and contrast the pathophysiology of Head injuries in the elderly with that of a
122. Discuss the assessment findings common in elderly patients with Head injuries. (C-1)
123. Discuss the management/ considerations when treating an elderly patient with Head
injuries. (C-1)
Section 4: Page 56
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Burns

124. Compare and contrast the pathophysiology of Burns in the elderly with that of a
125. Discuss the assessment findings common in elderly patients with Burns. (C-1)
126. Discuss the management/ considerations when treating an elderly patient with Burns.
(C-1)
127. Demonstrate the ability to assess a geriatric patient. (P-2)
128. Demonstrate the ability to adjust the assessment of a geriatric patient. (P-3)
129. Demonstrate and advocate appropriate interaction with the elderly that conveys respect
for their position in life. (A-3)
130. Attend the emotional need for independence in the elderly while simultaneously
attending to their apparent acute dependence. (A-1)
131. Recognize and appreciate the many impediments to physical and emotional well being
in the elderly. (A-2)
NOTES:
Section 4: Page 57
NOTES:
Section 4: Page 58
Presentation
DECLARATIVE
I. Introduction
A. Special population with special needs
B. Epidemiology/demographics
1. Prevalence/“Graying of America” (over 65 years old)
C. Societal issues
1. Society’s view of aging
2. Social issues
a) Isolation
b) Marital status
3. Living environments
a) Independent living
(1) Spousal/family support
(2) Visiting nursing
b) Dependent living
(1) Live in nursing care
(2) Assisted living environments
(3) Nursing homes
4. Financial aspects
5. Ethics
a) Advanced directives
D. Referral Resources
1. National/State
2. Local
II. Pathophysiology, assessment and management
A. Pathophysiology
1. Multi system failure
a) Concurrent disease process
b) Non specific complaints
c) Decreased antibody failure
2. Pharmacology in the elderly
a) Age related pharmacokinetics
(1) Older adults are more sensitive to drugs
(2) Experience prolonged drug effects
(3) Have more adverse reactions
(4) Renal reduction - Increased medication toxicity affecting medication
elimination
Section 4: Page 59
b) Polypharmacy
(1) Many chronic illness
(2) Interactions with over the counter medication
c) Compliance
(1) Multiple dosage regimens
(2) Difficult reading/hearing/understanding directions
3. Problems with mobility and falls
a) Physiological changes
(1) Decreased muscle mass
(2) Decreased depth perception
(3) Loss of bone density
(4) Decreased hip and knee flexion
(5) Decrease in sight acuity and cataracts
b) Physical effects of decreased mobility
(1) Poor nutrition
(2) Difficulty with elimination
(3) Circulation
(4) Incontinence
(5) Predisposes patients to falls and injury
c) Psychological effect of decreased mobility
(1) Loss of independence
(2) Loss of confidence
(3) Feeling "old"
d) Risk factors for falls
(1) History of falls
(2) Dizziness, weakness, vision impaired
(3) Altered gait
(4) CNS problems/decreased mental status
(5) Medications
4. Problems with sensations
a) Problems with seeing
(1) Visual changes begin at age 40 and increase gradually
(2) Effects
(a) Reading
(b) Depth perception
(c) Loss of independence
(d) Limitations
(e) Poor accommodation
(f) Altered color perception
(g) Sensitivity to light and glare
(h) Decreased visual acuity
Section 4: Page 60
(i) Decreased color discrimination

b) Problems with hearing
(1) Not all elderly patient have hearing loss
(2) Overall hearing decreases
(3) Ability to perceive speech
(4) Tinnitus
(5) Meniere's disease
(6) Hearing aids
(a) Increase the ability to communicate
(b) May not restore hearing to normal
c) Problems with speech
(1) Word retrieval
(2) Decrease fluency of speech
(3) Slowed rate of speech
(4) Change in voice quality
d) Skin
(1) Decreased moisture
(2) Loss of elasticity
(3) Thinning of epidermis
(4) Uneven discoloration
(5) Decreased touch and pain sensations
e) Assessment findings specific to the elderly patient
f) Management implications for the elderly patient
(1) Alterations for sensory deficits
B. Assessment of the elderly patient
1. Patience is of utmost importance
2. Geriatric assessment
a) Factors complicating assessment
(1) Multiple diseases/complaints
(2) Absent classical symptoms
(3) Failure to relate symptoms
(4) Sensory alterations
(5) Polypharmacy
(6) Other
b) History
(1) Common medical complaints
(2) Environment assessment
(3) Difficulty in getting adequate history
c) Physical exam
(1) Mental status assessment
Section 4: Page 61
C. Management considerations in for the elderly

paramedics.
3. Circulation
a) Oxygen
b) Contact ALS for additional resources
7. Psychological support/communication strategies
a) Communication strategies
(1) Encourage the patient to express their feelings
(2) Acknowledge nonverbal messages
(3) Avoid questions which are judgment
(4) Confirm what the patient says
(5) Take responsibility for communication breakdowns
(6) Talk clearly facing patient’s face
III. System pathophysiology, assessment and management
A. Pulmonology in the elderly
1. Normal and abnormal changes with age
a) Kyphosis may affect pulmonary function
b) Decrease lung function due to
(1) Chronic exposure to pollutants
(2) Decrease respiratory muscle tone
(3) Changes in alveolar/capillary exchange
(4) Respiratory center changes
c) Physiological problems
(1) decreased cough
(2) Decreased secretion elimination
(3) decreased oxygen uptake
2. Assessment findings specific to the elderly
a) Pneumonia
(1) Leading cause of death in the elderly
b) Pulmonary embolism
(1) Mortality is high due to difficulty in diagnosis
c) Obstructive airway diseases
(1) Combined bronchitis and emphysema in patients with a long history of
smoking
Section 4: Page 62
3. Management implications for the elderly

c) Circulation
direction/control.
(1) Oxygen
g) Psychological support/communications strategies
4. Specific illnesses
a) Pneumonia in the elderly
(1) Assessment findings specific for the elderly patient
(a) Fever
(b) Cough - may be productive
(c) Shortness of breath
(d) Often presents with mental status alterations
(e) May be afebrile
(f) Tachypnea
(2) Management considerations for the elderly patient
(b) Manage life threats
(c) Maintain oxygenation
(d) Must be transported for diagnosis
(e) High rate of hospital admission
b) Chronic Obstructive Pulmonary Disease in the elderly
(a) Obtain history of prior intubation or steroid therapy
(b) Wheezing and prolonged expiratory phase
(c) Breath sounds are unreliable
(c) Circulation
Section 4: Page 63

ILS/AW Technicians following approval by on-line or off-line
(i) Oxygen
(ii) Albuterol - Adult:
(a) Dosage - based upon order from medical direction/control
15 min
(ii) Metered dose inhaler: 1-2 inhalations (90 µg each).
May be repeated every 15 min as needed.
(iii) Albuterol - Pediatric:
(a) Dosage - based upon order from medical direction/control
(iv) Contact ALS for additional resources
(g) Psychological support/communications strategies
c) Pulmonary embolism in the elderly
(a) Dyspnea
(b) Pleuritic chest pain
(c) Cough
(d) Tachypnea
(c) Circulation
(d) Pharmacological
(f) Rapid transport
B. Cardiology in the elderly
a) Arteries become increasingly rigid
b) Decrease peripheral resistance
c) Reduced blood flow to all organs
d) Increased systolic and diastolic pressures
Section 4: Page 64
e) Widened pulse pressure

f) Heart muscle stiffens and slows
g) Increased incidence of postural hypotension
h) Increased atherosclerosis throughout the body
a) History
(1) Cardiovascular fitness
(2) Changes in exercise tolerance
(3) Recent diet history
(4) Medications
(5) Smoking
(6) Breathing difficulty, especially at night
(7) Palpitations, flutter, skipped beats
b) Physical Exam
(1) The heart increases in size
(2) Hypertension and orthostatic hypotension
(3) Dependent edema
(4) Consider checking the blood pressure in both arms
(5) Check pulses in all extremities routinely
(6) Check for dehydration
c) Circulation
direction/control.
(1) Oxygen
(2) Use caution to avoid medication interaction
(3) Proper dosing is very important due to
(a) Less lean body mass
(b) Low fluid reserve
(c) Slow metabolism
(d) Decreased renal and hepatic function
g) Psychological support/communication strategies
Section 4: Page 65
a) Myocardial infarction in the elderly
(a) Chest pain is less common in the elderly
(b) Much greater incidence of silent MI
(c) Dyspnea is the most common sign in patients over 85
(d) Any nonspecific complaints of upper trunk discomfort
(c) Position of comfort
(i) Oxygen
(ii) Nitroglycerin
(a) Dosage - one dose (0.4 mg), repeated in 3-5 minutes if no
relief; BP greater than 100, and authorized by medical
direction/control. Up to a maximum of three doses.
(iii) Administration of IV and when to administer based on local
MPD protocols
(iv) Aspirin (administer if chest pain appears to be of cardiac origin)
and dosage based on local MPD protocols
(a) Initial:
(i) 160 or 325 mg; may use chewable children’s aspirin
which tastes better
(v) Contact ALS for additional resources
(e) Non-phamacological
(i) Monitor vitals
(ii) ECG monitoring is indicated due to increased cardiac disease
(iii) Pulse oximetry
(f) Transport
(i) Indications for rapid transport
(a) Sense of urgency for reperfusion
(b) No relief with medications
(c) Hypotension/hypoperfusion
(3) Support and communications strategies
(a) Explanation for patient, family, significant others
(b) Communications and transfer of data to the physician
b) Heart failure in the elderly
(a) First symptom of left failure is often fatigue
Section 4: Page 66
(b) Two pillow orthopnea

(c) Dyspnea
(d) Hacking cough progressing to productive cough
(e) Dependent edema due to right failure
(f) Nocturia
(g) Anorexia, hepatomegaly, ascites
(c) Sitting position during exam
(i) Oxygen
(ii) Nitroglycerin
(a) Dosage - one dose (0.4 mg), repeated in 3-5 minutes if no
relief; BP greater than 100, and authorized by medical
direction/control. Up to a maximum of three doses.
(iii) Administration of IV based on local MPD protocols
(iv) Contact ALS for additional resources
(e) Non-phamacological
(i) Monitor vitals
(f) Transport sitting up
c) Aneurysm in the elderly
(1) Assessment findings for the elderly patient are similar to younger
patients
(i) Oxygen
(ii) Administration of 2 large bore IVs based on local MPD
protocols
Section 4: Page 67
(d) Non-phamacological
(i) Monitor vitals frequently, at least every 5 minutes
(e) Transport patient very gently in supine position
d) Hypertension in the elderly
(a) Often presents as memory loss
(i) Epistaxis
(ii) Slow tremors
(iii) Nausea and vomiting
(b) Headache
(i) Oxygen
(ii) Administration IV based on local MPD protocols
(d) Non-phamacological
(i) Monitor vitals
(e) Transport patient in sitting position
C. Neurology in the elderly
a) Cognition requires perceptual organs and the brain
b) Cognitive function is not affected by the normal aging process
c) Slight changes in the following are normal
(1) Difficulty with recent memory
(2) Psychomotor slowing
(3) Forgetfulness
(4) Decrease in reaction time
Section 4: Page 68

a) Best if conducted over time
b) Ask family or caretakers for information to determine the progression
c) Focus on the patients
(1) Perceptions
(2) Thinking processes
(3) Communication
d) Provide an environment with minimal distractions
e) Mental status/cognitive functioning exam
(1) Be calm, unhurried
(2) Ask clear, direct questions
(3) Give the patient time to respond
(4) Establish normal patterns of behavior and changes in behavior
(5) Include ability to perform activities of daily living
(6) Look for patters of behavior over time
(7) Assess the patients mood and affective or emotional state
f) Assess for
(1) Weakness
(2) Chronic fatigue
(3) Changes in sleep patterns
(4) Syncope, or near syncope
c) Circulation
direction/control.
(1) Contact ALS for Additional resources
f) Transport consideration
(1) Care for the patient with respect and dignity
a) Delirium
(1) Pathophysiology
(a) Organic brain dysfunction
(b) Possible causes
(i) Tumor
(ii) Metabolic disorder
Section 4: Page 69
(iii) Fever
(iv) Drug reaction
(v) Alcohol intoxication/withdrawal
(a) Acute onset of anxiety
(b) Unable to focus
(c) Unable to think logically or maintain attention
(d) Memory is intact
b) Altered Level of Consciousness
(1) Pathophysiology in the elderly
(a) Many causes
(i) Strokes
(ii) Genetic or viral factors
(iii) Alzheimer's
(iv) Hypoglycemia
(v) Dementia
(vi) Intracranial Hemorrhage
(vii) Hypothermia
(b) Progressive loss of cognitive function
(2) Assessment
(a) Progressive disorientation
(b) Shortened attention span
(c) Aphasia, nonsense talking
(d) Hallucinations
(3) Management implications
(a) Severely limits ability to communicate
c) Alzheimer disease
(1) Pathophysiology
(a) Causes
(2) Assessment
d) Parkinson’s disease
(1) Pathophysiology
(2) Assessment
Section 4: Page 70
e) Intracranial hemorrhage in the elderly

(1) Pathophysiology
(2) Assessment
f) Hypoglycemia
(1) Pathophysiology
(2) Assessment
g) Stroke - Stroke, CVA, TIA
(1) Pathophysiology
(2) Assessment
h) Hypothermia
(1) Pathophysiology
(2) Assessment
i) Dementia
(1) Pathophysiology
(2) Assessment
D. Endocrinology in the elderly
c) Circulation
direction/control.
a) Diabetes in the elderly
(a) Test for neuropathy
(b) Test visual acuity
(c) Blood sugar levels
Section 4: Page 71
(d) Insulin or non-insulin dependent

(e) Food or meal history
(c) Oxygen
(d) Current blood sugar level
(f) Pharmacological - Medications only to be administered by ILS or
(i) Administration of IV based on local MPD protocols
(ii) If Blood sugar less than 60 and altered level of consciousness
is not present, give orange juice with sugar, instant glucose,
food
(iii) If Blood sugar less than 60 with altered level of consciousness,
give 50 ml Dextrose 50% , IV
(iv) Contact ALS for Additional resources
(g) Transport consideration
(i) Care for the patient with respect and dignity
E. Gastroenterology in the elderly
a) Look for indication of malnutrition
b) Hiatus hernia
2. Management implications
c) Circulation
direction/control.
f) Transport consideration
Section 4: Page 72
a) GI hemorrhage in the elderly
(1) Increased risk in elderly
b) Bowel obstruction in the elderly
F. Toxicology in the elderly
1. Pathophysiology/Pharmacokinetics
a) Decreased kidney function alters elimination
b) Increased likelihood of CNS side effects
c) Altered GI absorption
d) Decreased liver blood flow alters metabolism and excretion
2. Specific
a) Alcohol abuse in the elderly
(1) Assessment findings
(a) Often very subtle signs
(b) Small amounts of alcohol can cause intoxication
(c) Mood swings, denial, and hostility
(d) Question family and friends
(e) Confusion
(f) History of falls
(g) Anorexia
(h) Insomnia
(a) Requires identification and referral
b) Drug abuse in the elderly
(1) Assessment findings
(a) Memory changes
(b) Drowsy
(c) Decrease vision/hearing
(d) Orthostatic hypotension
(e) Poor dexterity
(c) Circulation
(e) Pharmacological - Medications only to be administered by ILS or
(i) Administration of IV based on local MPD protocols
(a) If needed, correct volume deficits
Section 4: Page 73
(ii) Contact ALS for Additional resources

(f) Transport consideration
(h) Requires identification and referral
G. Environmental Considerations in the elderly
c) Circulation
direction/control.
a) Hypothermia in the elderly
b) Hyperthermia in the elderly
H. Behavioral/Psychiatric Disorders in the elderly
c) Circulation
direction/control.
4. Specific situations
a) Depression in the elderly
Section 4: Page 74

b) Suicide in the elderly
(c) Circulation
(e) Pharmacological - Medications only to be administered by ILS or
(i) Contact ALS for Additional resources
(f) Transport consideration
I. Musculoskeletal changes with age
a) Bone fractures with mild trauma
c) Circulation
direction/control.
J. Trauma in the elderly
1. Pathophysiology
a) Osteoporosis and muscle weakness increases likelihood of fractures
b) Reduced cardiac reserve decreases the ability to compensate for blood loss
c) Decreased respiratory function increases likelihood of adult respiratory
distress syndrome (ARDS)
Section 4: Page 75
d) Impaired renal function decreases the ability to adapt to fluid shifts

a) Mechanism of injury
(1) Falls
(2) Motor vehicle accidents
(3) Burns
(4) Assault/abuse
(5) Other - syncope, MI, etc. May be underlying cause of trauma
b) Initial level of consciousness very important
c) Blood pressure that is normal, may be hypovolemic
d) Fractures can be hidden due to diminished pain perception
e) Observe scene for clues of abuse and neglect
3. Management
(1) Dentures may need to be removed
(2) Oxygen is very important due to vascular disease
c) Circulation
(1) Fluid administration should be closely monitored for signs/symptoms of
pulmonary edema
d) Other
(1) Prevent hypothermia by keeping patient warm
(2) ECG monitoring is indicated due to increased cardiac disease
e) Transportation consideration
(2) Appropriate facilities
f) Psychological support/communications strategies
4. Specific Injures
a) Orthopedic injuries
(1) Hip fracture is the most common acute orthopedic condition
(2) Elderly are susceptible to stress fractures of femur, pelvis, tibia
(3) Packaging should include bulk, and padding to fill in areas
(4) Kyphosis may require extra padding under the shoulders to maintain
alignment
b) Burns
(1) Increased risk of significant mortality and morbidity due to pre-existing
disease
(2) Skin changes result in increased burn depth
(3) Altered nutrition decrease defense against infection
(4) Fluid important to prevent renal tubular damage
Section 4: Page 76
(5) Assess hydration in initial hours after burn injury by B/P and pulse
c) Head Injury
(1) More serious in the elderly
(2) Brain shrinkage allows brain to move
(3) Subdural hematoma may develop more slowly, sometimes over days or
weeks
(4) Skull fracture due to lower bone density
(5) Poor disc elasticity and bone mass loss should make you protect c-
spine with all head injuries
IV. Medical/legal considerations
Section 4: Page 77
NOTES:
Section 4: Page 78
APPENDICES
Table of Contents
APPENDICES
Appendix A - EMT-Intermediate: Description of the Profession ......................A-1
Appendix B - EMT-Intermediate: Educational Model .........................................B-1
Appendix C - Field Test Program Hours .............................................................C-1
Appendix D - Affective Evaluations .....................................................................D-1
Appendix E - Module and Lesson Objective Summary......................................E-1
Module and Lesson Objective Summary ...........................................................E-3
Specific Lesson Objectives ................................................................................E-5
Section 1 - Preparatory........................................................................................................ E-5
Lesson 1-1: Roles and Responsibilities of the EMT Intermediate ................................. E-5
Lesson 1-2: Medical/Legal Issues and Ethics ................................................................ E-6
Lesson 1-3: Documentation ............................................................................................ E-7
Section 2 - Essentials........................................................................................................... E-8
Lesson 2-1: Overview of Human Systems...................................................................... E-8
Lesson 2-2: Patient Assessment.................................................................................... E-11
Lesson 2-3: Clinical Decision Making ............................................................................ E-17
Lesson 2-4: Airway Management & Ventilation for ILS Technicians Only..................... E-17
Lesson 2-5: Airway Management & Ventilation for Airway Technicians Only ............... E-22
Lesson 2-6: Assessment and Management of Shock .................................................... E-28
Lesson 2-7: Intravenous & Intraosseous Line Placement and Infusion ......................... E-30
Section 3 - Pharmacology and Emergency Care .............................................................. E-31
Lesson 3-1: Pharmacology of Emergency ILS Medications .......................................... E-32
Lesson 3-2: Cardiology .................................................................................................. E-35
Lesson 3-3: Medical ....................................................................................................... E-39
Section 4 - Special Considerations .................................................................................... E-44
Lesson 4-1: Pediatrics .................................................................................................... E-44
Lesson 4-2: Geriatrics .................................................................................................... E-47
APPENDIX F - Minimal Essential Supplies & Equipment...................................F-1
APPENDIX G - EMT-Intermediate Course Evaluation Forms.............................G-1
APPENDIX H - EMT-I Practical Evaluation Guidelines & Skill Sheets...............H-1
APPENDIX I - Trauma Triage Tool - Student Handout........................................I-1
APPENDIX J - Possible Abandonment Situations - Student Handout..............J-1
APPENDIX K - Washington Administrative Code (WAC)
Pertaining to EMT-Intermediate Training Courses ...................................... K-1
Appendix A - EMT-Intermediate: Description of the Profession
Appendix A: EMT-Intermediate: Description of the Profession
Appendix A: Page 2
Description of the Profession
EMT-Intermediate
EMT-Intermediates have fulfilled prescribed requirements by a credentialing agency to
practice the art and science of out-of-hospital medicine in conjunction with medical
direction. Through performance of assessments and providing medical care, their goal
is to prevent and reduce mortality and morbidity due to illness and injury for emergency
patients in the out-of-hospital setting.
EMT-Intermediates possess the knowledge, skills and attitudes consistent with the
expectations of the public and the profession. EMT-Intermediates recognize that they
are an essential component of the continuum of care and serve as a link for emergency
patients to acute care resources.
The primary roles and responsibilities of EMT-Intermediates are to maintain high quality,
out-of-hospital emergency care. Ancillary roles of the EMT-Intermediate may include
public education and health promotion programs as deemed appropriate by the
community.
EMT-Intermediates are responsible and accountable to medical direction, the public,

and their peers. EMT-Intermediates recognize the importance of research. EMT-
Intermediates seek to take part in life-long professional development, peer evaluation,
and assume an active role in professional and community organizations.
Appendix A: Page 3
Appendix A: EMT-Intermediate: Description of the Profession
Appendix A: Page 4
Appendix B - EMT-Intermediate: Educational Model
Appendix B: EMT-Intermediate: Educational Model
Appendix B: Page 2
EMT-INTERMEDIATE: NATIONAL STANDARD CURRICULUM - Washington State

Amended Edition, Revised - April, 2000
DIAGRAM OF EDUCATIONAL MODEL
PREREQUISITE
EMT or EMT-Basic
PREPARATORY
Roles and Responsibilities of the EMT-Intermediate

Clinical/Field Medical/Legal/Ethics Clinical/Field
Documentation
PHARMACOLOGY AND ESSENTIALS SPECIAL CONSIDERATIONS

EMERGENCY CARE
Overview of Human Systems Pediatrics
Pharmacology of Emergency Patient Assessment Geriatrics
Medications Clinical Decision Making
Medication Administration Airway Management & Ventilation - ILS Tech Only
Cardiovascular Emergencies Airway Management & Ventilation - AW or ILS/AW only
Medical Emergencies Assessment and Management of Shock
Intravenous & Intraosseous Line Placement and Infusion
Clinical/Field Clinical/Field
LIFE LONG LEARNING
Continuing Education
Appendix B: Page 3
Appendix B: EMT-Intermediate: Educational Model
Appendix B: Page 4
Appendix C - Field Test Program Hours
Appendix C: EMT-Intermediate: Estimated Program Hours
Appendix C: Page 2
EMT-INTERMEDIATE CURRICULUM - ESTIMATED COURSE HOURS

WASHINGTON STATE AMENDED EDITION - Revised - April, 2000
This Program is Competency Based. Hours may vary.
Practical Lab/
Lesson Topic Didactic Evaluation
Lesson 1-1: EMT-I Roles & Resp. 3 .5
Lesson 1-2: Med./Legal/ Ethics 3 1
Lesson 1-3: Documentation 3 1
Lesson 2-1: Human Systems 6 1
Lesson 2-2: Patient Assessment 9 3
Lesson 2-3: Clinical Decision Making 3 .5
Lesson 2-4: Airway Management and Ventilation - ILS 9 4
Techs only OR OR
Lesson 2-5: Airway Management and Ventilation - AW 9 4
Technicians or ILS/AW Technicians only
Lesson 2-6: Assessment and Management of Shock 4 1
Lesson 2-7: IV & IO Infusion 7 3
Lesson 3-1: Pharmacology and Medication Administration 6 4
Lesson 3-2: Cardiology 6 1
Lesson 3-3: Medical 6 1
Lesson 4-1: Pediatrics 6 1
Lesson 4-2: Geriatrics 6 1
End of Course Evaluations/Examinations
Practical Skill Evaluations during the course AND
Individual Comprehensive End of Course Practical Skill Approx 3
Evaluations as identified in the Appendices
Washington State Written Certification Examination for the Approx 2
appropriate certification level following course completion
Clinical/Field Internships Clinical Field
Clinical Internship requirements
NOTE: It is recommended that some IV insertions and/or ET Varies Varies
intubations are accomplished during the field internship.
Hours may vary. Competency for all skills is determined by
the County Medical Program Director.
Field internship requirements
Note: Hours may vary, competence determined by the Varies Varies
Total Estimated Didactic And Prac Lab/Eval Hours Didactic Only Prac Lab/Evals
103 77 26
Appendix C: Page 3
Appendix C: EMT-Intermediate: Estimated Program Hours
Appendix C: Page 4
Appendix D - Affective Evaluations
Appendix D: Affective Evaluations
Appendix D: Page 2
INSTRUCTIONS FOR AFFECTIVE STUDENT EVALUATIONS

There are two primary purposes of an affective evaluation system: 1) to verify competence
in the affective domain, and 2) to serve as a method to change behavior. Although affective
evaluation can be used to ultimately dismiss a student for unacceptable patterns of
behavior, that is not the primary purpose of these forms. It is also recognized that there is
some behavior that is so serious (abuse of a patient, gross insubordination, illegal activity,
reporting for duty under the influence of drugs or alcohol, etc) that it would result in
immediate dismissal from the educational program.
The two forms included in the EMT-Intermediate: National Standard Curricula were
developed by the Joint Review Committee on Educational Programs for the EMT-
Paramedic. They represent extensive experience in the evaluation of student’s affective
domain. The nature of this type of evaluation makes it impossible to achieve complete
objectivity, but these forms attempt to decrease the subjectivity and document affective
evaluations.
In attempting to change behavior it is necessary to identify, evaluate, and document the
behavior that you want. The eleven affective characteristics that form the basis of this
evaluation system refer to content in the Roles and Responsibilities of the Paramedic unit of
the curriculum. Typically, this information is presented early in the course and serves to
inform the students what type of behavior that is expected of them. It is important that the
instructor is clear about these expectations.
Cognitive and psychomotor objectives are relatively easy to operationalize in behavioral
terms. Unfortunately, the nature of the affective domain makes it practically impossible to
enumerate all of the possible behaviors that represent professional behavior in each of the
eleven areas. For this reason, the instructor should give examples of acceptable and
unacceptable behavior in each of the eleven attributes, but emphasize that these are
examples and do not represent an all inclusive list.
The affective evaluation instruments included in this curriculum take two forms: A
Professional Behavior Evaluation and a Professional Behavior Counseling Record. The
Professional Behavior Evaluation should be completed regularly (i.e. every other week,
once a month, etc.) by faculty and preceptors about each student. It is recommended that
this form be completed by as many people as practically possible and that it becomes part
of the students record. The more independent evaluations of the student, the more reliable
are the results.
The only two options for rating the student on this form are “competent” and “not yet
competent”. For each attribute, a short list of behavioral markers is listed that indicates
what is generally considered a demonstration of competence for entry level paramedics.
This is not an all inclusive list, but serves to help the evaluator in making judgments. Clearly
there are behaviors which warrant a “not yet competent” evaluation that are not listed. Any
ratings of “not yet competent” require explanation in the space provided.
Appendix D: Page 3
Establishing a cut score to use in conjunction with the Professional Behavior Evaluation
instrument is important. A cut score can be established by judgment of the local programs
community of interest. The question the community should ask is, what percent score do
we expect of graduates of our education program to achieve in the affective domain in order
to demonstrate entry level competency for a (first month, second semester, graduate, etc.)
level student?
When the cut score judgment is made on acceptability or deviation of competent behavior
for each characteristic a percent score can be achieved. For example, a student may
received 10 competent checks out of 11 (10 of 11 = 91%), or 5 of 7 (because 4 areas were
not evaluated) for a score of 71%. This student may then continue to obtain scores of 91%,
91% 82%, etc and have a term grade of 86% in the affective domain. Each student in the
program would receive an average score. Results of multiple evaluations throughout the
program would indicate if the score set by the community of interest was too high or too low.
When a number of evaluations had evolved adjustments in acceptable score would yield a
standard for the community. This standard coupled with community of interest judgments
based upon graduate student and employer survey feedbacks would identify additional
validity evidence for the cut score each year. A valid cut score based upon years of
investigation could then be used as a determining factor on future participation in the
education program.
For all affective evaluations, the faculty member should focus on patterns of behavior, not
isolated instances that fall outside the students normal performance. For example, a
student who is consistently on time and prepared for class may have demonstrated
competence in time management and should not be penalized for an isolated emergency
that makes him late for one class. On the other hand, if the student is constantly late for
class, they should be counseled and if the behavior continues, rated as “not yet competent”
in time management. Continued behavior may result in disciplinary action.
The second form, the Professional Behavior Counseling form is used to clearly
communicate to the student that their affective performance is unacceptable. This form
should be used during counseling sessions in response to specific incidents (i.e. cheating,
lying, falsification of documentation, disrespect/insubordination, etc.) or patterns of
unacceptable behavior. As noted before, their is some behavior that is so egregious as to
result in immediate disciplinary action or dismissal. In the case of such serious incidents,
thorough documentation is needed to justify the disciplinary action. For less serious
incidents, the Professional Behavior Counseling form can serve as an important tracking
mechanism to verify competence or patterns of uncorrected behavior.
On the Professional Behavior Counseling form, the evaluator checks all of the areas that the
infraction affects in the left hand column (most incidents affect more than one area) and
documents the nature of the incident(s) in the right hand column. Space is provided to
document any follow-up. This should include specific expectations, clearly defined positive
behavior, actions that will be taken if the behavior continues, and dates of future counseling
sessions.
Appendix D: Page 4
Using a combination of these forms helps to enable the program to demonstrate that
graduating students have demonstrated competence in the affective domain. This is
achieved by having many independent evaluations, by different faculty members at different
times, stating that the student was competent. These forms can also be used to help
correct unacceptable behavior. Finally, these forms enable programs to build a strong case
for dismissing students following a repeated pattern of unacceptable behavior. Having
numerous, uncorroborated evaluations by faculty members documenting unacceptable
behavior, and continuation of that behavior after remediation, is usually adequate grounds
for dismissal.
Appendix D: Page 5
Appendix D: Page 6
PROFESSIONAL BEHAVIOR EVALUATION

Student’s Name:________________________________________________________________________
Date of evaluation:______________________________________________________________________
1. INTEGRITY Competent [ ] Not yet competent [ ]
Examples of professional behavior include, but are not limited to: Consistent honesty; being able to be trusted with the property of others;
can be trusted with confidential information; complete and accurate documentation of patient care and learning activities.
2. EMPATHY Competent [ ] Not yet competent [ ]
Examples of professional behavior include, but are not limited to: Showing compassion for others; responding appropriately to the
emotional response of patients and family members; demonstrating respect for others; demonstrating a calm, compassionate, and helpful
demeanor toward those in need; being supportive and reassuring to others.
3. SELF - MOTIVATION Competent [ ] Not yet competent [ ]
Examples of professional behavior include, but are not limited to: Taking initiative to complete assignments; taking initiative to improve
and/or correct behavior; taking on and following through on tasks without constant supervision; showing enthusiasm for learning and
improvement; consistently striving for excellence in all aspects of patient care and professional activities; accepting constructive feedback in
a positive manner; taking advantage of learning opportunities
4. APPEARANCE AND PERSONAL HYGIENE Competent [ ] Not yet competent [ ]
Examples of professional behavior include, but are not limited to: Clothing and uniform is appropriate, neat, clean and well maintained;
good personal hygiene and grooming.
5. SELF - CONFIDENCE Competent [ ] Not yet competent [ ]
Examples of professional behavior include, but are not limited to: Demonstrating the ability to trust personal judgment;
demonstrating an awareness of strengths and limitations; exercises good personal judgment.
6. COMMUNICATIONS Competent [ ] Not yet competent [ ]
Examples of professional behavior include, but are not limited to: Speaking clearly; writing legibly; listening actively; adjusting
communication strategies to various situations
7. TIME MANAGEMENT Competent [ ] Not yet competent [ ]
Examples of professional behavior include, but are not limited to: Consistent punctuality; completing tasks and assignments on time.
8. TEAMWORK AND DIPLOMACY Competent [ ] Not yet competent [ ]
Examples of professional behavior include, but are not limited to: Placing the success of the team above self interest; not undermining the
team; helping and supporting other team members; showing respect for all team members; remaining flexible and open to change;
communicating with others to resolve problems.
9. RESPECT Competent [ ] Not yet competent [ ]
Examples of professional behavior include, but are not limited to: Being polite to others; not using derogatory or demeaning terms; behaving
in a manner that brings credit to the profession.
10. PATIENT ADVOCACY Competent [ ] Not yet competent [ ]
Examples of professional behavior include, but are not limited to: Not allowing personal bias to or feelings to interfere with patient care;
placing the needs of patients above self interest; protecting and respecting patient confidentiality and dignity.
11. CAREFUL DELIVERY OF SERVICE Competent [ ] Not yet competent [ ]
Examples of professional behavior include, but are not limited to: Mastering and refreshing skills; performing complete equipment checks;
demonstrating careful and safe ambulance operations; following policies, procedures, and protocols; following orders.
Appendix D: Page 7
Use the space below to explain any “not yet competent” ratings. When possible, use specific behaviors, and
corrective actions.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_________________________________- Faculty Signature
Appendix D: Page 8

Student’s Name: Janet L.
Date of evaluation: September 1998
1. INTEGRITY Competent [9] Not yet competent [ ]
2. EMPATHY Competent [9] Not yet competent [ ]
3. SELF - MOTIVATION Competent [9] Not yet competent [ ]
4. APPEARANCE AND PERSONAL HYGIENE Competent [9] Not yet competent [ ]
5. SELF - CONFIDENCE Competent [9] Not yet competent [ ]
6. COMMUNICATIONS Competent [ ] Not yet competent [9]
7. TIME MANAGEMENT Competent [ ] Not yet competent [9]
8. TEAMWORK AND DIPLOMACY Competent [9] Not yet competent [ ]
9. RESPECT Competent [9] Not yet competent [ ]
10. PATIENT ADVOCACY Competent [9] Not yet competent [ ]
11. CAREFUL DELIVERY OF SERVICE Competent [9] Not yet competent [ ]
Appendix D: Page 9
corrective actions.
h Janet’s run reports, written case reports, and home work are illegible and disorganized.
She has numerous spelling and grammatical errors. i Janet repeatedly hands in
assignments after due dates. She does not complete clinical time in a organized, organized
manner. She did not report for five scheduled clinical shifts this semester and reported to
medic 6 twice when she was not scheduled. Janet has not completed the required clinical
for this semester.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
John Brown - Faculty Signature
Appendix D: Page 10

Student’s Name: Steve R.
Date of evaluation: December 1999
2. EMPATHY Competent [ ] Not yet competent [9]
5. SELF - CONFIDENCE Competent [ ] Not yet competent [9]
7. TIME MANAGEMENT Competent [9] Not yet competent [ ]
8. TEAMWORK AND DIPLOMACY Competent [ ] Not yet competent [9]
9. RESPECT Competent [ ] Not yet competent [9]
10. PATIENT ADVOCACY Competent [ ] Not yet competent [ ]
11. CAREFUL DELIVERY OF SERVICE Competent [ ] Not yet competent [ ]
Appendix D: Page 11
corrective actions.
#2 Steve is constantly disrupting class with irrelevant questions. He is disrespectful to

guest instructors, classmates and the program.
#5 Steve seems to have an impression that he is better than the others students because
he has more field experience. He is overconfident and overbearing.
#6 Steve has not changed his communication skills despite verbal counseling.
#8 Steve’s disruptions are destructive to the team environment by placing his needs above
those of the group.
#9 Disruptions are disrespectful.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
A. Cox -Faculty Signature
Appendix D: Page 12

Date of evaluation: November 1999
2. EMPATHY Competent [ ] Not yet competent [9]
5. SELF - CONFIDENCE Competent [ ] Not yet competent [9]
7. TIME MANAGEMENT Competent [9] Not yet competent [ ]
8. TEAMWORK AND DIPLOMACY Competent [ ] Not yet competent [9]
9. RESPECT Competent [ ] Not yet competent [9]
10. PATIENT ADVOCACY Competent [9] Not yet competent [ ]
11. CAREFUL DELIVERY OF SERVICE Competent [9] Not yet competent [ ]
Appendix D: Page 13
corrective actions.
#2, 5, 6, 8, & 9 Steve has demonstrated inappropriate classroom behavior by

monopolizing class time, answering questions intended for other students, and making
sarcastic remarks about other students answers. Steve demonstrates a superiority
complex over fellow classmates belittling and has repeatedly belittled their experience, while
boasting and exaggerating about his field experience.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
T. Jones - Faculty Signature
Appendix D: Page 14
PROFESSIONAL BEHAVIOR COUNSELING RECORD
Student’s Name:________________________________________________________________________
Date of counseling:______________________________________________________________________
Date of incident:________________________________________________________________________
_ Reason for Counseling Explanation (use back of form if more space is needed):
Integrity
Empathy
Self - Motivation
Appearance/Personal Hygiene
Self - Confidence
Communications
Time Management
Teamwork and Diplomacy
Respect
Patient Advocacy
Careful delivery of service
Follow-up (include specific expectations, clearly defined positive behavior, actions that will be taken if behavior
continues, dates of future counseling sessions, etc.):
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_________________________________-Faculty signature
I have read this notice and I understand it.
_________________________________-Student signature
_________________________________-Administrative or Medical Director Review
Appendix D: Page 15
Student’s Name: Joe L.

Date of counseling: February 23, 1999
Date of incident: February 21, 1999
Integrity Joe reported to a field rotation 16 minutes late, he
was not wearing (nor
Empathy did he have in his possession) a uniform belt and with
“at least 2 days
Self - Motivation beard growth” according to field supervisor Johnson.
When Joe was
_ Appearance/Personal Hygiene approached regarding this situation he became
argumentative and told
Self - Confidence Mr. Johnson to “... mind your own business.” Joe
was asked to leave.
Communications Others that witnessed this exchange were
Paramedics Davis and
_ Time Management Lawrence.
Teamwork and Diplomacy
_ Respect
Patient Advocacy
• Reviewed clinical Policies and Procedures manual section referring to personal
appearance and hygiene, time management, and respect. I also reviewed the
conduct at clinical rotations with Joe.
• Asked Joe to writ a letter of apology to field supervisor Johnson, and Paramedics Davis
and Lawrence, which he
agreed to do. I informed Joe that any further display of disrespectful behavior will result in
dismissal from the program.
A continued pattern of poor time management and/or poor appearance/personal hygiene
could also result in dismissal.
Appendix D: Page 16
Bill Smith -Faculty signature
Joe L. -Student signature
Dr. Jones -Administrative or Medical Director Review
Appendix D: Page 17

Date of counseling: December 14, 1998
Date of incident: November and December 1999
Integrity This counseling session was in response to the two
Professional Behavior
8 Empathy Evaluations file by Instructors Cox and Jones. They
both indicated that
Self - Motivation Steve has been disruptive in classes (see attached)
Appearance/Personal Hygiene
8 Self - Confidence
8 Communications
Time Management
8 Teamwork and Diplomacy
8 Respect
Patient Advocacy
•Student was advised that his behavior is inappropriate and unacceptable. Continuation of
this behavior will result in dismissal from class.
• Written warning from program director. • Instructors Cox and Jones to complete
Professional Behavior Evaluations bi- weekly throughout next semester
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
M. Travis -Faculty signature

Steve R. -Student signature
Dr. O’Hara -Administrative or Medical Director Review

Appendix D: Page 18
Appendix D: Page 19
Appendix D: Page 20
Appendix E - Module and Lesson Objective Summary
Appendix E: Module and Unit Objective Summary
Appendix E: Page 2
EMT-Intermediate: National Standard Curriculum

Washington State Amended Edition, Revised - April, 2000
Module and Lesson Objective Summary

1 At the completion of this module, the EMT-Intermediate student will understand
the roles and responsibilities of a EMT-Intermediate within an EMS system.
1-1 At the completion of this unit, the EMT-Intermediate student will:
understand his or her roles and responsibilities within an EMS system,
and how these roles and responsibilities differ from other levels of
providers; understand the role of medical direction in the out-of-hospital
environment;
1-2 At the completion of this unit, the EMT-Intermediate will understand the
legal issues that impact decisions made in the out-of-hospital environment;
and value the role that ethics plays in decision making in the out-of-hospital
environment.
1-3 At the completion of this unit, the EMT-Intermediate student will be able to
effectively document the essential elements of patient assessment, care
and transport.
2 At the completion of this module, the EMT-Intermediate student will be able to
apply the basic concepts of anatomy and physiology to the assessment and
management of emergency patients, take a proper history and perform an
advanced physical assessment on an emergency patient, and communicate the
findings to others. They will be able to establish and/ or maintain a patent airway,
oxygenate, and ventilate a patient as well as establish and maintain vascular
access.
2-1 At the completion of this unit, the EMT-Intermediate student will be
understand basic anatomy and physiology and how it relates to the
foundations of medicine.
2-2 At the end of this unit, the EMT-Intermediate student will be able to
integrate the principles of history taking and techniques of physical exam
to perform a patient assessment on an emergency patient.
2-3 At the end of this unit, the EMT-Intermediate student will be able to apply
a process of clinical decision making to use the assessment findings to
help form a field impression.
establish and/ or maintain a patent airway, oxygenate, and ventilate a
patient utilizing a Multi-lumen airway.
establish and/ or maintain a patent airway, oxygenate, and ventilate a
patient utilizing a Multi-lumen airway or an Endotracheal tube.
2-6 At the completion of this unit, the EMT-Intermediate student will be utilize
the assessment findings to formulate a field impression and implement the
treatment plan for the patient with hemorrhage or shock.
safely and precisely access the venous circulation and administer fluids
intraosseously.
Appendix E: Page 3

formulate a field impression and implement the treatment plan for the medical
patient and safely use and administer emergency medications.
understand the basic principles of pharmacology and be able to develop a
drug profile for common emergency medications.
3-2 At the end of this unit, the EMT-Intermediate student will be able to utilize
treatment plan and manage the patient with a cardiac emergency.
3-3 At the end of this unit, the EMT-Intermediate student will be able to utilize
treatment plan for the patient with respiratory emergencies, diabetic
emergency, an allergic or anaphylactic reaction, a toxic exposure, a
neurological emergency, non-traumatic abdominal pain, with an
environmentally-induced or exacerbated emergency, and behavioral
emergencies.
utilize assessment findings to formulate a field impression and implement the
treatment plan for pediatric, and geriatric patients.
utilize assessment findings to formulate a field impression and implement
the treatment plan for a pediatric patient.
use assessment findings to formulate a management plan for the geriatric
patient.
Appendix E: Page 4
Specific Lesson Objectives

1. At the completion of this lesson, the EMT-Intermediate will understand his or her
roles and responsibilities within an EMS system, and how these roles and
responsibilities differ from other levels of providers.
2. Integrate the principles of the Washington State Trauma Triage Procedures into
trauma response situations.
• Medical direction
• Medical Control
• Protocols
• Patient Care Procedures
• Trauma Triage Tool
4. Describe the recognized levels of EMS training/education, leading to
licensure/certification in his or her state. (C-1)
5. Explain EMT-Intermediate recertification requirements in Washington state [Provide
Student Handout on recertification in Washington state . (C-1)
6. Review examples of local protocols. (C-1)
7. Discuss prehospital care as an extension of the physician. (C-1)
8. Describe the relationship between ALS on the scene, the EMT-Intermediate on the
scene, and the EMS physician providing on-line medical direction/control (C-1)
9. Discuss the Washington State Trauma Triage Tool and how it is used to direct
trauma patient. (C-1)
10. Understand the purpose of the Washington State Trauma Triage Tool. (C-1)
11. Understand who developed and approved the Washington State Trauma Triage
Tool. (C-1)
12. Understand the components of the Washington State Trauma Triage Tool. (C-1)
13. Understand regional patient care procedures. (C-1)
14. Understand how to use the Washington State Trauma Triage Tool according to the
regional approved Patient Care Procedures. (C-1)
15. Understand the difference between Regional Patient Care Procedures and Medical
Program Director approved Patient Care Protocols. (C-1)
16. Understand the purpose of trauma wristbands. (C-1)
Appendix E: Page 5
There are no affective objectives in this lesson.
There are no psychomotor objectives in this lesson.
Lesson 1-2: Medical/Legal Issues and Ethics

At the completion of this lesson, the EMT-Intermediate will understand the legal and
ethical issues that impact the decisions made in the out-of-hospital environment
MEDICAL LEGAL
1. Differentiate between the scope of practice and the standard of care for EMT-
Intermediate practice (C-3)
2. Define and describe what constitutes abandonment. (C-1)
3. Define and describe what constitutes Assault. (C-1)
4. Define and describe what constitutes Battery. (C-1)
5. Define and describe what constitutes Abandonment, i.e., when ILS Technician turns
a patient’s care over to an IV Technician. (C-1)
6. Given a scenario, describe appropriate patient management and care techniques in
a refusal of care situation. (C-3)
7. Identify the legal issues involved in the decision not to transport a patient, or to
reduce the level of care being provided during transportation. (C-1)
8. Discuss the responsibilities of the EMT-Intermediate relative to advanced
directives/EMS No-CPR, and withholding or stopping resuscitation efforts (Refer to
existing local protocols). (C-1)
9. Describe the actions that the EMT-Intermediate should take to preserve evidence at
a crime or accident scene. (C-1)
10. Describe the importance of providing accurate documentation (oral and written) in
substantiating an incident. (C-1)
11. Describe the characteristics of a prehospital care report required to make it an
effective patient care record. (C-1)
Appendix E: Page 6

In order to properly document, the EMT-Intermediate shall:
1. Identify and use medical terminology correctly. (C-1)
2. Recite appropriate and accurate medical abbreviations and acronyms. (C-1)
3. Record all pertinent administrative information. (C-1)
4. Describe the information pertinent to agency reimbursement. (C-1)
5. Analyze the documentation for accuracy and completeness, including spelling. (C-3)
6. Identify and eliminate extraneous or nonprofessional information. (C-1)
7. Describe the differences between subjective and objective elements of
8. Evaluate a finished document for errors and omissions. (C-3)
9. Evaluate a finished document for proper use and spelling of abbreviations and
acronyms. (C-3)
10. Advocate the confidential nature of an EMS report. (C-1)
11. Describe the potential consequences of poor documentation. (C-1)
12. Describe the special considerations concerning patient refusal of transport. (C-1)
13. Describe the special considerations concerning mass casualty incident
14. Apply the principles of documentation to computer charting, as this technology
becomes available. (C-3)
15. Identify the pertinent, reportable clinical data of each patient interaction. (C-1)
16. Record the pertinent reportable clinical data appropriately. (C-1)
17. Note and record “pertinent negative” clinical findings. (C-1)
Affective Objectives
18. Assume responsibility for self-assessment of all documentation.
19. Advocate among peers, the relevance and importance of properly completed
documentation.
20. Correct errors and omissions, using proper procedures as defined under local
protocol.
21. Revise documents, when necessary, using locally approved procedures.
22. Resolve the common negative attitudes toward the “task” of documentation.
Psychomotor Objectives
23. Demonstrate the potential consequences of poor documentation. (P-2, P-3)
24. Write legibly. (P-1)
25. Demonstrate consistency in thoroughly attending to each area of the report form. (P-1)
26. Demonstrate consistent narrative format (P-1)
27. Illustrate pertinent patient comments, such as suicide threats, by writing accurate
direct quotes, using quotation marks.(P-1)
Appendix E: Page 7
Lesson 2-1: Overview of Human Systems

At the completion of this lesson, the EMT Intermediate student will be able to use the
principles of anatomy and physiology as a foundation for the clinical practice of out of
hospital emergency medicine.
Organization and General Plan of the Body
1. Review the definition of anatomy & physiology. (C-1)
2. Define homeostasis, and use an example to explain. (C-1)
3. Review and state the anatomical terms for the parts of the body. (C-1)
4. Use proper terminology to describe the location of body parts with respect to one
another. (C-1)
5. Name the body cavities, their membranes, and some organs within each cavity. (C-1)
6. Explain how and why the abdomen is divided into smaller areas. Be able to name
organs in these areas. (C-1)
Tissues and Membranes
7. Describe the general characteristics of each of the four major categories of tissues. (C-1)
8. Describe the functions of the types of epithelial tissues with respect to the organs in
which they are found. (C-1)
9. Describe the functions of the connective tissues, and relate them to the functioning
of the body or a specific organ system. (C-1)
10. Explain the differences, in terms of location and function, among skeletal muscle,
smooth muscle, and cardiac muscle. (C-1)
11. Name some membranes made of connective tissue. (C-1)
The Integumentary System
12. Name the two major layers of the skin and the tissue of which each is made. (C-1)
13. Describe how the arterioles in the dermis respond to heat, cold, and stress. (C-1)
14. Name the tissues that make up the subcutaneous tissue, and describe their
functions. (C-1)
The Skeletal System
1. Describe the functions of the skeleton
2. Explain how bones are classified, and give an example of each type. (C-1)
3. Name the major bones of the human skeleton (Be able to point to each on
diagrams, skeleton models, or yourself). (C-1)
4. Describe the functions of the skull, vertebral column, rib cage, scapula, and pelvic
bone. (C-1)
5. Explain how joints are classified. For each type, give an example, and describe the
movement possible. (C-1)
Appendix E: Page 8
The Muscular System

6. Describe muscle structure in terms of muscle cells, tendons, and bones. (C-1)
7. Describe the structure and function of the muscle system and identify three types of
muscle. (C-1)
8. Learn the major muscles of the body and their functions. (C-1)
The Nervous System
9. Name the divisions of the nervous system and the parts of each, and state the
general functions of the nervous system. (C-1)
10. State the functions of the parts of the brain; be able to locate each part on a
diagram. (C-1)
11. Name the meninges and describe their locations. (C-1)
12. State the locations and functions of cerebrospinal fluid. (C-1)
13. Explain how the sympathetic division of the autonomic nervous system enables the
body to adapt to a stress situation. (C-1)
14. Explain how the parasympathetic division of the autonomic nervous system
promotes normal body functioning in relaxed situations. (C-1)
The Senses
15. Explain the general purpose of sensations. (C-1)
16. Describe the characteristics of sensations. (C-1)
17. Explain referred pain and its importance. (C-1)
18. Explain the importance of baroreceptor. (C-1)
Blood
19. Describe the composition and explain the functions of blood plasma. (C-1)
20. State the function of red blood cells, including the protein and the mineral involved. (C-1)
21. State what platelets are, and explain how they are involved in hemostasis. (C-1)
The Heart
22. Describe the location of the heart and the pericardial membranes. (C-1)
23. Name the chambers of the heart and the vessels that enter or leave each. (C-1)
24. Name the valves of the heart, and explain their functions. (C-1)
25. Describe coronary circulation, and explain its purpose. (C-1)
26. Describe the cardiac cycle. (C-1)
27. Explain stroke volume, cardiac output. (C-3)
The Vascular System

28. Describe the structure of arteries and veins, and relate their structure to function. (C-1)
29. Describe the structure of capillaries, and explain the exchange processes that take
place in capillaries. (C-1)
30. Describe the pathway and purpose of pulmonary circulation. (C-1)
31. Name the branches of the aorta and their distributions. (C-1)
32. Name the major systemic veins, and the parts of the body they drain of blood. (C-1)
33. Describe the modifications of fetal circulation, and explain the purpose of each. (C-1)
34. Define blood pressure. (C-1)
Appendix E: Page 9
35. Explain how the heart and kidneys are involved in the regulation of blood pressure. (C-3)
The Respiratory System
36. State the general function of the respiratory system. (C-1)
37. Describe the structure and functions of the nasal cavities and pharynx. (C-1)
38. Describe the structure of the larynx and explain the speaking mechanism. (C-1)
39. Describe the structure and functions of the trachea and bronchial tree. (C-1)
40. State the locations of the pleural membranes, and explain the functions of serous
fluid. (C-1)
41. Describe the structure of the alveoli and pulmonary capillaries, and explain the
importance of surfactant. (C-1)
42. Name and describe the important air pressures involved in breathing. (C-1)
43. Describe normal inhalation and exhalation and forced exhalation. (C-1)
44. Explain the diffusion of gases in external respiration and internal respiration. (C-1)
45. Describe how oxygen and carbon dioxide are transported in the blood. (C-1)
46. Name the pulmonary volumes and define each. (C-1)
The Digestive System
47. Describe the general functions of the digestive system, and name its major
divisions. (C-1)
48. Describe the structure and functions of the teeth and tongue. (C-1)
49. Describe the location and function of the pharynx and esophagus. (C-1)
50. Describe the location, structure, and function of the stomach, liver, gallbladder,
pancreas, and small intestine. (C-1)
51. Describe the location and functions of the large intestine. (C-1)
52. Describe the functions of the liver. (C-1)
The Urinary System
53. Describe the location and general function of each organ of the urinary system. (C-1)
54. State the general function of the urinary system. (C-1)
Fluid-Electrolyte and Acid-Base Balance
55. Describe the water compartments and the name for the water in each. (C-1)
56. Explain how water moves between compartments. (C-1)
57. Explain the regulation of the intake and output of water. (C-1)
58. Describe the effects of acidosis and alkalosis. (C-1)
None defined
None defined
Appendix E: Page 10
Topic - History Taking

1. Describe the techniques of history taking. (C-1)
2. Describe techniques of establishing a rapport with the patient. (C-1)
3. Describe the importance of using good listening skills during the interview process. (C-1)
4. Describe the use of body language and touch for a means of communication. (C-1)
5. Describe methods to manage communication barriers. (C-1)
6. Describe open-ended questions. (C-1)
7. Describe direct questions. (C-1)
8. Differentiate between the use of open-ended and direct questions in patient
interviewing. (C-3)
9. Describe the components of a S.A.M.P.L.E. patient history. (C-1)
10. Describe history-taking techniques when dealing with sensitive topics. (C-1)
11. Describe special challenges to history taking. (C-1)
• Silence
• Over talkative patients
• Patients with multiple symptoms
• Anxious patients
• Reassurance
• Anger and hostility
• Intoxication
• Crying
• Depression
• Sexually attractive or seductive patients
• Confusing Behaviors or Histories
• Limited communication skills
• Talking with family and friends
12. Describe why patience and repetition may be necessary while taking a patient
S.A.M.P.L.E. history. (C-1)
13. Describe the importance of empathy when obtaining a health history.
14. Describe the importance of confidentiality when obtaining a health history.
Appendix E: Page 11
15. Obtain a S.A.M.P.L.E. history from a simulated patient suffering from an acute
illness or injury.
16. Use the techniques of history taking to collect a complete patient history.
17. Use methods to manage communication barriers in a simulated patient interview.
18. Document the patient history.
19. Interpret the findings of the patient history.
Topic - Techniques of Physical Examination

At the end of this topic, the EMT-Intermediate student will be able to explain the clinical
significance of physical exam findings.
20. Define the following terms: inspection, palpation, and auscultation. (C-1)
21. Describe the techniques of inspection, palpation, percussion, and auscultation. (C-1)
22. Evaluate the importance of a general survey. (C-3)
23. Describe the examination of skin (C-1)
24. Differentiate normal and abnormal findings of the skin assessment. (C-3)
25. Distinguish the importance of abnormal findings of the skin assessment. (C-3)
26. Describe the examination of the head and neck. (C-1)
27. Describe the normal assessment findings of the skull. (C-1)
28. Describe the assessment of temperature. (C-1)
29. Describe the examination of the eyes. (C-1)
30. Distinguish between normal and abnormal assessment findings of the eyes. (C-3)
31. Describe the examination of the ears. (C-1)
32. Describe the examination of the nose. (C-1)
33. Describe the examination of the mouth. (C-1)
34. Describe the examination of the neck. (C-1)
35. Describe the survey of the chest. (C-1)
36. Describe the examination of the posterior chest. (C-1)
37. Differentiate the characteristics of breath sounds. (C-3)
38. Describe the examination of the anterior chest. (C-1)
39. Differentiate normal and abnormal assessment findings of the chest examination. (C-3)
40. Describe the examination of the arterial pulse including rate and rhythm. (C-1)
41. Distinguish normal and abnormal findings of arterial pulse. (C-3)
42. Describe the assessment of the jugular veins. (C-1)
43. Describe special examination techniques of the cardiovascular examination. (C-1)
44. Describe the examination of the abdomen. (C-1)
45. Describe the examination of the extremities. (C-1)
46. Describe the proper sequence of physical examination. (C-1)
Appendix E: Page 12
47. Describe the general guidelines of recording examination information. (C-1)

48. Organize the findings of a patient examination. (C-1)
49. Discuss the considerations of examination of an infant or child. (C-1)
50. Discuss the considerations of examination of a patient with special needs. (C-1)
1. Demonstrate a caring attitude when performing physical examination skills. (A-3)
2. Discuss the importance of a professional appearance and demeanor when
performing physical examination skills. (A-1)
3. Appreciate the limitations of conducting a physical exam in the prehospital
environment. (A-2)
4. Demonstrate the techniques of inspection, palpation, and auscultation. (P-1, 2)
5. Demonstrate the examination of skin(P-1, P-2)
6. Demonstrate the examination of the head and neck. (P-1, 2)
7. Demonstrate the normal assessment findings of the skull. (P-1, 2)
8. Demonstrate the assessment of temperature. (P-1, 2)
9. Demonstrate the examination of the eyes. (P-1, 2)
10. Demonstrate the examination of the ears. (P-1, 2)
11. Demonstrate the examination of the nose. (P-1, 2)
12. Demonstrate the examination of the mouth. (P-1, 2)
13. Demonstrate the examination of the neck. (P-1, 2)
14. Demonstrate the survey of the chest. (P-1, 2)
15. Demonstrate the examination of the posterior chest. (P-1, 2)
16. Demonstrate the examination of the anterior chest. (P-1, 2)
17. Demonstrate the examination of the arterial pulse including rate and rhythm(P-1,2)
18. Demonstrate the assessment of the jugular veins. (P-1, 2)
19. Demonstrate special examination techniques of the cardiovascular examination. (P-1, 2)
20. Demonstrate the examination of the abdomen. (P-1, 2)
21. Demonstrate the examination of the extremities. (P-1, 2)
22. Demonstrate the proper sequence of physical examination. (P-1, 2)
23. Demonstrate the general guidelines of recording examination information. (P-1, 2)
24. Organize the findings of a patient examination. (P-1, 2)
25. Discuss the considerations of examination of an infant or child. (P-1, 2)
26. Discuss the considerations of examination of a patient with special needs. (P-1, 2)
27. Demonstrate the sequence of physical examination. (P-1,2)
28. Demonstrate the guidelines of recording examination information. (P-1,2)
Appendix E: Page 13
Topic - Patient Assessment

At the end of this topic, the EMT-Intermediate student will be able to integrate the
principles of history taking and techniques of physical exam to perform a scene
size-up, initial assessment, focused history and physical exam, detailed physical
exam and an ongoing assessment.
29. Recognize hazards/potential hazards.(C-1)
30. Describe common hazards found at the scene of a trauma and a medical patient.(C-1)
31. Determine hazards found at the scene of a medical or trauma patient. (C-2)
32. Differentiate safe from unsafe scenes.(C-3)
33. Describe methods to making an unsafe scene safe. (C-1)
34. Discuss common mechanisms of injury/nature of illness.(C-1)
35. Predict patterns of injury based on mechanism of injury.(C-2)
36. Compare data regarding mechanism of injury to actual scenes. (C-3)
37. Discuss the reason for identifying the total number of patients at the scene.(C-1)
38. Organize the management of a scene following size-up.(C-3)
39. Explain the reason for identifying the need for additional help or assistance.(C-1)
40. Summarize the reasons for forming a general impression of the patient during the
initial assessment.(C-1)
41. Discuss methods of assessing mental status.(C-1)
42. Differentiate levels of consciousness in the adult, infant and child. (C-3)
43. Differentiate between assessing the altered mental status in the adult, child and
infant patient.(C-3)
44. Discuss methods of assessing the airway in the adult, child and infant patient.(C-1)
45. State reasons for management of the cervical spine once the patient has been
determined to be a trauma patient.(C-1)
46. Analyze a scene to determine if spinal precautions are required. (C-3)
47. Describe methods used for assessing if a patient is breathing.(C-1)
48. Differentiate between a patient with adequate and inadequate minute ventilation. (C-3)
49. Distinguish between methods of assessing breathing in the adult, child and infant
patient.(C-3)
50. Compare the methods of providing airway care to the adult, child and infant patient.(C-3)
51. Describe the methods used to obtain a pulse.(C-1)
52. Differentiate between obtaining a pulse in an adult, child and infant patient.(C-3)
53. Discuss the need for assessing the patient for external bleeding.(C-1)
54. Describe normal and abnormal findings when assessing skin color.(C-1)
55. Describe normal and abnormal findings when assessing skin temperature.(C-1)
56. Describe normal and abnormal findings when assessing skin condition.(C-1)
57. Describe normal and abnormal findings when assessing skin capillary refill in the
infant and child patient.(C-1)
Appendix E: Page 14
58. Explain the reason for prioritizing a patient for care and transport.(C-1)
59. Differentiate patients requiring immediate transport versus those not requiring
immediate transport. (C-3)
60. Describe the evaluation of patient’s perfusion status based on findings in the initial
assessment. (C-1)
61. Determine a patient’s pulse pressure and relate it to the patient’s perfusion status. (C-1)
62. Describe orthostatic vital signs and evaluate their usefulness in assessing a
patient in shock. (C-1)
63. Compare and contrast the relative advantages and disadvantages of capillary refill. (C-3)
64. Apply the techniques of physical examination to the medical patient. (C-1)
65. Describe the unique needs for assessing an individual with a specific chief
complaint with no known prior history.(C-1)
66. Differentiate between the history and physical exam that is performed for
responsive patients with no known prior history and patients responsive with a
known prior history.(C-3)
67. Describe the unique needs for assessing an individual who is unresponsive or has
an altered mental status.(C-1)
68. Differentiate between the assessment that is performed for a patient who is
unresponsive or has an altered mental status and other medical patients requiring
assessment.(C-3)
69. Discuss the reasons for reconsidering the mechanism of injury.(C-1)
70. Define and state the reasons for performing a rapid trauma assessment.(C-1)
71. Recite examples and explain why patients should receive a rapid trauma
assessment.(C-1)
72. Apply the techniques of physical examination to the trauma patient. (C-1)
73. Describe the areas included in the rapid trauma assessment and discuss what
should be evaluated.(C-1)
74. Differentiate cases when the rapid assessment may be altered in order to provide
patient care.(C-3)
75. Discuss the reason for performing a focused history and physical exam.(C-1)
76. Describe when and why a detailed physical examination is necessary. (C-1)
77. Discuss the components of the detailed physical exam in relation, to the
techniques of examination.(C-1)
78. State the areas of the body that are evaluated during the detailed physical exam.(C-1)
79. Explain what additional care should be provided while performing the detailed
physical exam.(C-1)
80. Distinguish between the detailed physical exam that is performed on a trauma
patient and that of the medical patient.(C-3)
81. Differentiate patients requiring a detailed physical exam from those who do not. (C-3)
82. Discuss the reasons for repeating the initial assessment as part of the on-going
assessment.(C-1)
83. Describe the components of the on-going assessment.(C-1)
84. Describe trending of assessment components.(C-1)
Appendix E: Page 15
85. Explain the rationale for crew members to evaluate scene safety prior to entering.(A-2)
86. Serve as a model for others explaining how patient situations affect your
evaluation of mechanism of injury or illness.(A-3)
87. Explain the importance of forming a general impression of the patient.(A-1)
88. Explain the value of performing an initial assessment.(A-2)
89. Demonstrate a caring attitude when performing an initial assessment. (A-3)
90. Attend to the feelings that patients with medical conditions might be experiencing.(A-1)
assessment.(A-1)
94. Explain the rationale for the feelings these patients might be experiencing.(A-3)
95. Demonstrate a caring attitude when performing a detailed physical examination. (A-3)
96. Explain the value of performing an on-going assessment.(A-2)
97. Explain the value of reassessing a patient after interventions. (A-2)
assessment.(A-1)
99. Explain the value of trending assessment components to other health
professionals who assume care of the patient.(A-2)
At the completion of this topic, the EMT-Intermediate will be able to:
100. Observe various scenarios and identify potential hazards. (P-1)
101. Demonstrate the scene-size-up. (P-2)
102. Demonstrate the techniques for assessing mental status.(P-1,2)
103. Demonstrate the techniques for assessing the airway.(P-1,2)
104. Demonstrate the techniques for assessing if the patient is breathing.(P-1,2)
105. Demonstrate the techniques for assessing if the patient has a pulse.(P-1,2)
106. Demonstrate the techniques for assessing the patient for external bleeding.(P-1,2)
107. Demonstrate the techniques for assessing the patient's skin color, temperature,
condition and capillary
108. Demonstrate the ability to prioritize patients.(P-1,2)
109. Using the techniques of examination, demonstrate the assessment of a medical
patient. (P-1,2)
110. Demonstrate the patient care skills that should be used to assist with a patient who
is responsive with no known history.(P-1,2)
Appendix E: Page 16
111. Demonstrate the patient care skills that should be used to assist with a patient who
is unresponsive or has an altered metal status.(P-1,2)
112. Perform a rapid medical assessment. (P-1,2)
113. Perform a focused history and physical exam of the medical patient. (P-1,2)
114. Using the techniques of physical examination demonstrate the assessment of a
trauma patient. (P-1,2)
115. Demonstrate the rapid trauma assessment that should be used to assess a patient
based on mechanism of injury.(P-1,2)
116. Perform a focused history and physical exam on a non-critically injured patient. (P-1,2)
117. Perform a focused history and physical exam on a patient with life-threatening
injuries. (P-1,2)
118. Demonstrate the skills involved in performing the detailed physical exam.(P-1,2)
119. Perform a detailed physical examination. (P-1,2)
120. Demonstrate the skills involved in performing the on-going assessment.(P-1,2)

1. Explain and demonstrate critical thinking skills(C-1, C-3)
2. Explain and demonstrate decision making skills(C-1, C-3)
3. Explain and demonstrate assessment Based Patient Care(C-1, C-3)
Lesson 2-4: Airway Management & Ventilation for ILS Technicians Only

assessment findings to formulate a field impression and implement the management
plan for the patient experiencing an airway or breathing emergency.
3. Explain the differences in the anatomy of the upper and lower airway between an
adult and a pediatric patient. (C-1)
6. Define the partial pressures and list the concentration of gases, which comprise
11. Define:
Appendix E: Page 17
• Hypoxia. (C-1)
• The tongue
• Laryngeal spasm
• Laryngeal edema
• Trauma
• Finger sweep
• Chest thrusts
Appendix E: Page 18

• Soft catheters
• Mouth-to-mouth
• Mouth-to-nose
• Mouth-to-mask
44. Review the advantage of the 2 person method to perform ventilation with the bag-
valve-mask. (C-1)
47. List the steps to perform ventilation with the flow-restricted oxygen-powered
ventilation device (C-1)
48. Describe complications of ventilation with the flow-restricted oxygen-powered
ventilation device. (C-1)
Appendix E: Page 19
• Nasal cannula
• Venturi mask
60. Identify special considerations in airway management and ventilation for the
pediatric patient. (C-1)
61. Identify special considerations in airway management and ventilation for patients
with facial injuries. (C-1)
63. Identify indications for multi-lumen intubation. (C-1)
65. Discuss and understand the use of quantitative measurement of patient
oxygenation and end-tidal CO2. (C-1)
67. List the equipment used to perform insertion of the multi-lumen airway. (C-1)
68. List the steps to insert a multi-lumen airway. (C-1)
69. Describe complications of insertion of a multi-lumen airway. (C-1)
70. Describe extubation of a multi-lumen airway. (C-1)
71. Identify the indications for extubation of a multi-lumen airway. (C-1)
72. Describe the complications of extubation of a multi-lumen airway. (C-1)
73. Explain the rationale for selection of each of the following basic approaches to
74. Explain the rationale for use of the multi-lumen airway for airway management. (A-1)
75. Explain quantitative measurement of patient oxygenation and end-tidal CO2. (A-1)
Appendix E: Page 20
76. Explain the rationale for selection of each of the following approaches to ventilation: (A-1)
• Flow-restricted, oxygen powered ventilation device
1. Perform body substance isolation (BSI) procedures during basic airway
management, advanced airway management, and ventilation. (P-1, P-2)
• Finger sweep
• Chest thrusts
7. Perform suctioning of an advanced airway device by selecting a suction device,
catheter, and technique. (C-3, P-2)
10. Perform mouth-to-mask ventilation (P-1,P-2)
11. Perform ventilation with a bag-valve-mask, including:(P-1,P-2)
• 1 person method
• 2 person method
12. Perform ventilations with a bag-valve-mask with an in-line small-volume nebulizer. (P-1, P-2)
Appendix E: Page 21

17. Perform medication administration with a small-volume nebulizer. (P-1, P-2)
21. Perform extubation of a multi-lumen airway. (P-1, P-2)
Lesson 2-5: Airway Management & Ventilation for Airway Technicians Only

plan for the patient experiencing an airway or breathing emergency.
3. Explain the differences in the anatomy of the upper and lower airway between an
adult and a pediatric patient. (C-1)
6. Define partial pressures and list the concentration of gases, which comprise
11. Define:
• Hypoxia. (C-1)
Appendix E: Page 22

• The tongue
• Laryngeal spasm
• Laryngeal edema
• Trauma
29. Describe the Sellick's (cricoid pressure) maneuver (C-1)
• Finger sweep
• Chest thrusts
Appendix E: Page 23

• Soft catheters
37. Identify techniques of tracheobronchial suctioning in the intubated patient. (C-1)
38. Identify special considerations of tracheobronchial suctioning in the intubated patient. (C-1)
39. Describe indications for tracheobronchial suctioning in the intubated patient. (C-3)
• Mouth-to-mouth
• Mouth-to-nose
• Mouth-to-mask
48. Review the method of mouth-to-mouth ventilation. (C-1)
49. Review the steps of mouth-to-nose ventilation. (C-1)
50. Review the steps of mouth-to-mask method to perform ventilation. (C-1)
51. Review the ventilator mask. (C-1)
52. Review the steps to perform mouth-to-mask ventilation. (C-1)
53. Review complications of mouth-to-mask ventilation. (C-1)
54. Review methods to perform ventilation with the bag-valve-mask, including: (C-1)
• 1 person method
• 2 person method
55. Review the advantage of the 2 person method to perform ventilation with the bag-
valve-mask. (C-1)
56. Review the bag-valve-mask used to perform ventilation. (C-1)
57. Review the steps to perform ventilation with a bag-valve-mask, including: (C-1)
• 1 person method
• 2 person method
Appendix E: Page 24

60. List the steps to perform ventilation with the flow-restricted oxygen-powered
ventilation device (C-1)
61. Describe complications of ventilation with the flow-restricted oxygen-powered
ventilation device. (C-1)
65. Explain safety considerations of oxygen storage and delivery. (C-1)
66. Identify types of oxygen cylinders. (C-1)
67. Identify types of pressure regulators, including: (C-1)
• High-pressure regulator
• Therapy regulator
68. List the steps for delivering oxygen from a cylinder and regulator. (C-1)
69. Identify an oxygen humidifier. (C-1)
• Nasal cannula
• Venturi mask
78. Identify special considerations in airway management and ventilation for the
pediatric patient. (C-1)
79. Identify special considerations in airway management and ventilation for patients
with facial injuries. (C-1)
80. Describe laryngoscopy for foreign body airway obstruction. (C-1)
81. Identify equipment used to retrieve foreign bodies from the upper airway. (C-1)
83. Differentiate endotracheal intubation from other methods of advanced airway
management. (C-3)
84. Describe endotracheal intubation. (C-1)
85. Identify indications for endotracheal intubation. (C-1)
Appendix E: Page 25
86. Identify contraindications for endotracheal intubation. (C-1)

87. Describe general precautions for endotracheal intubation. (C-1)
88. Describe cricoid pressure. (C-1)
89. Describe complications of endotracheal intubation. (C-1)
90. Describe methods of endotracheal intubation in the trauma patient. (C-1)
91. Describe methods of endotracheal intubation in the pediatric patient. (C-1)
92. Discuss appropriate endotracheal intubation equipment for adults, infants and children.(C-1)
93. Identify complications of improper endotracheal intubation procedure in adults, infants
and children. (C-1)
94. Determine when endotracheal intubation is appropriate for a newborn. (C-1)
95. Discuss appropriate endotracheal intubation techniques for a newborn. (C-1)
96. Assess patient improvement due to endotracheal intubation. (C-3)
97. Identify complications related to endotracheal intubation for a newborn. (C-1)
100.Discuss and understand the use of quantitative measurement of patient
oxygenation and end-tidal CO2. (C-1)
101.List the equipment used to perform insertion of the multi-lumen airway. (C-1)
102.List the steps to insert a multi-lumen airway. (C-1)
103.Describe complications of insertion of a multi-lumen airway. (C-1)
104.Describe extubation. (C-1)
105.Identify the indications for extubation. (C-1)
106.Describe the complications of extubation. (C-1)
107.Explain the rationale for selection of each of the following basic approaches to
108.Explain the rationale for selection of each of the following advanced approaches to
• Multi-lumen airway
• Endotracheal intubation
109.Explain quantitative measurement of patient oxygenation and end-tidal CO2. (A-1)
110.Explain the rationale for selection of each of the following approaches to ventilation: (A-1)
• Flow-restricted, oxygen-powered ventilation device
Appendix E: Page 26
1. Perform body substance isolation (BSI) procedures during basic airway
management, advanced airway management, and ventilation. (P-1, P-2)
4. Perform the Sellick's (cricoid pressure) maneuver. (P-1, P-2)
• Finger sweep
• Chest thrusts
7. Perform tracheobronchial suctioning in the intubated patient by selecting a suction
device, catheter, and technique. (C-3, P-2)
10. Perform mouth-to-mask ventilation. (P-1, P-2)
11. Perform ventilation with a bag-valve-mask, including: (P-1, P-2)
• 1 person method
• 2 person method
12. Perform ventilations with a bag-valve-mask with an in-line small-volume nebulizer.(P-1, P-2)
Appendix E: Page 27

20. Perform retrieval of foreign bodies from the upper airway. (P-1, P-2)
21. Describe assessment to confirm correct placement of the endotracheal tube. (P-1, P-2)
22. Perform cricoid pressure during endotracheal intubation. (P-1, P-2)
23. Perform orotracheal intubation. (P-1, P-2)
24. Perform endotracheal intubation in the trauma patient. (P-1, P-2)
25. Perform endotracheal intubation in the pediatric patient. (P-1, P-2)
27. Perform extubation. (P-1, P-2)

assessment findings to formulate a field impression and implement the treatment plan
for the bleeding patient or the patient in shock.
At the conclusion of this lesson, the EMT-Intermediate student will be able to:
GENERAL
1. Describe the epidemiology, including the morbidity/mortality and prevention
strategies, for shock and hemorrhage. (C-1)
2. Discuss the anatomy and physiology of the cardiovascular system. (C-1)
3. Predict shock and hemorrhage based on mechanism of injury. (C-3)
4. Discuss the various types and degrees of shock and hemorrhage. (C-1)
PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Cardiovascular

System
5. Discuss the pathophysiology of hemorrhage and shock. (C-1)
6. Discuss the assessment findings associated with hemorrhage and shock. (C-1)
7. Identify the need for intervention and transport of the patient with hemorrhage or
shock. (C-1)
8. Discuss the treatment plan and management of hemorrhage and shock. (C-1)
Appendix E: Page 28
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT -

Hemorrhage
9. Describe the incidence, morbidity, and mortality of hemorrhage.(C-1)
10. Discuss the management of external hemorrhage.(C-1)
11. Differentiate between the administration rate and amount of IV fluid in a patient with
controlled versus uncontrolled hemorrhage.(C-3)
12. Relate internal hemorrhage to the pathophysiology of compensated and
13. Relate internal hemorrhage to the assessment findings of compensated and
14. Discuss the management of internal hemorrhage.(C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Shock
1. Describe the incidence, morbidity, and mortality of shock.(C-1)
2. Describe the body's physiologic response to changes in perfusion.(C-1)
3. Discuss the assessment findings of hemorrhagic shock.(C-1)
4. Relate pulse pressure changes to perfusion status.(C-3)
5. Relate orthostatic vital sign changes to perfusion status.(C-3)
6. Define compensated and uncompensated hemorrhagic shock.(C-1)
7. Discuss the pathophysiological changes associated with compensated shock.(C-1)
8. Discuss the assessment findings associated with compensated shock.(C-1)
9. Identify the need for intervention and transport of the patient with compensated shock.
10. Discuss the treatment plan and management of compensated shock.(C-1)
11. Discuss the pathophysiological changes associated with uncompensated shock.(C-1)
12. Discuss the assessment findings associated with uncompensated shock.(C-1)
13. Identify the need for intervention and transport of the patient with uncompensated shock.
14. Discuss the treatment plan and management of uncompensated shock.(C-1)
15. Differentiate between compensated and uncompensated shock.(C-3)
16. Relate external hemorrhage to the pathophysiology of compensated and
17. Relate external hemorrhage to the assessment findings of compensated and
18. Differentiate between the administration of fluid in the normotensive, hypotensive,
and profoundly hypotensive patient.(C-3)
19. Discuss the physiologic changes associated with the pneumatic anti-shock garment
(PASG).(C-1)
20. Discuss the indications and contraindications for the application and inflation of the
PASG.(C-1)
INTEGRATION
21. Apply epidemiology to develop prevention strategies for hemorrhage and shock. (C-1)
hemorrhage or shock. (C-1)
Appendix E: Page 29
impression for the patient with hemorrhage or shock. (C-2)
24. Develop, execute and evaluate a treatment plan based on the field impression for
the hemorrhage or shock patient. (C-1)
25. Demonstrate the assessment of a patient with signs and symptoms of hemorrhagic
shock. (P-2)
26. Demonstrate the management of a patient with signs and symptoms of hemorrhagic
shock. (P-2)
27. Demonstrate the assessment of a patient with signs and symptoms of compensated
28. Demonstrate the management of a patient with signs and symptoms of
compensated hemorrhagic shock. (P-2)
29. Demonstrate the assessment of a patient with signs and symptoms of
uncompensated hemorrhagic shock.(P-2)
30. Demonstrate the management of a patient with signs and symptoms of
uncompensated hemorrhagic shock. (P-2)
31. Demonstrate the assessment of a patient with signs and symptoms of external
hemorrhage.(P-2)
32. Demonstrate the management of a patient with signs and symptoms of external
hemorrhage. (P-2)
33. Demonstrate the assessment of a patient with signs and symptoms of internal
hemorrhage.(P-2)
34. Demonstrate the management of a patient with signs and symptoms of internal
hemorrhage. (P-2)
At the end of this lesson, the student will be able to:
1. Define the term intravenous cannulation. (C-1)
2. Describe universal precautions and body substance isolation (BSI) procedures
when performing an intravenous cannulation. (C-1)
4. Differentiate among the different solutions and intravenous cannulation devices
used when administering intravenous cannulations for the management of trauma
and medical emergencies. (C-3)
5. Identify anatomic landmarks utilized in administering intravenous cannulations. (C-1)
6. Correctly locate three appropriate sites for intraosseous needle insertion. (C-1)
7. Describe the equipment needed, indications, contraindications, complications, and
procedures for the preparation and administration intravenous cannulations. (C-1)
Appendix E: Page 30
8. Identify the equipment needed and procedures used for discontinuing an

intravenous cannulation. (C-1)
9. Describe the procedures, the preparation and administration of a fluid challenge.(C-1)
10. Describe on-line and off-line medical direction/control for intravenous cannulation. (C-1)
11. State the indications and contraindications for insertion of an intraosseous line. (C-1)
12. List the necessary equipment for an intraosseous insertion. (C-1)
13. Describe the steps required for intraosseous needle insertion and confirmation of
correct placement. (C-1)
14. Describe the process of securing the intraosseous needle. (C-1)
15. Compare the rate of fluid infusion through a peripheral line versus an intraosseous
line, and describe methods of increasing the rate of infusion through an intraosseous
line. (C-1)
16. Describe the concept of fluid limitation in patients under 100 pounds. (C-1)
17. State the potential complications of intraosseous needle insertion and infusion. (C-1)
18. Differentiate among the different techniques for obtaining a blood sample. (C-3)
19. Identify locations utilized in obtaining a blood sample. (C-1)
principles for obtaining a blood sample. (C-1)
21. Describe and understand the use and testing of blood glucose monitoring devices. (C-1)
25. Perform universal precautions and body substance isolation (BSI) procedures
during medication administration. (P-1, P-2)
26. Perfect clean technique during intravenous cannulation, blood draws and glucose
monitoring. (P-3)
27. Demonstrate preparation and techniques for performing an intravenous cannulation.
(P-1, P-2)
28. Demonstrate the procedures, the preparation and administration of a fluid
challenge.(P-1, P-2)
29. Demonstrate preparation and techniques for performing an intraosseous needle
insertion and confirmation of correct placement. (P-1, P-2)
30. Locate sites utilized in obtaining a blood sample. (P-1, P-2)
31. Demonstrate preparation and techniques for obtaining a blood sample. (P-1, P-2)
32. Demonstrate preparation and techniques for using blood glucose monitoring
devices. (P-1, P-2)
Appendix E: Page 31

1. Discuss the EMT-Intermediate's responsibilities and scope of management
pertinent to the administration of medications, and understand the physiological
effects of narcotics. (C-1)
2. List and differentiate among routes of drug administration. (C-3)
3. Describe mechanisms of drug action. (C-1)
4. Describe factors altering drug responses, predictable drug responses, drug
responses unintentionally producing adverse effects (iatrogenic drug responses),
and unpredictable adverse drug responses pertinent to ILS Medications. (C-1)
5. Differentiate among drug interactions. (C-3)
6. Discuss considerations for storing drugs pertinent to ILS medications. (C-1)
7. List and describe drugs, which the ILS Technician or ILS/Airway Technician may
carry on an ambulance or aid vehicle, and administer according to Washington
• Epinephrine 1:1000 for anaphylaxis, administered by a commercially pre-
loaded measured dose device:
• Classification
• Indications
• Aspirin:
• Classification
• Indications
• Albuterol administered by inhalation:
• Classification
• Indications
Appendix E: Page 32
• Dextrose 50% and 25%:
• Classification
• Indications
• Nitroglycerin administered sublingually and/or spray:
• Classification
• Indications
• Naloxone:
• Classification
• Indications
8. Discuss obtaining a history by identifying classifications of drugs pertinent to ILS
medications. (C-1)
9. Discuss identifying the pathophysiology of a patient's condition by identifying
classifications of drugs pertinent to ILS medications. (C-1)
10. Discuss considerations for administering a drug when combined with a drug the
patient may have taken. (C-1)
11. Review the specific anatomy and physiology pertinent to medication administration. (C-1)
12. Review pharmacology. (C-1)
13. Define specific terminology of medication administration. (C-1)
14. Define specific abbreviations of medication administration. (C-1)
Appendix E: Page 33
15. Discuss applying basic principles of mathematics, to the calculation of problems

associated with medication dosages, pertinent to ILS Technicians. (C-1)
16. Discuss legal aspects affecting medication administration. (C-1)
17. Describe on-line medical direction/control for medication administration. (C-1)
18. Describe off-line medical direction/control for medication administration. (C-1)
19. Discuss the "six rights" of drug administration and correlate these with the principles
of medication administration. (C-1)
21. Describe universal precautions and body substance isolation (BSI) procedures
when administering a medication. (C-1)
22. Differentiate among the different parenteral administration routes for medication,
which the EMT-Intermediate may administer according to Washington
23. Differentiate among the different dosage forms in administering parenteral
24. Identify anatomic landmarks utilized in administering parenteral medications, which
the EMT-Intermediate may administer according to Washington Administrative code
principles for the preparation and administration of parenteral medications, which
the EMT-Intermediate may administer according to Washington Administrative code
26. Differentiate among the different percutaneous administration routes for medication,
administrative code and local MPD protocol. (C-3)
27. Differentiate among the different dosage forms in administering percutaneous
28. Identify anatomic landmarks utilized in administering percutaneous medications,
principles for the preparation and administration of percutaneous medications,
31. Comply with EMT-Intermediate standards of medication administration. (A-1)
Appendix E: Page 34
34. Perfect obtaining a history by identifying classifications of drugs pertinent to ILS

medications. (P-3)
35. Perfect applying mathematical equivalents to calculation of problems associated
with medication dosages. (P-3)
36. Perfect documentation of medication administration. (P-3)
37. Perform universal precautions and body substance isolation (BSI) procedures
during medication administration. (P-1, P-2)
38. Perfect clean technique during medication administration. (P-3)
39. Perform medication administration for all medications, which the EMT-Intermediate
may administer according to Washington Administrative code and local MPD
protocol. (P-1, P-2, P-3)
INTEGRATION
41. Integrate pathophysiological principles of pharmacology with patient assessment. (C-3)
42. Synthesize patient history information and assessment findings to form a field
impression. (C-3)
43. Synthesize a field impression to implement a pharmacologic management plan. (C-3)
44. Synthesize a pharmacologic management plan including medication administration. (C-3)
45. Integrate pathophysiological principles of medication administration with patient
management. (C-3)

plan for the patient experiencing a cardiac emergency.
At the completion to this lesson, the EMT-Intermediate student will be able to:
1. Review the position of the heart within the thoracic cavity (C-1)
2. Describe each of four cardiac chambers (C-1)
3. Review the major structures of the vascular system (C-1)
4. Define cardiac output (C-1)
5. Identify and describe how the heart's pacemaking control, rate, and rhythm are
determined (C-2)
6. Identify and describe the components of the focused history as it relates to the
patient with cardiovascular compromise (C-1)
7. Describe the components of the OPQRST of chest pain assessment (C-1)
8. Describe the epidemiology, morbidity and mortality of Chest Pain, (C-1)
9. Identify the pathophysiology of Chest Pain (C-1)
Appendix E: Page 35
10. List and describe the assessment parameters to be evaluated in a patient with
Chest Pain (C-1)
11. Describe the significant elements of the focused history in a patient with suspected
Chest Pain (C-1, C-2)
12. Identify what is meant by the OPQRST of chest pain assessment (C-1, C-3)
13. List other clinical conditions that may mimic signs and symptoms of coronary artery
disease and Chest Pain (C-1)
14. Differentiate the characteristics of the pain/discomfort occurring in angina pectoris
and acute myocardial infarction. (C-2)
15. Identify the responsibilities associated with management of patient with Chest Pain (C-2)
16. Based on the pathophysiology and clinical evaluation of the patient with chest pain, list
the anticipated clinical problems according to their life-threatening potential (C-2, C-3)
17. Describe the ILS and ILS/Airway medications (02, nitro, aspirin) used in the
management of chest pain and when ALS should be contacted for additional
resources.(C-1, C-3)
18. Define the principle causes and terminology associated with heart failure (C-1)
19. Identify the factors that may precipitate or aggravate heart failure (C-1, C-3)
20. Describe the physiological effects of heart failure (C-2)
21. Define the term "acute pulmonary edema" and describe its relationship to left
ventricular failure (C-1, C-3)
22. List the interventions prescribed for the patient in acute congestive heart failure (C-1, C-2)
23. Define the term "cardiac tamponade" (C-1)
24. List the mechanisms by which cardiac tamponade may be produced by traumatic
and non-traumatic events. (C-1, C-2)
25. Identify the EMT-Intermediate responsibilities associated with management of a
patient with cardiac tamponade in conjunction with Advanced life support and air
ambulance transport (C-2)
26. Describe the incidence, morbidity and mortality of hypertensive crisis (C-1)
27. Define the term "hypertensive crisis" (C-1)
28. Identify the characteristics of patient population at risk for developing hypertensive
crisis (C-1)
29. Identify the progressive vascular changes associate with sustained hypertension(C-1)
30. Describe the clinical features of the patient in hypertensive crisis (C-2, C-3)
31. Rank the clinical problems of patients in hypertensive crisis according to their sense
of urgency (C-3)
32. From the priority of clinical problems identified, state the management
responsibilities for the patient with hypertensive crisis (C-2)
33. Correlate abnormal findings with clinical interpretation of the patient with
34. List the interventions prescribed for the patient in cardiogenic shock (C-1, C-2)
35. Describe the pathophysiology of vascular disorders (C-1)
36. List the traumatic and non-traumatic causes of vascular disorders (C-1)
37. Define the terms "aneurysm" (C-1)
Appendix E: Page 36
38. Identify the peripheral arteries most commonly affected by occlusive disease (C-1)
39. Identify the major factors involved in the pathophysiology of aortic aneurysm (C-1)
40. Recognize the usual order of signs and symptoms that develop following peripheral
artery occlusion (C-2, C-3)
41. Describe the clinical significance of unequal arterial blood pressure readings in the
arms (C-3)
42. Recognize and describe the signs and symptoms of dissecting thoracic or
abdominal aneurysm (C-2, C-3)
43. Describe the significant elements of the patient history in a patient with vascular
disease (C-1, C-2)
44. Identify the hemodynamic effects of vascular disorders (C-1)
45. Identify the complications of vascular disorders (C-1)
46. Identify the responsibilities associated with management of patient with vascular
disorders (C-2)
47. Value the sense of urgency for initial assessment and intervention in the patient with
cardiac compromise (A-3)
48. Based on the pathophysiology and clinical evaluation of the patient with chest pain,
characterize the clinical problems according to their life-threatening potential (A-3)
49. Defend the urgency based on the rank the clinical problems of patients in
hypertensive crisis (A-3)
50. From the priority of clinical problems identified, state the management
responsibilities for the patient with hypertensive crisis (A-3)
51. Based on the pathophysiology and clinical evaluation of the patient with vascular
disorders, characterize the clinical problems according to their life-threatening
potential (A-3)
52. Value and defend the sense of urgency in identifying peripheral vascular occlusion (A-3)
53. Value and defend the sense of urgency in identifying aortic aneurysm (A-3)
56. Distinguish between normal and abnormal heart sounds. P-2
59. Given a list of signs and elements of a patient's history, identify those significant for
Chest Pain (P-2, P-3)
60. Given a list of signs and elements of a patient's history, identify those representative
of heart failure (P-2, P-3)
61. Given the model of a patient with signs and symptoms of heart failure, position the
patient to afford comfort and relief (P-1, P-2)
62. Given a list of signs of cardiac compromise, identify those representative of cardiac
tamponade (P-2, P-3)
Appendix E: Page 37
63. Given a list of signs of cardiac compromise, identify those representative of

hypertensive crisis (P-2, P-3)
64. Given a list of signs of cardiac compromise, identify those representative of
cardiogenic shock (P-2, P-3)
65. Demonstrate how to evaluate major peripheral arterial pulses (P-1)
66. Given a list of signs and elements of a patient's history, identify those representative
of vascular disorders (P-1, P-2, P-3)
INTEGRATION
67. Apply knowledge of the epidemiology of cardiovascular disease to develop
prevention strategies. (C-3)
68. Integrate the pathophysiological principles into the assessment of a patient with
cardiovascular disease. (C-3)
69. Integrate the pathophysiological principles to the assessment of a patient with chest
pain (C-3)
70. Synthesize patient history, assessment findings to form a field impression for the
patient with Chest Pain (C-2, C-3)
the patient with chest pain. (C-2, C-3)
heart failure (C-2, C-3)
impression of the patient with heart failure (C-3)
74. Develop, execute, and evaluate a treatment plan for based on the field impression
for the heart failure patient. (C-2, C-3)
cardiac tamponade. (C-3)
impression of the patient with cardiac tamponade (C-2, C-3)
the patient with cardiac tamponade (C-2, C-3)
impression for OF the patient with hypertensive crisis (C-2, C-3)
the patient with hypertensive crisis (C-2, C-3)
cardiogenic shock (C-2, C-3)
impression of the patient with cardiogenic shock (C-2, C-3)
83. Develop, execute, and evaluate a treatment plan based on the field impression for
the patient with cardiogenic shock (C-2, C-3)
Appendix E: Page 38

vascular disorders (C-3)
85. Synthesize assessment findings and patient history to form a field impression for
the patient with vascular disorders (C-3)
the patient with vascular disorders (C-2, C-3)
Lesson 3-3: Medical

assessment findings to formulate a field impression and implement the treatment plan
for the patient with respiratory, neurological, endocrine, anaphylactic or toxicological
emergencies.
1. Review the function of the structures located in the upper and lower airway. (C-1)
2. Review the physiology of ventilation and respiration. (C-1)
3. Review common pathological events that effect the pulmonary system. (C-1)
4. Review abnormal assessment findings associated with pulmonary diseases and
conditions. (C-1)
5. Review various airway and ventilation techniques used in the management of
pulmonary diseases. (C-1)
6. Review the pharmacological preparations that EMT-Intermediates use for
management of respiratory diseases and conditions. (C-1)
7. Review the use of equipment used during the physical examination of patients with
complaints associated with respiratory diseases and conditions. (C-1)
8. Identify the epidemiology, anatomy, physiology, assessment findings, and
management for the following respiratory diseases and conditions: (C-1)
• COPD
• Bronchial Asthma
• Chronic Bronchitis
• Emphysema
• Pneumonia
• Non Cardiogenic Pulmonary Edema
• Pulmonary Thromboembolism
• Upper Respiratory Infections
• Epiglottitis
• Hyperventilation Syndrome
• Spontaneous pneumothorax
Appendix E: Page 39
The following underlined material is for ILS/Airway (receiving training and

1. Discuss the pathophysiology lung injuries - NOTE: Instruction in the performance
of chest decompression is limited to ILS/Airway Technicians (receiving
training and certification in both ILS and Airway Technician) ONLY. (C-1)
• Tension pneumothorax
• Simple pneumothorax
• Open pneumothorax
• Hemothorax
• Hemopneumothorax
• Pulmonary contusion
2. Discuss the assessment findings associated with lung injuries. . (C-1)
3. Discuss the management of lung injuries. . (C-1)
4. Identify the need for rapid intervention and transport of the patient with lung injuries. (C-1)
5. Discuss the pathophysiology of non-traumatic neurologic emergencies. (C-1)
6. Discuss the assessment findings associated with non-traumatic neurologic
emergencies. (C-1)
7. Identify the need for rapid intervention and the transport of the patient with non-
traumatic emergencies. (C-1)
8. Discuss the management of non-traumatic emergencies. (C-1)
9. Discuss the pathophysiology of coma and altered mental status. (C-1)
10. Discuss the assessment findings associated with coma and altered mental status. (C-1)
11. Discuss the management/treatment plan of coma and altered mental status. (C-1)
12. Describe the ILS and ILS/Airway medications (Naloxone, Dextrose, oral glucose)
used in the management of coma and altered mental status and when ALS should
be contacted. (C-1)
13. Define coma. (C-1)
14. Define altered mental status. (C-1)
15. Discuss the pathophysiology of syncope. (C-1)
16. Discuss the assessment findings associated with syncope. (C-1)
17. Discuss the management/treatment plan of syncope. (C-1)
18. Discuss the pathophysiology of seizures. (C-1)
19. Discuss the assessment findings associated with seizures. (C-1)
20. Discuss the management/treatment plan of a patient presenting with seizures (C-1)
21. Discuss the pathophysiology of CVA. (C-1)
22. Describe the types of CVA (C-1)
23. Discuss the assessment findings associated with CVA. (C-1)
24. Discuss the management/treatment plan of CVA. (C-1)
25. Discuss the pathophysiology of transient ischemic attack (C-1)
26. Discuss the assessment findings associated with transient ischemic attack (C-1)
27. Discuss the management/treatment plan of transient ischemic attack (C-1)
28. Identify the assessment findings of a patient with a diabetic emergency.
29. Discuss the management of diabetic emergencies.
Appendix E: Page 40
30. Identify the assessment findings of a hypoglycemia patient(C-1)

31. Recognize the signs and symptoms of the patient with hypoglycemia. (C-1)
32. Describe the management of a responsive hypoglycemia patient. (C-1)
33. Describe the management of an unresponsive hypoglycemia patient. (C-1)
34. Correlate abnormal findings in assessment with clinical significance in the patient
with hypoglycemia. (C-2, C-3)
35. Describe the ILS and ILS/Airway medications (Naloxone, Dextrose, oral glucose)
used in the management of hypoglycemia and when ALS should be contacted. (C-1)
36. Identify the assessment findings of a hyperglycemic patient. C-1)
37. Recognize the signs and symptoms of the patient with hyperglycemia. C-1)
38. Describe the management of hyperglycemia. C-1)
anaphylaxis. (C-1)
51. Differentiate among the various treatment and pharmacological interventions used
in the management of anaphylaxis. (C-3)
52. Describe the ILS and ILS/Airway medications (epinephrine 1:1000 by a
commercially pre-loaded measured dose device) used in the management of
anaphylaxis and when ALS should be contacted. (C-1)
53. Recognize and differentiate between adult and pediatric doses of epinephrine
1:1000, for the management of anaphylaxis(mg/kg), when using a commercially
pre-loaded measured dose device. (C-1)
54. Review the incidence, morbidity and mortality of toxic emergencies. (C-1)
55. Review the risk factors most predisposing to toxic emergencies. (C-1)
56. Review the anatomy and physiology of the organs and structures related to toxic
emergencies. (C-1)
57. Review the routes of entry of toxic substances into the body. (C-1)
58. Review the role of the Poison Control Center in the United States and in
Washington State. (C-1)
59. Review the toxic substances that are specific to regions. (C-1)
60. Discuss the incidence of drug abuse in the United States. (C-1)
• Substance or drug abuse
Appendix E: Page 41
• Substance or drug dependence

• Tolerance
• Withdrawal
• Addiction
62. Review the pathophysiology of the entry of toxic substances into the body. (C-1)
63. Review the assessment findings associated with toxic substances. (C-1)
64. Review the need for rapid intervention and the transport of the patient with a toxic
substance emergency. (C-1)
65. Review the management of toxic substances. (C-1)
66. Review poisoning by ingestion. (C-1)
67. Review the most common poisoning by ingestion. (C-1)
68. Review the signs and symptoms related to the most common poisoning by ingestion. (C-1)
69. Review the abnormal findings in assessment with the clinical significance in the
patient with the most common poisoning by ingestion. (C-1)
70. Review among the various treatments and pharmacological interventions in the
management of the most common poisoning by ingestion. (C-1)
71. Review the factors affecting the decision to induce vomiting in a patient with
ingested poison. (C-1)
72. Apply the assessment findings to formulate a field impression and implement a
treatment plan for the patient with the most common poisoning by ingestion. (C-2)
73. Review poisoning by inhalation. (C-1)
74. Review the most commonly poisoning by inhalation. (C-1)
75. Review the signs and symptoms related to the most common poisoning by inhalation. (C-1)
patient with the most common poisoning by inhalation. (C-1)
77. Review the various treatments and pharmacological interventions in the
management of the most common poisoning by inhalation. (C-1)
treatment plan for the patient with the most common poisoning by inhalation. (C-2)
79. Review poisoning by injection. (C-1)
80. Review the most commonly poisoning by injection. (C-1)
81. Review the signs and symptoms related to the most common poisoning by injection. (C-1)
patient with the most common poisoning by injection. (C-1)
management of the most common poisoning by injection. (C-1)
treatment plan for the patient with the most common poisoning by injection. (C-2)
85. Review poisoning by surface absorption. (C-1)
86. Review the most commonly poisoning by surface absorption. (C-1)
87. Review the signs and symptoms related to the most common poisoning by surface
absorption. (C-1)
Appendix E: Page 42
patient with the most common poisoning by surface absorption. (C-1)
management of the most common poisoning by surface absorption. (C-1)
plan for the patient with the most common poisoning by surface absorption. (C-2)
91. List the most commonly abused drugs (by both chemical name and street names). (C-1)
92. Recognize the signs and symptoms related to the most common drug abuse. (C-1)
93. Correlate the abnormal findings in assessment with the clinical significance in the
patient with the most common drug abuse. (C-3)
94. Differentiate among the various treatments and pharmacological interventions in the
management of the most common drug abuse. (C-3)
treatment plan for the patient with the most common drug abuse. (C-2)
96. Recognize and value the assessment and treatment of patients with respiratory diseases
97. Indicate appreciation for the critical nature of accurate field impressions of patients
with respiratory diseases and conditions
98. Characterize the feelings of a patient who regains consciousness among strangers. (A-2)
99. Formulate means of conveying empathy to patients whose ability to communicate is
limited by their condition. (A-3)
100.Demonstrate and record pertinent assessment findings associated with pulmonary
diseases and conditions
The following underlined material is for ILS/Airway (receiving training and
101.Demonstrate chest decompression techniques for the management of lung injuries:
- NOTE: Instruction in the performance of chest decompression is limited to
ILS/Airway Technicians (receiving training and certification in both ILS and
Airway Technician) ONLY:
102.Review proper use of airway and ventilation devices
103.Conduct a simulated history and patient assessment, record the findings, and
report appropriate management of patients with pulmonary diseases and conditions
104.Perform an appropriate assessment of a patient with coma or altered mental status. (P-2,3)
105.Appropriately manage a patient with coma or altered mental status, including the
administration of oxygen oral glucose, dextrose 50%, dextrose 25% and naloxone. (P-3)
106.Perform an appropriate assessment of a patient with syncope. (P-2,3)
107.Appropriately manage a patient with syncope. (P-3)
108.Perform an appropriate assessment of a patient with seizures. (P-2,3)
Appendix E: Page 43
109.Appropriately manage a patient with seizures. (P-3)

110.Perform an appropriate assessment of a patient with CVA or TIA. (P-2,3)
111.Appropriately manage a patient with CVA or TIA. (P-3)
INTEGRATION
112.Differentiate between neurological emergencies based on assessment findings.
113.Correlate abnormal assessment findings with the clinical significance in the patient
with neurological complaints
neurological emergencies.
115.Differentiate between endocrine emergencies based on assessment and history.
116.Correlate abnormal findings in the assessment with clinical significance in the
patient with endocrinologic emergencies.
endocrinologic emergency.
118.Integrate the pathophysiological principles of the patient with anaphylaxis
119.Correlate abnormal findings in assessment with the clinical significance in the
patient with anaphylaxis
120.Develop a treatment plan based on field impression in the patient with allergic
reaction and anaphylaxis
121.Correlate abnormal findings in the assessment with the clinical significance in the
patient exposed to a toxic substance (C-2)
122.Develop a patient management plan based on field impression in the patient
exposed to a toxic substance
LESSON TERMINAL INSTRUCTIONAL OBJECTIVE.

assessment findings to formulate a field impression and implement the treatment plan for
the pediatric emergency patient.
1. Identify the growth and development characteristics of infants and children. (C-1)
2. Identify anatomy and physiology characteristics of infants and children. (C-1)
3. Describe techniques for successful evaluation of infants and children. (C-1)
4. Describe techniques for successful treatment of infants and children. (C-1)
5. Identify the common responses of families to acute illness and injury of an infant or
child. (C-1)
6. Describe techniques for successful interaction with families of acutely ill or injured
infants and children. (C-1)
Appendix E: Page 44
7. Describe how infant and child anatomical and physiological features affect patient
management. (C-1)
8. Discuss pediatric patient assessment. (C-1) PLEASE REFERENCE THE
PEDIATRIC ASSESSMENT INFORMATION PROVIDED AT THE END OF THIS
LESSON.
9. Determine appropriate airway adjuncts for infants and children. (C-1)
10. Discuss complications of improper utilization of airway adjuncts with infants and children. (C-1)
11. Discuss appropriate ventilation devices for infants and children. (C-1)
12. Discuss complications of improper utilization of ventilation devices with infants and
children. (C-1)
13. Define respiratory distress. (C-1)
14. Define respiratory failure. (C-1)
15. Differentiate between upper and lower airway obstruction. (C-3)
16. Discuss the common causes of hypoperfusion in infants and children. (C-1)
17. Evaluate the severity of hypoperfusion in infants and children. (C-1)
18. Describe the primary etiologies of altered level of consciousness in infants and
children. (C-1)
19. Discuss the primary etiologies of cardiopulmonary arrest in infants and children. (C-1)
20. Discuss age appropriate vascular access sites for infants and children. (C-1)
21. Discuss the appropriate equipment for vascular access in infants and children. (C-1)
22. Identify complications of vascular access for infants and children. (C-1)
23. Discuss anatomical features of children that predispose or protect them from certain
injuries. (C-1)
24. Discuss fluid management and shock treatment for infant and child trauma patient. (C-1)
25. Describe why critical incident stress debriefing plays a vital role for EMT-
Intermediate’s. (C-1)
26. Discuss the pathophysiology of respiratory distress/failure in infants and children(C-1)
27. Discuss the assessment findings associated with respiratory distress/failure in infants
and children. (C-1)
28. Discuss the management/treatment plan for respiratory distress/failure in infants and
children. (C-1)
29. Discuss the pathophysiology of hypoperfusion in infants and children. (C-1)
30. Discuss the assessment findings associated with hypoperfusion in infants and
children. (C-1)
31. Discuss the management/treatment plan for hypoperfusion in infants and children. (C-1)
32. Discuss the assessment findings associated with seizures in infants and children(C-1)
33. Discuss the management/treatment plan for seizures in infants and children. (C-1)
34. Discuss the assessment findings associated with hypoglycemia in infants and
children. (C-1)
35. Discuss the management/treatment plan for hypoglycemia in infants and children. (C-1)
Appendix E: Page 45
anaphylaxis. (C-1)
48. Differentiate among the various treatment and pharmacological interventions used
in the management of anaphylaxis. (C-3)
49. Describe the ILS and ILS/Airway medications (epinephrine 1:1000 by a commercially pre-
loaded measured dose device) used in the management of anaphylaxis and when ALS
should be contacted. (C-1)
50. Recognize and differentiate between adult and pediatric doses of epinephrine 1:1000, for
the management of anaphylaxis(mg/kg), when using a commercially pre-loaded measured
dose device. (C-1)
51. Discuss the assessment findings associated with head injury in infants and children. (C-1)
52. Discuss the management/treatment plan for head injury in infants and children. (C-1)
53. Discuss the pathophysiology of burns in infants and children. (C-1)
54. Discuss the assessment findings associated with burns in infants and children. (C-1)
55. Discuss the management/treatment plan for burns in infants and children. (C-1)
56. Describe the epidemiology, including the incident, morbidity/mortality, risk factors and
prevention strategies for abuse and neglect in infants and children. (C-1)
57. Discuss the pathophysiology of abuse and neglect in infants and children. (C-1)
58. Discuss the assessment findings associated with abuse and neglect in infants and
children. (C-1)
59. Discuss the management/treatment plan for abuse and neglect in infants and
children. (C-1)
60. Discuss the assessment findings associated with SIDS infants. (C-1)
61. Discuss the management/treatment plan for SIDS in infants. (C-1)
62. Demonstrate the appropriate approach for treating infants and children.
63. Demonstrate appropriate intervention techniques with families of acutely ill or injured
64. Demonstrate an appropriate assessment for different developmental age groups.
65. Evaluate the severity of respiratory distress/failure in infants and children.
66. Demonstrate the techniques/procedures for treating infants and children with
respiratory distress.
Appendix E: Page 46
67. Demonstrate appropriate technique for insertion of peripheral intravenous catheters

for infants and children.
68. Demonstrate appropriate treatment of infants and children requiring advanced airway
and breathing control.
69. Demonstrate appropriate treatment of infants and children with burns.
70. Demonstrate appropriate parent/care giver interviewing techniques for infant and child
death situations.
INTEGRATION
71. Integrate the pathophysiological principles of the patient with anaphylaxis
72. Correlate abnormal findings in assessment with the clinical significance in the
patient with anaphylaxis
73. Develop a treatment plan based on field impression in the patient with allergic
reaction and anaphylaxis

At the completion of this lesson, the EMT-Intermediate student will be able to utilize the
assessment findings to formulate and implement the treatment plan for the geriatric
patient.
GENERAL
1. Discuss population demographics demonstrating the rise in elderly population in
the U.S. (C-1)
2. Discuss society's view of aging and the social, financial, and ethical issues facing
the elderly. (C-1)
3. Describe the various living environments of elderly patient. (C-1)
4. Assess the local resources available to assist the elderly and create strategies to
refer at risk patients to appropriate community services. (C-3)
5. Discuss issues facing society concerning the elderly. (C-1)
6. Describe local community resources available for referral to the elderly. (C-1)
7. Discuss the expected anatomical and physiological changes as well as common
pathology that accompany the aging process to include the following systems: (C-1)
• Skin
• Sensory
• Cardiovascular
• Respiratory
• Gastrointestinal
• Renal
• Musculoskeletal
• Urological
Appendix E: Page 47
• Immunologic
8. Discuss common emotional and psychological reactions to aging to include causes
and manifestations. (C-1)
GENERAL PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Geriatrics
9. Apply the pathophysiology of multi-system failure to the assessment and
management of medical conditions in the elderly patient. (C-1)
10. Compare the pharmacokinetics of an elderly patient to that of a young adult. (C-2)
11. Discuss the problems with mobility in the elderly. (C-1)
12. Discuss the implications of problems with sensation, communication and patient
assessment. (C-2)
13. Discuss the problems with continence and elimination and develop communication
strategies to provide psychological support. (C-3)
14. Discuss factors that may complicate the assessment of the elderly patient. (C-1)
15. Describe principles that should be employed when assessing and communicating
with the elderly. (C-1)
16. Compare the assessment of a young patient with that of an elderly patient. (C-3)
17. Discuss common complaints of elderly patients. (C-1)
18. Discuss the impact of polypharmacy and medication non-compliance on patient
assessment and management. (C-1)
19. Discuss drug distribution, metabolism, and excretion in the elderly patient. (C-3)
20. Discuss medication issues of the elderly including polypharmacy, dosing errors and
increased drug sensitivity. (C-1)
21. Discuss the use and effects of commonly prescribed drugs for the elderly patient.
PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT -Pulmonology
22. Discuss the normal and abnormal changes with age of the pulmonary system. (C-1)
23. Discuss the assessment of the elderly patient with pulmonary complaints related to
the pulmonary complaints. (C-1)
24. Identify the need for intervention and transport of the elderly pulmonary patient. (C-1)
25. Develop and execute a treatment plan and management of the elderly pulmonary
patient. (C-3)
PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT -Pneumonia
26. Compare and contrast the pathophysiology of pneumonia in the elderly with that of
a younger adult. (C-3)
27. Discuss the assessment findings common in elderly patients with pneumonia. (C-1)
28. Discuss the management considerations when treating an elderly patient with
pneumonia. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Chronic
Obstructive Pulmonary Diseases
29. Compare and contrast the pathophysiology of chronic obstructive pulmonary
diseases in the elderly with that of a younger adult. (C-1)
30. Discuss the assessment findings common in elderly patients with chronic
obstructive pulmonary diseases. (C-1)
Appendix E: Page 48
chronic obstructive pulmonary diseases. (C-1, C-3)
PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT -Cardiology
32. Discuss the normal and abnormal changes with age of the cardiovascular system. (C-1)
cardiovascular system. (C-1)
34. Identify the need for intervention and transport of the elderly patient with
cardiovascular complaints. (C-1)
cardiovascular complaints. (C-2, C-3)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Myocardial

infarction
36. Compare and contrast the pathophysiology of myocardial infarction in the elderly
with that of a younger adult. (C-3)
37. Discuss the assessment findings common in elderly patients with myocardial
infarction. (C-1)
myocardial infarction. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Heart
failure
39. Compare and contrast the pathophysiology of heart failure in the elderly with that of
40. Discuss the assessment findings common in elderly patients with heart failure. (C-1)
heart failure. (C-1)
PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT -Aneurysms
42. Compare and contrast the pathophysiology of aneurysms in the elderly with that of
43. Discuss the assessment findings common in elderly patients with aneurysms. (C-1)
aneurysms. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Hypertension
45. Compare and contrast the pathophysiology of hypertension in the elderly with that
46. Discuss the assessment findings common in elderly patients with hypertension. (C-1)
hypertension. (C-1)
PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT -Neurology
48. Discuss the normal and abnormal changes with age of the nervous system. (C-1)
nervous system. (C-1)
Appendix E: Page 49
50. Identify the need for intervention and transport of the patient with complaint related
to the nervous system. (C-1, C-2)
complaints related to the nervous system. (C-2)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT -Delirium
52. Compare and contrast the pathophysiology of delirium in the elderly with that of a
53. Discuss the assessment findings common in elderly patients with delirium. (C-1)
delirium. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT -Altered
Level of Consciousness
55. Compare and contrast the pathophysiology of states of altered levels of
consciousness in the elderly with that of a younger adult. (C-3)
56. Discuss the assessment findings common in elderly patients with altered levels of
consciousness. (C-1)
altered levels of consciousness. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Alzheimer
Diseases
58. Compare and contrast the pathophysiology of Alzheimer disease in the elderly with
that of a younger adult.
59. Discuss the assessment findings common in elderly patients with Alzheimer
disease.
Alzheimer disease.
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Parkinson
Disease
1. Compare and contrast the pathophysiology of Parkinson disease in the elderly with
2. Discuss the assessment findings common in elderly patients with Parkinson disease. (C-1)
Parkinson disease. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Hypoglycemia
4. Compare and contrast the pathophysiology of hypoglycemia in the elderly with that
5. Discuss the assessment findings common in elderly patients with hypoglycemia. (C-1)
hypoglycemia. (C-1)
7. Compare and contrast the pathophysiology of Hypothermia in the elderly with that
8. Discuss the assessment findings common in elderly patients with Hypothermia. (C-1)
Appendix E: Page 50

Hypothermia. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Stroke, CVA, TIA
10. Compare and contrast the pathophysiology of a stroke, CVA, TIA in the elderly with
11. Discuss the assessment findings common in elderly patients with a stroke, CVA, TIA. (C-1)
12. Discuss the management/ considerations when treating an elderly patient with a
stoke, CVA, TIA. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Dementia

13. Compare and contrast the pathophysiology of Dementia in the elderly with that of a
14. Discuss the assessment findings common in elderly patients with Dementia. (C-1)
Dementia. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Intracranial
Hemorrhage
16. Compare and contrast the pathophysiology of intracranial hemorrhage in the
elderly with that of a younger adult. (C-2, C-3)
17. Discuss the assessment findings common in elderly patients with intracranial
hemorrhage. (C-1)
intracranial hemorrhage. (C-1)
PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT -Endocrinology
19. Discuss the normal and abnormal changes with age of the endocrine system. (C-1)
endocrine system. (C-1)
21. Identify the need for intervention and transport of the patient with endocrine
endocrine problems. (C-2, C-3)
PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT -Diabetes
23. Compare and contrast the pathophysiology of diabetes in the elderly with that of a
24. Discuss the assessment findings common in elderly patients with diabetes. (C-1)
diabetes. (C-1)
PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT -Gastroenterology
26. Discuss the normal and abnormal changes with age of the gastrointestinal system. (C-1)
gastrointestinal system. (C-1)
28. Identify the need for intervention and transport of the patient with gastrointestinal
Appendix E: Page 51
gastrointestinal problems. (C-2, C-3)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - GI Hemorrhage
30. Compare and contrast the pathophysiology of GI hemorrhage in the elderly with
that of a younger adult. (C-2, C-3)
31. Discuss the assessment findings common in elderly patients with GI hemorrhage. (C-1)
32. Discuss the management/ considerations when treating an elderly patient with GI
hemorrhage. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Bowel Obstruction
33. Compare and contrast the pathophysiology of bowel obstruction in the elderly with
34. Discuss the assessment findings common in elderly patients with bowel obstruction. (C-1)
bowel obstruction. (C-1)
PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT -Toxicology
36. Discuss the normal and abnormal changes with age of the toxicology. (C-1)
37. Discuss the assessment of the elderly patient with complaints related to toxicology. (C-1)
38. Identify the need for intervention and transport of the patient with toxicological
toxicological problems. (C-2, C-3)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Drug toxicity
40. Compare and contrast the pathophysiology of drug toxicity in the elderly with that of
a younger adult. (C-2, C-3)
41. Discuss the assessment findings common in elderly patients with drug toxicity. (C-1)
toxicity. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Drug and
alcohol abuse
43. Compare and contrast the pathophysiology of drug and alcohol abuse in the elderly
44. Discuss the assessment findings common in elderly patients with drug and alcohol
abuse. (C-1)
and alcohol abuse. (C-1)
PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Environmental
Consideration
46. Discuss the normal and abnormal changes with age of the thermoregulation. (C-1)
47. Discuss the assessment of the elderly patient with complaints related to
thermoregulation. (C-1)
48. Identify the need for intervention and transport of the patient with environmental
considerations. (C-1, C-2)
Appendix E: Page 52
environmental considerations. (C-2, C-3)
Hypothermia
50. Compare and contrast the pathophysiology of hypothermia in the elderly with that
of a younger adult. (C-2, C-3)
51. Discuss the assessment findings common in elderly patients with hypothermia. (C-1)
hypothermia. (C-1)
Hyperthermia
53. Compare and contrast the pathophysiology of hyperthermia in the elderly with that
54. Discuss the assessment findings common in elderly patients with hyperthermia. (C-1)
hyperthermia. (C-1)
PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Behavioral/
Psychiatric Disorders
56. Discuss the normal and abnormal psychiatric changes of aging. (C-1)
57. Discuss the assessment of the elderly patient with psychiatric complaints. (C-1)
58. Identify the need for intervention and transport of the psychiatric patient. (C-1, C-2)
59. Develop and execute a treatment plan and management of the elderly psychiatric
patient. (C-2, C-3)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT -Depression
60. Compare and contrast the psychiatry of depression in the elderly with that of a
61. Discuss the assessment findings common in depressed elderly patients. (C-1)
62. Discuss the management/ considerations when treating a depressed elderly
patient. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT -Suicide
63. Compare and contrast the psychiatry of suicide in the elderly with that of a younger
adult. (C-2, C-3)
64. Discuss the assessment findings common in suicidal elderly patients. (C-1)
65. Discuss the management/ considerations when treating a suicidal elderly patient. (C-1)
PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT -Musculoskeletal System
66. Discuss the normal and abnormal changes with age of the musculoskeletal system. (C-1)
musculoskeletal system. (C-1)
68. Identify the need for intervention and transport of the patient with musculoskeletal
musculoskeletal complaints. (C-2, C-3)
Appendix E: Page 53
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Trauma in

the elderly
1. Compare and contrast the pathophysiology of trauma in the elderly with that of a
2. Discuss the assessment findings common in elderly patients with traumatic injuries. (C-1)
traumatic injures. (C-1)
PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT -Trauma in the elderly
4. Discuss the assessment of the elderly patient with traumatic injures. (C-1)
5. Identify the need for intervention and transport of the elderly patient with trauma. (C-1, C-2)
trauma. (C-2, C-3)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Long bone
fractures
7. Compare and contrast the pathophysiology of long bone fractures in the elderly
8. Discuss the assessment findings common in elderly patients with long bone fractures. (C-1)
9. Discuss the management/ considerations when treating an elderly patient with long
bone fractures. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Hip
fractures
10. Compare and contrast the pathophysiology of hip fractures in the elderly with that
11. Discuss the assessment findings common in elderly patients with hip fractures. (C-1)
12. Discuss the management/ considerations when treating an elderly patient with hip
fractures. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Head
injuries
13. Compare and contrast the pathophysiology of Head injuries in the elderly with that
14. Discuss the assessment findings common in elderly patients with Head injuries. (C-1)
Head injuries. (C-1)
SPECIFIC PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT - Burns
16. Compare and contrast the pathophysiology of Burns in the elderly with that of a
17. Discuss the assessment findings common in elderly patients with Burns. (C-1)
18. Discuss the management/ considerations when treating an elderly patient with Burns. (C-1)
19. Demonstrate the ability to assess a geriatric patient. (P-2)
20. Demonstrate the ability to adjust the assessment of a geriatric patient. (P-3)
Appendix E: Page 54
21. Demonstrate and advocate appropriate interaction with the elderly that conveys
respect for their position in life. (A-3)
22. Attend the emotional need for independence in the elderly while simultaneously
attending to their apparent acute dependence. (A-1)
23. Recognize and appreciate the many impediments to physical and emotional well
being in the elderly. (A-2)
NOTES:
Appendix E: Page 55
NOTES:
Appendix E: Page 56
APPENDIX F - Minimal Essential Supplies & Equipment
Appendix F - Minimal Supplies & Equipment for EMT-Intermediate Training
Appendix F: Page 2
Washington State Department of Health

Minimal Essential Supplies and Equipment Checklist
For EMT-Intermediate Training Programs
EDUCATIONAL AIDS/AUDIO VISUAL RESOURCES:

____ White board/chalk board
____ Flip charts
____ Overhead projector
____ Slide projector
____ VCR with TV/Monitor
____ Movie projector (as necessary)
____ Projector screen (as necessary)
____ Appropriate slide sets, Overhead aids, Films
COURSE DISPOSABLE/REUSABLE SUPPLIES:

____ Moulage kit or similar substitute
____ Cut away or removable outer garments for patient assessment
____ Examination gloves, Masks, Goggles, Gowns
____ Tape, 1/2", 1", 2", 3"
____ Disposable syringes, various sizes to include 10 ml, 20 ml, 35 ml
____ Endotracheal tubes and stylettes, Adult and Pediatric
____ Selection of oropharyngeal airways including all pediatric sizes
____ Multi-Lumen Airways
____ Nasogastric tubes (various sizes)
____ Oxygen connecting tubing
Appendix F: Page 3
COURSE DISPOSABLE/REUSABLE SUPPLIES (CONTINUED):

____ Various supplemental oxygen devices (nasal cannula, non-rebreather mask w/reservoir.
etc.)
____ Lubricant (silicone spray)
____ Conductive medium (gel, pads, etc.)
____ Chest decompression needles
____ Gauze pads (2x2, 4x4, etc.)
____ Gauze roller bandages
____ Elastic roller bandages
____ Multi-Trauma dressings
____ Burn sheets
____ Cravats/triangular bandages
____ Tourniquets
____ Suction tubing
____ Various rigid suction tips
____ French suction catheters (various sizes)
____ Alcohol preps or similar substitute
____ Winged infusion needles
____ IV catheters (various sizes and gauges)
____ IV administration sets
____ Various types and sizes of IV solutions (bottles, bags)
____ Vials & ampules of sterile water (Labeled to simulate IV, IM, and SQ medications)
____ IV push medications (prefilled syringes) (Filled with sterile water and labeled to
simulate IV medications)
Appendix F: Page 4
PATIENT ASSESSMENT/MANAGEMENT EQUIPMENT:

____ Blood pressure cuffs, Adult and Pediatric
____ Stethoscopes
____ Scissors
____ Pen Lights
VENTILATORY MANAGEMENT EQUIPMENT:

____ Intubation Manikins - Adult and Pediatric
____ Laryngoscope handles and blades (straight and curved) - Adult and Pediatric
____ Magill forceps
____ Bag-valve-mask devices (with reservoir)
____ Oxygen cylinders with regulators
____ Portable suction unit
____ Pocket masks
CARDIAC ARREST ASSESSMENT/MANAGEMENT EQUIPMENT:

____ Monitor/defibrillator(s) with charged batteries and spares
____ Defibrillation manikin
____ CPR manikins - Adult, child and Infant
INTRAVENOUS THERAPY AND MEDICATION SKILL EQUIPMENT:

____ IV infusion arm(s) with flashback
____ Rubber tubing tourniquets
____ Approved sharps containers
Appendix F: Page 5
NOTES:
Appendix F: Page 6
APPENDIX G - EMT-Intermediate Course Evaluation Forms
Appendix G - EMT-Intermediate Course Evaluation
Appendix G: Page 2
EMS TRAINING PROGRAM

STUDENT LECTURE EVALUATION FORM
Note: The results of this evaluation does not reflect the quality of the instructor.
Instructor or
Lecturer's Name _________________________________________ Date _______________
EMS course type __________________ Course location ____________________________
Lesson Topic: _______________________________________________________________
Directions: Circle the number that applies. 1) Needs improvement 2) Satisfactory 3) Good 4)
Excellent. If you circled number 1 for any item, include an explanation on the reverse
of this form. You may add any additional comments on the reverse of this form.
DURING TODAY'S LECTURE:
1. The material presented was well prepared/organized 1 2 3 4
2. The material presented was interesting 1 2 3 4
3. The material was clearly presented and easily understood 1 2 3 4
4. The lesson objectives were clearly stated at the beginning

of the class 1 2 3 4
5. The lesson objectives were met during the lecture 1 2 3 4
6. Class participation/questions was encouraged 1 2 3 4
7. All your questions were answered to your satisfaction 1 2 3 4
8. Terms and concepts used were explained adequately 1 2 3 4
9. Objectives listed in the text book closely followed the objectives

in the lesson presented. (Please list any differences on reverse) 1 2 3 4
10. The key points of the lecture were summarized at the end
of the lecture 1 2 3 4
EVALUATION CONTINUED ON REVERSE OF PAGE
Appendix G: Page 3
PLEASE PROVIDE SUGGESTIONS FOR IMPROVEMENT:
PLEASE PROVIDE COMMENTS ON OUTSTANDING AREAS:
PLEASE PROVIDE ANY ADDITIONAL COMMENTS:
Appendix G: Page 4

STUDENT PRACTICAL SKILL LAB EVALUATION FORM
Instructor or
Lecturer's Name ________________________________________ Date _________________
EMS course type ______________ Course location _________________________________
Lesson/Lecture Topic: __________________________________________________________

Directions: Circle the number that applies. 1) Needs improvement 2) Satisfactory 3) Good 4)
Excellent. If you circled number 1 for any item, include an explanation on the
reverse of this form. You may add any additional comments on the reverse of this
form.
DURING TODAY'S PRACTICAL SKILL LAB:
1. The material was clearly presented and easily understood 1 2 3 4

2. The practical skill lab objectives were clearly stated 1 2 3 4
3. The practical skill lab objectives were met 1 2 3 4
4. Clear instructions on how to perform the skill(s) were provided 1 2 3 4
5. The practical skill(s) were demonstrated skill(s) enough for you to
feel confident 1 2 3 4
6. Equipment was provided that was in good working order 1 2 3 4
7. instructor was available to assist every 6 students 1 2 3 4
8. Assistance was provided to students while practicing skill(s) 1 2 3 4
9. Student skill performance was reviewed and feedback was
provided to students 1 2 3 4
10. All skill performance corrections during practice were
consistent with the skill demonstration provided 1 2 3 4
11. The practical lab was long enough for students to practice
and learn the skill(s) presented 1 2 3 4
12. The key points of the practical skill(s) presented were
summarized at the end of the practical skill lab 1 2 3 4
Appendix G: Page 5
Appendix G: Page 6

STUDENT END OF COURSE EVALUATION FORM
Instructor or
Lecturer's Name: ________________________________________ Date __________________
EMS course type ________________ Course location ________________________________
PART 1 DIRECTIONS: Please answer YES or NO. If you answered NO, include an
explanation on the reverse of this form. You may add any additional
comments on the reverse of this form.
COURSE INFORMATION:
1. Have you been previously trained as at an intermediate level (IV or Airway)? YES NO
2. Was the textbook clear, easy to follow and a useful learning tool? YES NO
3. Was there any confusion between what was listed in the text book
for objectives versus the objectives presented during the course? YES NO
4. Were you able to complete reading assignments in the time allowed? YES NO
5. Was the text's workbook helpful to you during the course? YES NO
6. Were course expectations reasonable? YES NO
7. Was the lecture time sufficient to learn the material? YES NO
8. Was the practical skill lab time sufficient to properly learn the skills? YES NO
9. Do you feel prepared to assess and identify a patient's needs? YES NO
10. Do you feel competent with your training to provide care in the field? YES NO
11. Were you provided weekly reports regarding your course progress? YES NO
12. Were you prepared for the certification paperwork? YES NO
13. This course used an assessment-based approach. Would more technical
background information have helped you take care of patients? YES NO
14. At the end of the course, were you able to differentiate between
a critical and non-critical patient? YES NO
15. Would you recommend this course to other students? YES NO
Appendix G: Page 7
EVALUATION CONTINUED ON NEXT PAGE
Appendix G: Page 8
PART 2 DIRECTIONS: Please circle the number that applies. 1) Needs improvement 2) Satisfactory 3) Good 4)
Excellent. If you circled number 1 for any item, include an explanation on the reverse of this
form. You may add any additional comments on the reverse of this form.
THE INSTRUCTOR:
1. Clearly stated the course goals/objectives 1 2 3 4

2. Clearly stated the objectives for each lecture/practical skill lab 1 2 3 4
3. Met objectives for each lecture/practical skill lab 1 2 3 4
4. Was knowledgeable of the lecture topics and skill(s) presented 1 2 3 4
5. Clearly presented material and was easily understood 1 2 3 4
6. Was prepared and made good use of class time 1 2 3 4
7. Used appropriate and easy to follow Audio-visual aids 1 2 3 4
8. Taught lesson material in a logical progression 1 2 3 4
9. Made lectures/practical skill labs interesting 1 2 3 4
10. Correlated classroom instruction to actual field application 1 2 3 4
11. Was positive about class/practical skill labs 1 2 3 4
12. Was approachable and willing to listen 1 2 3 4
13. Encouraged class participation/questions 1 2 3 4
14. Answered all your questions to your satisfaction 1 2 3 4
15. Gave organized and frequent skill demonstrations 1 2 3 4
16. Participated in practical skill labs 1 2 3 4
17. Was punctual 1 2 3 4
18. Was available before and after class 1 2 3 4
19. Provided adequate amounts of equipment for practical skill labs 1 2 3 4
20. Provided equipment that was in good working order 1 2 3 4
21. Treated all students fairly and equally 1 2 3 4
Appendix G: Page 9
Appendix G: Page 10

OBSERVER VISITATION EVALUATION FORM
Instructor or
Lecturer's Name: _________________________________________ Date ________________
Lecture/Skill Lab Topic __________________________________________________________
Observers Name: ___________________________ Signature _________________________
Part 1 DIRECTIONS: Please complete this evaluation form for each instructor during each course visit. Please
circle the number that applies. 1) Needs improvement 2) Satisfactory 3) Good 4) Excellent.
If you circled number 1 for any item, include an explanation on the reverse of this form (see
attached guide). You may add any additional comments on the reverse of this form.
THE INSTRUCTOR:
1. Clearly stated only the objectives listed for each lecture/practical lab 1 2 3 4
2. Met but did not exceed the stated objectives for each lecture/
practical lab 1 2 3 4
3. Was knowledgeable in the lecture topic/practical skill(s) 1 2 3 4
4. Clearly presented material and was easily understood 1 2 3 4
5. Was prepared and made good use of class time 1 2 3 4
6. Used appropriate and easy to follow Audio-visual aids 1 2 3 4
7. Taught lesson material in a logical progression 1 2 3 4
8. Made lecture/practical skill lab interesting 1 2 3 4
9. Presented information in various ways to accommodate
information retention, i.e., charts, visuals? 1 2 3 4
10. Correlated classroom instruction to actual field application 1 2 3 4
11. Was positive about class/practical labs 1 2 3 4
12. Encouraged class participation/questions 1 2 3 4
13. Answered students' questions appropriately 1 2 3 4
Appendix G: Page 11
14. Clearly demonstrates skill(s) (several times if necessary) 1 2 3 4

15. Demonstrated skill(s) correctly 1 2 3 4
16. Provided equipment that was in good working order 1 2 3 4
17. Provided sufficient equipment during practical labs 1 2 3 4
18. Provided 1 instructor for every 6 students during practical skill lab 1 2 3 4
19. Closely monitors each students' performance and provides feedback 1 2 3 4
20. Gives the opportunity to practice skill(s) until students are
comfortable and can meet standards 1 2 3 4
21. Was Punctual 1 2 3 4
22. Treated all students fairly and equally 1 2 3 4
PART 2 DIRECTIONS: Please answer YES or NO. If you answered NO, include an explanation below or on the
reverse of this form. You may add any additional comments below or on the reverse of this
form.
CLASS INFORMATION:
1. Did students appear interested/involved in the class? YES NO

2. Did students react positively to assessment-based philosophy? YES NO
3. Did the instructor teach only the objectives stated in the curriculum
for this section? YES NO
4. Were the listed objectives followed exactly? If NO, what was added
or what was omitted? YES NO
5. Did the curriculum outlines match the objectives? If NO, list the differences. YES NO
6. Did the instructor follow the outlines exactly? If NO, indicate
what was added or left out. YES NO
7. Was there enough time to address all the objectives/outlines/materials in the
allotted time? If NO, how did the instructor address this? If there was extra time,
how was it used? YES NO
8. Was there any confusion regarding what was listed in the textbook for
objectives versus what was listed in the curriculum? Indicate in comments
how the instructor addressed the differences, i.e., ignored, let students
figure it out themselves, or made it clear why they were different. YES NO
9. Were "affective" objectives addressed? Indicated how this was accomplished. YES NO
10. Did quizzes and/or exams for the class follow the objectives and
could they be referred to those listed in the curriculum? Provide samples used. YES NO
EVALUATION CONTINUED ON NEXT PAGE
Appendix G: Page 12
Appendix G: Page 13
Appendix G: Page 14

INSTRUCTOR COURSE LESSON EVALUATION FORM
NOTE: Complete one form for each lesson, i.e., 1-1, 1-2, etc.
Instructor's Name ________________________________________ Date ________________
Lesson Number: ______ Lesson Name: ___________________________________________
EMS course type __________________ Course location ______________________________
Directions: Circle the number that applies. 1) Needs improvement 2) Satisfactory 3) Good 4) Excellent. If you
circled number 1 for any item, include an explanation on the reverse of this form. You may add any
additional comments on the reverse of this form.
TODAY'S LECTURE/PRACTICAL SKILL LAB:
1. Provided enough time to clearly present all lesson objectives 1 2 3 4

2. Provided enough time for students to learn the lecture material or
learn and practice the skill(s) 1 2 3 4
3. Contained information necessary for students to be
knowledgeable in the lecture topic/practical skills presented 1 2 3 4
(please explain where content was lacking or excessive)
4. Was logical in its' progression of instruction 1 2 3 4
5. Correlated well with the text book reading assignments 1 2 3 4
6. Correlated well to the field application of the topic 1 2 3 4
7. Kept students interested/involved in the class 1 2 3 4
8. Assessment-based philosophy received a positive reaction
from students 1 2 3 4
9. Assessment-based thinking helped differentiate between
critical/non-critical patients 1 2 3 4
10. Prepared the students to properly manage patients 1 2 3 4
11. Enter the total length of time it took to complete this lesson. _______________ HOUR(S).
Appendix G: Page 15
Appendix G: Page 16

INSTRUCTOR END OF COURSE EVALUATION
FORM
Lead Instructor's Name ____________________________________ Date ________________
THE COURSE:
1. Provided enough time to clearly present all lesson objectives 1 2 3 4

2. Provided enough time for students to learn the lecture
material or learn and practice the skill(s) 1 2 3 4
3. Contained information necessary for students to be
knowledgeable in the lecture topics/practical skills presented 1 2 3 4
(please explain where content was lacking or excessive)
4. Was logical in its' progression of instruction 1 2 3 4
5. Correlated well with the text book reading assignments 1 2 3 4
6. Correlated well to the field application of the topics 1 2 3 4
7. Kept students interested/involved in the course 1 2 3 4
8. Assessment-based philosophy received a positive reaction
from students 1 2 3 4
9. Assessment-based thinking helped differentiate between
critical/non-critical patients 1 2 3 4
10. Assessment-based style provided a satisfactory approach
to patient care 1 2 3 4
11. Prepared the students to properly manage patients 1 2 3 4
12. Enter the total length of time it took to complete this course. ___________ HOUR(S).
Appendix G: Page 17
INDICATE WHAT YOU LIKED/DIDN'T LIKE ABOUT THE EMS TRAINING PROGRAM
CURRICULUM, i.e., STRENGTHS/WEAKNESSES:
Appendix G: Page 18
APPENDIX H – EMT-I Practical Evaluation Guidelines & Skill Sheets
Appendix H - ILS Practical Skill Evaluation Skill Sheets
FLOW CHART OF THE EMT-INTERMEDIATE LIFE SUPPORT COURSE

Step # 1
EMT-I Students must demonstrate proficiency on practical skills identified for each
lesson using practical evaluation skill sheets identified on page H-6. Some skill sheets
are used multiple times throughout the course. (EVALUATION LESSONS MAY BE
COMBINED WITH PRACTICAL SKILL LABS TO MEET THIS REQUIREMENT).
Students must achieve the required score for each skill listed on page H-35, and receive
NO check marks in the Critical Criteria section.

Step # 2
EMT-I Students must complete clinical/field rotations prior to entrance to the
comprehensive end of course evaluation. Information regarding clinical and field
rotations is located on pages H-3 and H-4.
Step # 3
EMT-I Students must complete the INDIVIDUAL COMPREHENSIVE END OF
COURSE PRACTICAL SKILLS EVALUATION using the role play model identified on H-
5, and skill sheets on pages H-29 and H-31. MPD-approved Evaluators must complete
all evaluations.
Step # 4
EMT-I Students: Instructors must issue a CERTIFICATE of COURSE COMPLETION
attesting to student competency for the student to be eligible to take the Washington
State written certification examination. Prior to issuing the certificate, Instructors must
verify the student’s:

2. Successful completion of the clinical/field rotation following the procedures identified
on pages H-3 and H-4.
Step # 5
EMT-I Students: Following receipt of an Instructor-issued Certificate of Course
Completion, the student is eligible to take the Washington State written certification
examination.
H-2
NARRATIVE OF THE EMT-INTERMEDIATE COURSE

Step # 1 - PRACTICAL SKILL EVALUATIONS
The practical skill evaluation sheets provided in this appendix are to be used in conjunction
with the core curriculum and are organized in the order of the corresponding lessons. They
should be copied and provided to each student at the beginning of the training course and
are to be used to document the performance of required skills evaluations throughout the
training course and during the Comprehensive End of Course Evaluation.
Required Practical skill Evaluations
Students must demonstrate proficiency on practical skills identified for each “evaluation lesson”
using the required practical skill evaluation sheets specified for that lesson on page H-6.
Some skill sheets are used multiple times throughout the course. (EVALUATION LESSONS
MAY BE COMBINED WITH PRACTICAL SKILL LABS TO MEET THIS REQUIREMENT).
Individual Practical skill Evaluation Sheets

The individual practical skill evaluation sheets located on pages H-7 through H-27 are to be
used to document the performance of students during course practical skill evaluations. MPD-
approved Evaluators must complete all evaluations. Evaluator names and signatures must
appear on each evaluation. All practical skill evaluations must be successfully completed
before participating in the Comprehensive End of Course Evaluation. Students must achieve
the required score for each skill listed on page H-35, and receive NO check marks in the
Critical Criteria section.
Individual Comprehensive End of Course Evaluation Skill Sheets

The Comprehensive End of Course Evaluation skill sheets located on pages H-29 and H-31
are to be used to document the performance of each student during the Individual
Comprehensive End of Course Evaluation. MPD-approved Evaluators must complete all
evaluations.
EMT-I Course Practical Skills Evaluation & Individual Comprehensive Course

Evaluation Summary Sheet
The Practical Skills Evaluation and Individual Comprehensive Course Evaluation Summary
Sheet located on page H-33 is to be used to document the final results of each student’s
performance following individual practical skill evaluations and the Comprehensive End of
Course Evaluation. The instructor or MPD signature is required on the Practical skill
Evaluation and Comprehensive End Of Course Evaluation Summary Sheet.
Step # 2 - CLINICAL/FIELD ROTATIONS
In addition to the hours of instruction and practical skill evaluations, this course requires
that the student successfully complete patient interactions in a clinical setting. The training
course may utilize emergency departments, clinics or physician offices. The program
director or medical director must establish appropriate relationships with various clinical
sites to assure adequate contact with patients and initiate written agreements with each
clinical/field site.
H-3
ambulance staff.
Clinical/Field Internship requirements

Internship Type IV Techs AW Techs ILS Techs only ILS/AW Techs
only
10 IV insertions 10 ET 10 IV insertions on 10 IV insertions on
Clinical Internship requirements on Humans. At intubations on Humans. At the Humans. At the
NOTE: It is recommended that the option of the Humans. At option of the MPD, 5 option of the MPD, 5
some IV insertions and/or ET MPD, 5 may be the option of may be performed may be performed on
intubations be accomplished performed on the MPD, 5 on training aids. training aids.
during the field internship. training aids. may be 10 ET intubations on
Competency for all skills is performed on Humans. At the
determined by the County Medical Lab skill training aids. Lab skill option of the MPD, 5
Program Director. proficiency proficiency may be performed on
required in: Lab skill required in: training aids.
• IO line proficiency • IO placement Lab skill proficiency
placement required in: • ML-AWs required in:
• ML-AWs • Medication • IO placement
Administration • ML-AWs
• Medication
Administration
Step # 3 - INDIVIDUAL COMPREHENSIVE END OF COURSE EVALUATION

The purpose of the Comprehensive End of Course Evaluation is to combine cognitive
knowledge and practical skills learned during the course to provide emergency care as if
responding to a real field situation. This evaluation is intended to be general rather than
specific in nature to determine if the team has the basic knowledge and skill necessary to
perform adequately during an EMS emergency.
The EMT-I Individual Comprehensive End of Course Evaluation is conducted in an individual

evaluation format using a BLS assistant as necessary to provide emergency care to the
patient.
• Only the individual student will be evaluated, not the BLS assistant. The assistant is provided
to assist the EMT-I with BLS procedures as if they were part of the response team.
H-4
• The Comprehensive End of Course Evaluation should be designed to be a realistic

experience for the students. The instructor is responsible for developing specific medical
and trauma scenarios to be used by the students during the Individual Comprehensive End
of Course Evaluation.
• The scenarios developed will not include any prescribed medications that could be
administered by EMT-Basic assistants. The student and their assistant must perform
appropriate patient care.
• If appropriate care is not provided, remediation and repeat of a station will be necessary.
ROLE PLAY MODEL

Role Play is practical skill performance evaluations from written scenarios. Students may have
the use of an EMT-Basic assistant. Only the individual student will be evaluated, not the EMT-
B assistant. The assistant is provided to assist the EMT-I with BLS procedures as if they were
part of the response team. This method must be used for the Individual Comprehensive End
of Course Evaluation. Role Play is also appropriate for end of lesson evaluations and practical
skill evaluations
SCENARIO DEVELOPMENT
It is the instructor’s responsibility to develop scenarios used in Role Play evaluation. During
the scenario development, skill combinations are encouraged. For example: for the Trauma
evaluation, oxygen, splinting, PASG stabilization, fluid replacement and immobilization could
be combined. For the Medical evaluation, pharmacology elements could be introduced to
include indications, contraindication, dosages, side effects, etc. Scenarios for EMT-
Intermediate evaluations must not include prescribed medications the EMT-B assistant
might assist the patient in administering.
Step # 4 - CERTIFICATE OF COURSE COMPLETION

Instructors must issue a CERTIFICATE OF COURSE COMPLETION attesting to student
competency for the student to be eligible to take the Washington State written certification
examination. Prior to issuing the certificate, Instructors must verify the student’s:
2. Successful completion on the clinical/field rotation following the procedures identified on
pages H-3 and H-4.
The CERTIFICATE OF COURSE COMPLETION MUST include:

• Course approval number (Issued by DOH – Emergency Medical and Trauma Prevention)
• Course location
• Student’s name
• Instructor’s name and signature
• Course completion date
Step # 5 - WASHINGTON STATE WRITTEN CERTIFICATION EXAMINATION

Following receipt of an Instructor issued Certificate of Course Completion; the student is
eligible to take the Washington State written certification examination.
H-5
REQUIRED PRACTICAL SKILL EVALUATIONS

FOR THE EMT-INTERMEDIATE COURSE
Complete those skill evaluations corresponding to the

required lessons for the certification level you are instructing
Lesson LESSON TITLE REQUIRED PRACTICAL

SKILL EVALUATION
Number
SHEETS
2-2 Patient Assessment H-7 & 9
2-4 Airway Mgmt. & Ventilation (ILS Techs ONLY) H-11
2-5 Airway Mgmt. & Ventilation (Airway and H-11 & 13
ILS/Airway Techs ONLY)
2-6 Assessment and Management of Shock H-9
2-7 Intravenous and Intraosseous Line Placement H-15 & 17
3-1 Pharmacology/Medical Administration H-19, 21, 23, 25, and
H-15 & 27 (as a set)
3-2 Cardiology H-7
3-3 Medical H-7
End of Individual Comprehensive End of Course H-29
Course Practical Evaluation MEDICAL
End of Individual Comprehensive End of Course H-31
Course Practical Evaluation TRAUMA
H-6
PATIENT ASSESSMENT/MANAGEMENT - MEDICAL
Scenarios must include interventions learned at the EMT Intermediate level
Student: __________________________________ Evaluator: __________________________________
Date: _____________________________________ Signature:

__________________________________
Time Start: ___________ Time End: ___________
Points Points
Possible Awarded
Takes or verbalizes body substance isolation precautions 1
SCENE SIZE-UP
Determines the scene is safe 1
Determines the mechanism of injury/nature of illness 1
Determines the number of patients 1
Requests additional help if necessary 1
Considers stabilization of spine 1
INITIAL ASSESSMENT
Verbalizes general impression of the patient 1
Determines chief complaint/apparent life threats 1
Determines responsiveness/level of consciousness 1
Assesses airway and Assessment 1
breathing Initiates appropriate oxygen therapy 1
Assures adequate ventilation 1
Assesses circulation Assesses/controls major bleeding 1
Assesses pulse 1
Assesses skin (color, temp, and condition) 1
Identifies priority patients/makes transport decision 1
FOCUSED PHYSICAL EXAM AND HISTORY/RAPID ASSESSMENT
Signs and Symptoms (Assess history of present illness) 1
Respiratory Cardiac Altered Allergic Poisoning/ Environmental Obstetrics Behavioral
Level of Reaction Overdose Emergency
Conscious-
ness
∗ Onset ∗Onset ∗Description ∗History of ∗Substance ∗Source ∗Are you ∗How do you
∗Provokes ∗Provokes of the allergies ∗When did you ∗Environment pregnant? feel?
episode ∗What were ingest or ∗How long ∗Determine
∗Quality ∗Quality ∗Duration
∗Onset you exposed become have you been suicidal
∗Radiates ∗Radiates to? exposed? ∗Loss of pregnant? tendencies
∗Duration consciousness
∗Severity ∗Severity
∗Associated ∗How were you ∗How much did ∗Effects - ∗Pain or ∗Is the patient
∗Time ∗Time symptoms exposed? you ingest? contractions a threat to self
General or local or others?
∗Interventions ∗Inter- ∗Evidence of ∗Effects ∗Over what ∗Bleeding or
ventions trauma ∗Progressions time period? discharge ∗Is there a
medical
∗Inter- ∗Interventions ∗Interventions ∗Do you feel
problem?
ventions ∗Estimated the need to
weight push? ∗Past medical
∗Seizures history
∗Effects ∗Last
∗Fever menstrual ∗Interventions
period ∗Medications
∗Crowning
H-7
Points Points
Possible Awarded
Allergies 1
Medications 1
Past medical history 1
Last meal 1
Events leading to present illness (rule out trauma) 1
Performs focused physical examination 1
Assesses affected body part/system or, if indicated, completes rapid
assessment
VITALS (Obtains baseline vital signs) 1
INTERVENTIONS - Obtains medical direction or verbalizes standing order for 1
medication interventions and verbalizes proper additional intervention/treatment
TRANSPORT (Identifies priority patients/ makes transport decisions) 1
DETAILED PHYSICAL EXAMINATION
Completes detailed physical examination 1
ONGOING ASSESSMENT (verbalized)
Repeats initial assessment 1
Re-assesses vital signs 1
Re-assesses all interventions 1
Management
Obtains medical direction or verbalizes standing orders 1
Initiates IV therapy appropriate for the patient’s condition 1
Performs the appropriate interventions in a safe and appropriate manner 1
according to standing orders in accordance with applicable skill sheets
Transports if not already performed (Re-evaluates transport decision) 1
TOTAL: 34
CRITICAL CRITERIA
Did not take or verbalize body substance isolation precautions if necessary
Did not determine scene safety
Did not obtain medical direction or verbalize standing orders for medication interventions
Did not provide high concentration of oxygen
Did not find or manage problems associated with airway, breathing, hemorrhage or shock (hypoperfusion)
Did not differentiate patient's needing transportation versus continued assessment at the scene
Does detailed or focused history/physical examination before assessing airway, breathing and circulation
Did not ask questions about the present illness
Did not perform IV therapy appropriate for patient’s condition
Did not perform appropriate interventions in a safe and appropriate manner according to standing orders
You must factually document your rationale for checking any critical items below.
EVALUATION NOTES
H-8
PATIENT ASSESSMENT/MANAGEMENT - TRAUMA
Scenarios must include interventions learned at the EMT Intermediate level
Student: __________________________________ Evaluator: _________________________________
Date: _____________________________________ Signature: _________________________________
Points Points
Possible Awarded
SCENE SIZE-UP
Determines the scene is safe 1
Determines the mechanism of injury 1
Determines the number of patients 1
Requests additional help if necessary 1
Considers stabilization of spine 1
INITIAL ASSESSMENT
Verbalizes general impression of patient 1
Determines chief complaint/apparent life threats 1
Determines responsiveness/Level of consciousness 1
Assesses airway Assessment 1
and breathing Initiates appropriate oxygen therapy 1
Assures adequate ventilation 1
Injury management 1
Assesses Assesses for & controls major bleeding 1
circulation Assesses pulse 1
Assesses skin (color, temp, and condition) 1
Identifies priority patients/makes transport decision 1
FOCUSED PHYSICAL EXAM AND HISTORY/RAPID TRAUMA ASSESSMENT
Selects appropriate assessment (focused or rapid assessment) 1
Obtains baseline vital signs 1
Obtains S.A.M.P.L.E. history 1
H-9
Points Points
Possible Awarded
DETAILED PHYSICAL EXAMINATION
Assesses the head Inspects and palpates the scalp and ears 1
Assesses the eyes 1
Assesses the facial area including oral & nasal area 1
Assesses the neck Inspects and palpates the neck 1
Assesses for JVD 1
Assesses for tracheal deviation 1
Assesses the chest Inspects 1
Palpates 1
Auscultates the chest 1
Assesses the Assesses the abdomen 1
abdomen/pelvis Assesses the pelvis 1
Verbalizes assessment of genitalia/perineum as needed 1
Assesses the 1 point for each extremity 4
extremities includes inspection, palpation, and assessment of
motor, sensory and circulatory functions
Assesses the Assesses thorax 1
posterior Assesses lumbar 1
ONGOING ASSESSMENT (verbalized)
Repeats initial assessment 1
Re-assesses vital signs 1
Re-assesses all interventions 1
Management
Obtains medical direction or verbalizes standing orders 1
Performs the appropriate interventions in a safe and appropriate manner 1
Applies & inflates PASG at appropriate time to maintain systolic BP of 90 mmHg 1
Establishes 2 large bore IV’s of a balanced salt solution, to maintain systolic BP of 1
90 mmHg at the appropriate time
Transports if not already performed (Re-evaluates transport decision) Transports 1
within the 10 minute time limit
TOTAL: 46
CRITICAL CRITERIA
Did not take or verbalize body substance isolation precautions
Did not determine scene safety
Did not assess for spinal protection
Did not provide for spinal protection when indicated
Did not provide high concentration of oxygen
Did not obtain medical direction or verbalize standing orders for medication interventions
Did not evaluate and find conditions of airway, breathing, circulation (hypoperfusion)
Did not manage/provide airway, breathing, hemorrhage control or treatment for shock (hypoperfusion)
Did not differentiate patient's needing transportation versus continued assessment at the scene
Does other detailed physical examination before assessing airway, breathing and circulation
Did not perform IV therapy appropriate for patient’s condition
Did not perform appropriate interventions in a safe and appropriate manner according to standing orders
Did not transport patient within ten (10) minute time limit
You must factually document your rationale for checking any critical items below.
EVALUATION NOTES
H-10
MULTI-LUMEN AIRWAY DEVICE (COMBITUBE® OR PTL®)
Date: _____________________________________ Signature: _________________________________
NOTE: If student elects to initially ventilate with BVM attached to reservoir and oxygen, full credit must be awarded for
steps denoted by “**”
Points Points
Possible Awarded
Opens airway manually 1
Elevates tongue, inserts simple adjunct [oropharyngeal or nasopharyngeal airway] 1
NOTE: Evaluator now informs student no gag reflex is present and patient accepts adjunct
**Ventilates patient immediately with BVM device unattached to oxygen 1
**Hyperventilates patient with room air 1
NOTE: Evaluator now informs student that ventilation is being performed without difficulty
Attaches oxygen reservoir to BVM & connects to high flow oxygen [12-15 liters/min.] 1
Ventilates patient at a rate of 10-20/min. and volumes of at least 800 ml 1
NOTE: After 30 seconds, evaluator auscultates and reports breath sounds are present and equal
bilaterally and medical control has ordered insertion of a multi-lumen airway. The evaluator must
now take over ventilation.
Directs assistant to hyperventilate patient 1
Checks/prepares airway device 1
Lubricates distal tip of the device (may be verbalized) 1
NOTE: Evaluator to remove OPA and move out of the way when student is prepared to insert device
Positions the head properly 1
Performs a tongue-jaw lift 1
USES COMBITUBE® USES PTL®
Inserts device in mid-line and to depth Inserts device in mid-line until bite block 1
so printed ring is at level of teeth flange is at level of teeth
Inflates pharyngeal cuff with proper Secures strap 1
volume and removes syringe
Inflates distal cuff with proper volume Blows into tube #1 to adequately inflate 1
and removes syringe both cuffs
Attaches/directs attachment of BVM to the first (esophageal placement) lumen and 1
ventilates
Confirms placement and ventilation through correct lumen by observing chest rise, 1
auscultation over the epigastrium, and bilaterally over each lung
NOTE: The evaluator states, “You do not see rise and fall of the chest and you only hear sounds
over the epigastrium.”
Attaches/directs attachment of BVM to the second (endotracheal placement) lumen 1
and ventilates
Confirms placement and ventilation through correct lumen by observing chest rise, 1
NOTE: Evaluator confirms adequate chest rise, absent sounds over the epigastrium, and equal
bilateral breath sounds
Secures device or confirms that the device remains properly secured 1
TOTAL: 20
Complete Critical Criteria on the reverse side of this form.
H-11
CRITICAL CRITERIA
Failure to initiate ventilations within 30 seconds after taking body substance isolation precautions or
interrupts ventilation for greater than 30 seconds at any time
Failed to take or verbalize body substance isolation precautions prior to venipuncture
Failure to voice and ultimately provide high oxygen concentrations [at least 85%]
Failure to ventilate patient at rate of at least 10/minute
Failure to provide adequate volumes per ventilation [maximum 2 errors/minute permissible
Failure to hyperventilate patient prior to placement of the multi-lumen airway device
Failure to insert the multi-lumen airway at a proper depth or at either proper place within 3 attempts
Failure to inflate both cuffs properly
Combitube - Failure to remove the syringe immediately after inflation of each cuff
PTL - Failure to secure the strap prior to inflation
Failure to confirm that the proper lumen of the device is being ventilated by observing chest rise,
Inserts any adjunct in a manner dangerous to patient
You must factually document your rationale for checking any of the above critical items
below:
EVALUATION NOTES
H-12
ENDOTRACHEAL TUBE PLACEMENT
(For Airway or ILS/AW Technicians ONLY)
Date: _____________________________________ Signature: _________________________________
NOTE: If student elects to initially ventilate with BVM attached to reservoir and oxygen, full credit must be awarded for
steps denoted by “**” so long as the first ventilation is delivered within initial 30 seconds.
Points Points
Possible Awarded
Opens airway manually 1
Elevates tongue, inserts simple adjunct [oropharyngeal or nasopharyngeal airway] 1
NOTE: Evaluator now informs student no gag reflex is present and patient accepts adjunct
**Ventilates patient immediately with BVM device unattached to oxygen 1
**Hyperventilates patient with room air 1
NOTE: Evaluator now informs student that ventilation is being performed without difficulty
Attaches oxygen reservoir to BVM device and connects to high flow oxygen 1
regulator [12-15 liters/min.]
Ventilates patient at a rate of 10-20/min. and volumes of at least 800 ml 1
NOTE: After 30 seconds, evaluator auscultates and reports breath sounds are present and equal
bilaterally and medical control has ordered intubation. The evaluator must now take over
ventilation.
Directs assistant to hyperventilate patient 1
Identifies/selects proper equipment for intubation 1
Check equipment for:
• Cuff leaks (1 point) 2
• Laryngoscope operational and bulb tight (1 point)
NOTE: Evaluator to remove OPA and move out of the way when student is prepared to intubate
Positions the head properly 1
Inserts blade while displacing tongue 1
Elevates mandible with laryngoscope 1
Introduces ET tube and advances to proper depth 1
Inflates cuff to proper pressure and disconnects syringe 1
Directs ventilation of patient 1
Confirms proper placement by auscultation bilaterally and over the epigastrium 1
NOTE: The evaluator asks “If you had proper placement, what would you expect to hear?”
Secures ET tube [may be verbalized] 1
TOTAL: 19
CRITICAL CRITERIA
Failure to initiate ventilations within 30 seconds after taking body substance isolation precautions or
interrupts ventilation for greater than 30 seconds at any time
Failure to voice and ultimately provide high oxygen concentrations [at least 85%]
Failure to ventilate patient at rate of at least 12/minute
Failure to provide adequate volumes per ventilation [maximum 2 errors/minute permissible
Failure to hyperventilate patient prior to intubation
Failure to successfully intubate within 3 attempts
Using teeth as a fulcrum
Failure to assure proper tube placement by auscultation bilaterally and over epigastrium
If used, stylette extends beyond end of ET tube
Inserts any adjunct in a manner dangerous to patient
You must factually document your rationale for checking any of the above critical items on
the reverse side of this form:
H-13
EVALUATION NOTES
H-14
INTRAVENOUS THERAPY
Date: _____________________________________ Signature:

__________________________________
Time Start: ____________ Time End: ____________
Points Points
Possible Awarded
Checks selected IV fluid for:
• Proper fluid (1 point) 2
• Clarity (1 point)
Selects appropriate catheter 1
Selects appropriate administration set 1
Connects IV tubing to the IV bag 1
Prepares administration set [fills drip chamber and flushes tubing] 1
Cuts or tears tape [at any time before venipuncture] 1
Takes/verbalizes Body Substance Isolation precautions [prior to venipuncture] 1
Applies tourniquet 1
Palpates suitable vein 1
Cleanses site appropriately 1
Performs venipuncture
• Inserts stylette (1 point) 5
• Notes or verbalizes flashback (1 point)
• Occludes vein proximal to catheter (1 point)
• Removes stylette (1 point)
• Connects IV tubing to catheter (1 point)
Releases tourniquet 1
Runs IV for a brief period to assure patent line 1
Secures catheter [tapes securely or verbalizes] 1
Adjusts flow rate as appropriate 1
Disposes/verbalizes disposal of needle in proper container 1
TOTAL: 21
CRITICAL CRITERIA
Exceeded the 6 minute time limit in establishing a patent and properly adjusted IV
Contaminates equipment or site without appropriately correcting situation
Any improper technique resulting in the potential for catheter shear or air embolism
Failure to successfully establish IV within 3 attempts during 6 minute time limit
Failure to dispose/verbalize disposal of needle in proper container
the reverse side of this form.
H-15
EVALUATION NOTES
H-16
INTRAOSSEOUS LINE PLACEMENT
Date: _____________________________________ Signature:

__________________________________
Points Points
Possible Awarded
Checks selected IV fluid for:
• Proper fluid (1 point) 2
• Clarity (1 point)
Selects appropriate needle 1
Selects appropriate administration set 1
Connects IV tubing to the IV bag 1
Prepares administration set [fills drip chamber and flushes tubing] 1
Cuts or tears tape [at any time before IO placement] 1
Takes/verbalizes Body Substance Isolation precautions [prior to IO placement] 1
Stabilizes leg 1
Cleanses site appropriately 1
Performs IO placement:
• Performs proper needle placement directed away from the knee
(1 point)
• Uses firm back and forth motion to pierce bony cortex (1 point) 5
• Removes stylette & aspirates marrow contents for storage tube
(1 point)
• Confirms intramedullary placement by instilling 10 cc of normal
saline (1 point ) [Indicate NO Resistance]
• Connects IV tubing to IO needle (1 point)
Secures IO needle [tapes securely or verbalizes] 1
Monitors the insertion site for signs of infiltration/fluid extravasation 1
Adjusts flow rate as appropriate 1
Disposes/verbalizes disposal of contaminated equipment in proper container 1
TOTAL: 19
CRITICAL CRITERIA
Exceeded the 6 minute time limit in establishing a patent and properly adjusted IO
Failed to take or verbalize body substance isolation precautions prior to needle placement
Failure to monitors the insertion site for signs of infiltration/fluid extravasation
Failure to successfully establish IO within 3 attempts during 6 minute time limit
Failure to dispose/verbalize disposal of contaminated equipment in proper container
H-17
EVALUATION NOTES
H-18
NITROGLYCERIN ADMINISTRATION
Date: _____________________________________ Signature:

__________________________________
Points Points
Possible Awarded
Takes or verbalizes body substance isolation 1
Obtains history asking questions about onset, provocation, 1
quality, radiation, severity, and shortness of breath
Asks about allergies, medications, past oral intake, events 1
leading to present illness
Administers oxygen at 15 lpm by non-rebreather mask 1
Obtains vital signs 1
Contacts on-line or off-line medical control for authorization 1
Checks medication for expiration date 1
Places a tablet or sprays a single dose under tongue 1
Reassesses patient’s blood pressure 1
Administers up to 3 doses every 3-5 minutes while chest pain is 1
present and blood pressure remains above 100 mmHg
Performs ongoing assessment, including asking about burning 1
under the tongue, headache, stiff neck or reduction of symptoms
Administers medication appropriately 1
TOTAL: 12
CRITICAL CRITERIA:
Did not take or verbalize body substance isolation
Did not ask about allergies, medications, past oral intake, events leading to illness
Did not initiate appropriate oxygen therapy
Did not obtain vital signs
Did not contact on-line or off-line medical control for authorization
Did not check medication expiration date
Did not administer medication appropriately
Did not reassess patient’s blood pressure
Did not perform ongoing assessment and monitor patient’s response
Did not assess and treat the patient within 5 minute limit
You must factually document your rationale for checking any of the above critical
items on the reverse side of this form.
H-19
EVALUATION NOTES
H-20
EPINEPHRINE AUTO-INJECTOR
Date: _____________________________________ Signature:

__________________________________
Points Points
Possible Awarded

Initiates oxygen at 15 lpm or by nasal cannula at 2-6 lpm if 1
mask is not tolerated
Removes safety cap from the injector 1
Selects appropriate injection site (thigh or shoulder) 1
Pushes injector firmly against site 1
Holds injector against site for a minimum of ten (10) seconds 1
Properly discards auto-injector 1
Verbalizes monitoring the patient while transporting 1
Administers medication in an appropriate manner 1
TOTAL: 12
CRITICAL CRITERIA:
___ Did not take or verbalize body substance isolation
___ Did not initiate appropriate oxygen therapy
___ Did not contact on-line or off-line medical control for authorization
___Did not check medication for expiration date
___ Did not use an appropriate injection site
___ Did not hold the injector against the site for a minimum of 10 seconds
___ Did not discard auto-injector into appropriate container
___ Did not administer medication in an appropriate manner
___Did not assess and treat the patient within 5 minute limit
H-21
EVALUATION NOTES
H-22
ALBUTEROL THERAPY WITH AEROSOL INHALER
Date: _____________________________________ Signature:

__________________________________
Points Points
Possible Awarded
Administers oxygen at 15 lpm or by nasal cannula at 2-6 lpm if 1
Administers medication appropriately 1
Reassesses patient’s shortness of breath 1
Administers up to maximum dose while shortness of breath is 1
present
Verbalize placement of IV lifeline with normal saline/Ringer’s 1
lactate or 5% dextrose in water
Performs ongoing assessment and monitors patient’s response 1
TOTAL: 12
CRITICAL CRITERIA:
Did not administer medication appropriately
Did not reassess patient’s shortness of breath
H-23
EVALUATION NOTES
H-24
ALBUTEROL THERAPY WITH NEBULIZER
Date: _____________________________________ Signature:

__________________________________
Points Points
Possible Awarded
Administers oxygen at 15 lpm or by nasal cannula at 2-6 lpm if 1
Mixes and administers medication appropriately 1
Adjusts oxygen flow to 4-6 lpm producing a steady, visible mist 1
Reassesses patient’s shortness of breath 1
Administers up to maximum dose while shortness of breath is 1
present
Verbalize placement of IV lifeline with normal saline/Ringer’s 1
lactate or 5% dextrose in water
Performs ongoing assessment and monitors patient’s response 1
TOTAL: 13
CRITICAL CRITERIA:
Did not mix and administers medication appropriately
Did not adjust oxygen flow to 4-6 lpm producing a steady, visible mist
Did not reassess patient’s shortness of breath
H-25
EVALUATION NOTES
H-26
INTRAVENOUS MEDICATION ADMINISTRATION
(For Use With D25 /D50 and Naloxone)
NOTE: Student must complete Intravenous Therapy skill sheet prior to IV medication Administration.
Check below if student did not establish a patent IV and do not evaluate these skills.
Date: _____________________________________ Signature:

__________________________________
[ ] These skills cannot be evaluated because the student did not establish a patent IV.
Points Points
Possible Awarded
Asks for known allergies 1
Selects correct medication 1
Assures correct concentration of medication 1
Assembles prefilled syringe correctly and dispels air 1
Continues infection control procedures 1
Cleanses injection site (Y-port or hub) 1
Reaffirms medication 1
Stops IV flow (pinches tubing) 1
Administers correct dose at proper push rate 1
Flushes tubing (runs wide open for a brief period) 1
Adjusts drip rate to TKO (KVO) 1
Disposes/verbalizes disposal of syringe and needle in proper 1
container
Verbalizes need to observe patient for desired effect/adverse 1
side effects
TOTAL: 14
CRITICAL CRITERIA
Failure to begin administration of medication within 3 minute time limit
Failure to contact on-line or off-line medical control for authorization
Failure to adequately dispel air resulting in potential for air embolism
Injects improper medication or dosage (wrong drug, incorrect amount, or pushes at
inappropriate rate)
Failure to flush IV tubing after injecting medication
Recaps needle or failure to dispose/verbalize disposal of syringe and needle in
proper container
H-27
EVALUATION NOTES
H-28
INDIVIDUAL COMPREHENSIVE END OF COURSE EVALUATION
MEDICAL SCENARIO
Scenario development: A realistic medical field scenario should be developed by the
instructor using medical interventions identified during the EMT-Intermediate course.
Student: ___________________________ Evaluator: __________________________
Date: ______________________________ Signature: __________________________
Time Start: _______ Time End: ________
SKILLS OBSERVED PERFORMANCE COMMENTS
Scene Size-Up
Initial Assessment
Focused History & Physical

Examination & Rapid Transport
Detailed Physical Examination
Emergency Medical Care
Vital Sign Assessment
Transport appropriate to local

protocols, procedures
Remediation and repeat of station may be necessary if evaluator determines poor

performance. You must factually document your rationale for unsuccessful
completion on the reverse side of this form.
H-29
EVALUATION NOTES
H-30
INDIVIDUAL COMPREHENSIVE END OF COURSE EVALUATION
TRAUMA SCENARIO
Scenario development: A realistic trauma field scenario should be developed by the
instructor using trauma interventions identified during the EMT-Intermediate course.
Student: ___________________________ Evaluator: __________________________
Date: ______________________________ Signature: __________________________
Time Start: _______ Time End: ________
Skill Observed Performance Comments
Scene Size-Up
Initial Assessment
Focused History & Physical

Examination & Rapid Transport
Detailed Physical Examination
Emergency Medical Care
Vital Sign Assessment
Transport appropriate to local

protocols, procedures and
Trauma Triage Tool.
Remediation and repeat of station may be necessary if evaluator determines poor

performance. You must factually document your rationale for unsuccessful
completion on the reverse side of this form.
H-31
EVALUATION NOTES
H-32
EMT-INTERMEDIATE COURSE
PRACTICAL SKILL EVALUATION AND
COMPREHENSIVE END OF COURSE EVALUATION SUMMARY SHEET
Student Name: ________________________________________________________
Lesson Page Practical Skill S U Instructor or MPD Signature and Date

Number Number
2-2 H-7 Patient Assessment –
Medical
Trauma
2-4 H-11 Multi-lumen Airways
ILS Only
OR
2-5 H-11 Multi-lumen Airways
AW &
ILS/AW
Only
H-13 ET Tube Placement

Trauma
2-7
IV, ILS & H-15 Intravenous Therapy
ILS/AW
Only
2-7
IV, ILS & H-17 Intraosseous line
ILS/AW Placement
Only
3-1 H-19 Nitroglycerin
Administration
3-1 H-21 Epinephrine Auto-Injector
3-1 H-23 Albuterol Therapy with

Aerosol Inhaler
3-1 H-25 Albuterol Therapy with
Nebulizer
H-15 Intravenous Therapy
3-1 &
H-27 Intravenous Medication
(As a set) Administration (for use
with D25 /D50 and
Naloxone)
Medical
Medical
End of H-29 Individual
Course Comprehensive End of
Course Evaluation -
MEDICAL
End of H-31 Individual
Course Comprehensive End of
Course Evaluation -
TRAUMA
H-33
EVALUATION NOTES
H-34
EMT-I COURSE PRACTICAL SKILL EVALUATION SHEETS
Required Scores for Successful Completion
Practical Points
Skill Required to
Lesson Sheet Practical Skill Points Successfully
Number Page Possible Complete
Number Practical Skill
H-7 Patient Assessment - Medical 34 28
2-2
H-9 Patient Assessment - Trauma 46 37
2-4
ILS H-11 Multi-lumen Airways 20 16
Techs
ONLY
2-5 H-11 Multi-lumen Airways 20 16
AW Techs &
ILS/AW
Techs H-13 ET Tube Placement 19 16
ONLY
2-6 H-9 Patient Assessment - Trauma 46 37
2-7 H-15 Intravenous Therapy 21 17
IV, ILS &
ILS/AW H-17 Intraosseous line Placement 19 16
Techs Only
H-19 Nitroglycerin Administration 12 10
H-21 Epinephrine Auto-Injector 12 10
H-23 Albuterol Therapy with Aerosol Inhaler 12 10
H-25 Albuterol Therapy with Nebulizer 13 11
3-1
(As a set)
H-15 Intravenous Therapy H-15 – 21 H-15 – 17
&
H-27 Intravenous Medication Administration H-27 – 14 H-27 – 12
(for use with D25 /D50 and Naloxone)
3-2 H-7 Patient Assessment - Medical 33 27
3-3 H-7 Patient Assessment - Medical 33 27
NOTE: A check mark in the Critical Criteria section of any of the above skills is a
failure of the station regardless of the points attained.
H-35
H-36
APPENDIX I - Trauma Triage Tool - Student Handout
Appendix I: Prehospital Trauma Triage Destination Procedures
Appendix I: Page 2
STATE OF WASHINGTON
PREHOSPITAL TRAUMA TRIAGE (DESTINATION) PROCEDURE
Purpose
The purpose of the Triage Procedure is to ensure that major trauma patients are transported to the most
appropriate hospital facility. This procedure has been developed by the Prehospital Technical Advisory Committee
(TAC), endorsed by the Governor's EMS and Trauma Care Steering Committee, and in accordance with RCW 70.168
and WAC 246-976 adopted by the Department of Health (DOH).
The procedure is described in the schematic with narrative. Its purpose is to provide the prehospital provider with quick
identification of a major trauma victim. If the patient is a major trauma patient, that patient or patients must be taken to
the highest level trauma facility within 30 minutes transport time, by either ground or air. To determine whether an injury
is major trauma, the prehospital provider shall conduct the patient assessment process according to the trauma triage
procedures.
Explanation of Process
A. Any certified EMS and Trauma person can identify a major trauma patient and activate the trauma system.
This may include requesting more advanced prehospital services or aero-medical evacuation.
B. The first step (1) is to assess the vital signs and level of consciousness. The words "Altered mental status"
mean anyone with an altered neurologic exam ranging from completely unconscious, to someone who responds to
painful stimuli only, or a verbal response which is confused, or an abnormal motor response.
The "and/or" conditions in Step 1 mean that any one of the entities listed in Step 1 can activate the trauma system.
Also, the asterisk (*) means that if the airway is in jeopardy and the on-scene person cannot effectively manage the
airway, the patient should be taken to the nearest medical facility or consider meeting up with an ALS unit. These
factors are true regardless of the assessment of other vital signs and level of consciousness.
C. The second step (2) is to assess the anatomy of injury. The specific injuries noted require activation of the
trauma system. Even in the assessment of normal vital signs or normal levels of consciousness, the presence of any
of the specific anatomical injuries does require activation of the trauma system.
Please note that steps 1 and 2 also require notifying Medical Control.
D. The third step (3) for the prehospital provider is to assess the biomechanics of the injury and address other
risk factors. The conditions identified are reasons for the provider to contact and consult with Medical Control
regarding the need to activate the system. They do not automatically require system activation by the prehospital
provider.
Other risk factors, coupled with a "gut feeling" of severe injury, means that Medical Control should be consulted and
consideration given to transporting the patient to the nearest trauma facility.
Please note that certain burn patients (in addition to those listed in Step 2) should be considered for immediate transport
or referral to a burn center/unit.
Patient Care Procedures

To the right of the attached schematic you will find the words "according to DOH-approved regional patient care
procedures." These procedures are developed by the regional EMS and Trauma council in conjunction with local
councils. They are intended to further define how the system is to operate. They identify the level of medical care
personnel who participate in the system, their roles in the system, and participation of hospital facilities in the system.
They also address the issue of inter-hospital transfer, by transfer agreements for identification, and transfer of critical care
patients.
In summary, the Prehospital Trauma Triage Procedure and the Regional Patient Care Procedures are intended to work in
a "hand in glove" fashion to effectively address EMS and Trauma patient care needs. By functioning in this manner,
these two instruments can effectively reduce morbidity and mortality.
If you have any questions on the use of either instrument, you should bring them to the attention of your local or regional
EMS and Trauma council or contact 1-800-458-5281.
1994/Disc 1/triage.exp
Appendix I: Page 3
Appendix I: Prehospital Trauma Triage Destination Procedures
STATE OF WASHINGTON
PREHOSPITAL TRAUMA TRIAGE (DESTINATION) PROCEDURES
EFFECTIVE DATE 1/95
• Prehospital triage is based on the following 3 steps: Steps 1 and 2 require prehospital EMS personnel to notify medical
control definitive and activate the Trauma System. Activation of the Trauma System in Step 3 is determined by medical
control**
STEP 1
ASSESS VITAL SIGNS & LEVEL OF CONSCIOUSNESS
• Systolic BP <90*
• HR >120*
* for pediatric (<15y) pts. use BP <90 or capillary refill >2 sec.
* for pediatric (<15y) pts. use HR <60 or >120
Any of the above vital signs associated with signs and symptoms of shock 1. Take patient to the
and/or highest level
• Respiratory Rate <10 >29 associated with evidence of distress YES trauma center
and/or within 30 minutes
• Altered mental status transport time via
ground or air
transport
according to DOH
**If prehospital personnel are unable to effectively manage airway, consider approved regional
rendezvous with ALS, or intermediate stop at nearest facility capable of patient care
immediate airway management. procedures.
NO
STEP 2 2. Apply "Trauma ID

ASSESS ANATOMY OF INJURY Band" to patient.
• Penetrating injury of head, neck, torso, groin; OR YES
• Combination of burns > 20% or involving face or airway; OR
• Amputation above wrist or ankle; OR
• Spinal cord injury; OR
• Flail chest; OR
• Two or more obvious proximal long bone fractures.
NO
STEP 3
ASSESS BIOMECHANICS OF INJURY AND 1. Take patient to the
OTHER RISK FACTORS highest level trauma
• Death of same car occupant; OR center within 30
• Ejection of patient from enclosed vehicle; OR minutes transport
• Falls > 20 feet; OR time via ground or
• Pedestrian hit at > 20 mph or thrown 15 feet CONTACT air transport
• High energy transfer situation MEDICAL according to DOH
Rollover approved regional
Motorcycle, ATV, bicycle accident YES CONTROL YES patient care
procedures.
Extrication time of > 20 minutes FOR
• Extremes of age <15 >60
• Hostile environment (extremes of heat or cold) DESTINATION 2. Apply "Trauma ID
• Medical illness (such as COPD, CHF, renal failure, etc.) DECISION Band" to patient
• Second/third trimester pregnancy
• Gut feeling of medic
NO
NO
TRANSPORT PATIENT PER REGIONAL PATIENT CARE PROCEDURES
Appendix I: Page 4
APPENDIX J - Possible Abandonment Situations - Student Handout
Appendix J - Possible Abandonment Situations - Student Handout
Appendix J: Page 2
Student Handout
Highest Level of Skill Performance Indicated By
Current or Anticipated Clinical Circumstances
Revised April, 2000
Highest Level of Skill Performance Indicated Abandonment can exist when

By Current or Anticipated Clinical
Procedures:
Paramedic Care is released to ILS personnel after

drugs have been administered that are not
within the ILS Technician’s scope of
training.
ILS/Airway Technician --------------------------- Care is released to an ILS Technician after

an ET has been placed in the patient and is
required to maintain the continuum of care.
ILS Technician ------------------------------------- Care is released to an IV/Airway Technician

when drug administration has been initiated
OR and is required to maintain the continuum of
care.
IV/Airway Technician----------------------------- Care is released to an ILS Technician when

an ET has been placed in the patient and
the same skills are required to maintain the
continuum of care.
Airway Technician -------------------------------- Care is released to an IV Technician or ILS

Technician when an ET has been initiated
and the same ET skills are required to
maintain the continuum of care.
IV Technician--------------------------------------- Care is released to an EMT or First

Responder when an IV has been initiated
and is required to maintain the continuum of
care.
EMT-B ----------------------------------------------- Care is released to an EMT-A who does not

have EMT-B (PTL) skills, and a PTL has
been initiated.
EMT-A ----------------------------------------------- Care is released to a First Responder who

then occupies the patient compartment.
State law requires a minimum of an EMT
during patient transport.
Appendix J: Page 3
Appendix J - Possible Abandonment Situations - Student Handout
Appendix J: Page 4
APPENDIX K - Washington Administrative Code (WAC)
Pertaining to EMT-Intermediate Training Courses
The most current statutes and rules are located on our web site at:
www.doh.wa.gov
APPENDIX K: Washington Administrative Code (WAC)
Appendix K: Page 2
WAC 246-976-010 Definitions. Definitions in RCW 18.71.200,

18.71.205, 18.73.030, and 70.168.015 apply to this chapter. In
addition, unless the context plainly requires a different meaning,
the following words and phrases used in this chapter mean:
"Approved" means approved by the department of health.
"Airway technician" means a person who:

• Has been trained in an approved program to perform
endotracheal airway management and other authorized aids to
ventilation under written or oral authorization of an MPD or
approved physician delegate; and
• Has been examined and certified as an airway technician
by the department or by the University of Washington's school of
medicine.
"Intermediate life support (ILS) technician" means a person

who:
• Has been trained in an approved program to perform specific
phases of advanced cardiac and trauma life support as specified in
this chapter, under written or oral direction of an MPD or approved
physician delegate; and
• Has been examined and certified as an ILS technician by the
department or by the University of Washington's school of medicine.
"Intravenous therapy technician" means a person who:

• Has been trained in an approved program to initiate IV
access and administer intravenous solutions under written or
oral authorization of an MPD or approved physician delegate; and
• Has been examined and certified as an intravenous
therapy technician by the department or by the University of
Washington's school of medicine.
"Paramedic" means a person who:

• Has been trained in an approved program to perform all
phases of prehospital emergency medical care, including advanced
life support, under written or oral authorization of an MPD or
approved physician delegate; and
• Has been examined and certified as a paramedic by the
department or by the University of Washington's school of
medicine.
Appendix K: Page 3
TRAINING
WAC 246-976-021 Training course requirements. (1) Department

responsibilities: The department will publish procedures for
agencies to conduct EMS training courses, including:
(a) The registration process;
(b) Requirements, functions, and responsibilities of course
instructional and administrative personnel;
(c) Necessary information and administrative forms to conduct
the course;
(2) Training agency responsibilities:
(a) General. Agencies providing initial training of certified
EMS personnel at all levels (except advanced first aid) must:
(i) Have MPD approval for the course content;
(ii) Have MPD approval for all instructional personnel, who
must be experienced and qualified in the area of training;
(iii) Have local EMS/TC council recommendation for each
course;
(iv) Have written approval from the department to conduct each
course;
(v) Approve or deny applicants for training consistent with
the prerequisites for applicants in WAC 246-976-041 and 246-976-
141.
(b) Basic life support (first responder, EMT). Agencies
providing initial training of basic life support personnel must
identify a senior EMS instructor to be responsible for the quality
of instruction and the conduct of the course.
(c) Intermediate life support (IV, airway and ILS
technicians). Agencies providing initial training of intermediate
life support personnel must:
(i) Have a written agreement with the clinical facility, if it
is separate from the academic facility;
(ii) Ensure that clinical facilities provide departments or
sections, personnel, and policies, including:
(A) Written program approval from the administrator and chief
of staff;
(B) A written agreement to participate in continuing
education;
(C) Supervised clinical experience for students during the
clinical portion of the program;
(D) An orientation program.
(d) Paramedics. Agencies training paramedics must be
accredited by a national accrediting organization approved by the
department.
Appendix K: Page 4
(3) Course curriculum. The department recognizes the following

National Standard EMS training courses published by the United
States Department of Transportation as amended by the department:
(a) First responder: The first responder training course
published 1996, amended by the department March 1998;
(b) EMT: The emergency medical technician -- Basic training
course published 1994, amended by the department February 1999;
(c) IV technician: Those parts of the emergency medical
technician -- Intermediate course published 1999 which relate to
intravenous therapy lessons 1-1, 1-2, 1-3, 2-1, 2-2, 2-3, 2-6, 2-7,
3-2, 3-3, 4-1, and 4-2; amended by the department February 1999;
(d) Airway technician: Those parts of the emergency medical
technician -- Intermediate course published 1999 which relate to
airway management lessons 1-1, 1-2, 1-3, 2-1, 2-2, 2-3, 2-5, 3-2,
3-3, 4-1, and 4-2; amended by the department February 1999;
(e) ILS technician: Those parts of the emergency medical
technician -- Intermediate course published 1999 which relate to IV
therapy and intraosseous infusion, the use of multi-lumen airway
adjuncts, and the following medications:
(i) Epinephrine for anaphylaxis administered by a commercially
preloaded measured-dose device;
(ii) Albuterol administered by inhalation;
(iii) Dextrose 50% and 25%;
(iv) Nitroglycerine, sublingual and/or spray;
(v) Naloxone;
(vi) Aspirin PO (oral), for suspected myocardial infarction
lessons 1-1, 1-2, 1-3, 2-1, 2-2, 2-3, 2-4, 2-6, 2-7, 3-1, 3-2, 3-3,
4-1, and 4-2; amended by the department February 1999;
(f) Paramedic: The emergency medical technician --Paramedic
training course published 1999, as amended by the department
January 2000.
(4) Initial training for first responders and EMTs must also
include approved infectious disease training that meets the
requirements of chapter 70.24 RCW.
(5) Specialized training. The department, in conjunction with
the advice and assistance of the L&C committee, may approve
specialized training for certified EMS personnel to use skills,
techniques, or equipment that is not included in standard course
curricula. Agencies providing specialized training must have MPD
and department approval of:
(a) Course curriculum;
(b) Lesson plans;
(c) Course instructional personnel, who must be experienced
and qualified in the area of training;
(d) Student selection criteria;
(e) Criteria for satisfactory completion of the course,
including student evaluations and/or examinations;
(f) Prehospital patient care protocols that address the
specialized skills.
Appendix K: Page 5
(6) Local government agencies: The department recognizes county

agencies established by ordinance and approved by the MPD to
coordinate EMS training. These agencies must comply with the
requirements of this section.
[Statutory Authority: Chapters 18.71, 18.73, and 70.168 RCW. 00-

08-102, § 246-976-021, filed 4/5/00, effective 5/6/00.]
WAC 246-976-041 To apply for training. (1) You must be at

least eighteen years old at the beginning of the course.
(2) For training at the intermediate (IV, airway and ILS
technicians) and advanced life support (paramedic) levels, you must
have completed at least one year as a certified EMT or above.

08-102, § 246-976-041, filed 4/5/00, effective 5/6/00.]
WAC 246-976-161 Continuing medical education (CME), skills

maintenance, and ongoing training and evaluation (OTEP). (1)
General requirements. See Tables A and B. You must document your
annual CME and skills maintenance requirements, as indicated in the
tables. You must complete all CME and skills maintenance
requirements for your current certification period to be eligible
for recertification.
(2)(a) You must complete the number of MPD-approved CME hours
appropriate to your level of certification, as indicated in Table
A.
(b) If you are a first responder or EMT, you may choose to
complete an approved OTEP program instead of completing the
required number of CME hours and taking the recertification exams.
(3) You must demonstrate proficiency in certain critical
skills, indicated in Table B, to the satisfaction of the MPD:
(4) IV starts.
(a) During your first year of certification as an IV
technician, combined IV/airway technician, ILS technician, or
paramedic, you must perform a minimum of thirty-six successful IV
starts. EXCEPTION: If you have completed a certification period as
an IV or ILS technician, you do not need to meet this requirement
during your first year of certification as a paramedic.
(b) By the end of your initial certification period, you must
perform a minimum of one hundred eight successful IV starts.
Appendix K: Page 6
(5) Intubations.
(a) During your first year of certification as an airway
technician, combined IV/airway technician, combined ILS/airway
technician or paramedic, you must perform a minimum of twelve
successful endotracheal intubations. EXCEPTION: If you have
completed a certification period as an airway technician, you do
not need to meet this requirement during your first year of
certification as a paramedic.
(b) By the end of your initial certification period, you must
perform a minimum of thirty-six successful endotracheal
intubations.
TABLE A: Basic Life Intermediate Life Support Paramedic

CME REQUIREMENTS Support
FR EMT IV Air IV/Air ILS ILS/Air Paramedic
Annual
CPR & Airway X X X X X X X
Spinal Immobilization X X X X X X X
Patient Assessment X X X X X X X
Certification Period
Infectious Disease X X X X X X X X
Trauma X X X X X X X
Pharmacology X X X X X X
Pediatrics X 2 hrs 2 hrs 2 hrs 2 hrs 2 hrs 2 hrs 6 hrs
Other CME, for a total of: 15 hrs 30 hrs 45 hrs 45 hrs 60 hrs 60 hrs 75 hrs 150 hrs
OR, complete an X X per per per per per per MPD
equivalent OTEP MPD MPD MPD MPD MPD for BLS
program as described in for for for for for BLS skills
WAC 246-976-171 BLS BLS BLS BLS skills
skills skills skills skills
Appendix K: Page 7
TABLE B: Intermediate Life Support Paramedic

SKILLS MAINTENANCE REQUIREMENTS
IV Air IV/Air ILS ILS/Air Paramedic

First Certification Period
• First Year of Certification
IV Starts - may not be averaged (see par 4) 36 36 36 36 36
Endotracheal intubations - may not be averaged (see 12 12 12 12
par 5)
Demonstrate intraosseous infusion proficiency X X X X X
• Second and Third Years of Certification
IV Starts - average (see par 4) 36 36 36 36 36
Endotracheal intubations - average (see par 5) 12 12 12 12
• During the Certification Period
Demonstrate pediatric airway proficiency X X X X
Multi-Lumen Airway per per
MPD MPD
Defibrillation per per
MPD MPD
Later Certification Periods

• Annual Requirements
IV Starts - demonstrate proficiency X X X X X
Endotracheal intubations - average (see par 4) 4 4 4 4
• During the Certification Period
Demonstrate pediatric airway proficiency X X X X
Multi-Lumen Airway per per
MPD MPD
Defibrillation per per
MPD MPD
Appendix K: Page 8
(6) Description of selected terms used in the table:

• Infectious disease: Infectious disease training must meet
the requirements of chapter 70.24 RCW.
• CPR includes the use of airway adjuncts appropriate to the
level of certification.
• Pharmacology: Pharmacology specific to the medications
approved by your MPD (not required for first responders).
• Pediatrics: This includes patient assessment, CPR and
airway management, and spinal immobilization and packaging.
• "IV starts": Proficiency in intravenous catheterization
performed on sick, injured, or preoperative adult and pediatric
patients. With written authorization of the MPD, IV starts may
be performed on artificial training aids.
• Endotracheal intubation: Proficiency in endotracheal
intubations, at least half of which must be performed on human
subjects. With written authorization of the MPD, up to half of
the intubations may be performed on artificial training aids.
• Intraosseous infusion: Proficiency in intraosseous line
placement in pediatric patients.
• Proficiency: Ability to perform a skill properly,
demonstrated to the satisfaction of the MPD.
• Pediatric airway: Proficiency in pediatric airway
management.

08-102, § 246-976-161, filed 4/5/00, effective 5/6/00.]
Appendix K: Page 9

Washington State Intermediate Life Support Manual, Guidelines and Curriculum

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EMT-INTERMEDIATE

National Standard Curriculum

Ronald N. Roth, MD, F.A.C.E.P.

Contract Number DTNH22-95-C-05108

Debra A. Lejeune, BS, NREMT-P

Gregory H. Lipson, MHA, MBA, NREMT

NATIONAL REVIEW TEAM

Mike Taigman, EMT-P Linda K. Honeycutt, EMT-P

Narrative Of The Emt-Intermediate Course Practical Skill Evaluation Process .........................................

The EMT-Intermediate: National Standard Curriculum represents the minimum required

United States Department of Transportation, National Highway Traffic Safety

Subject Matter Experts

Don Doynow, MD; Hudson Valley Community College

Charles Sowerbrower, BS, NREMT-P; Lancaster EMS Association

Arizona Pilot Test Site

Arizona Department of Health Services, Bureau of Emergency Medical Services

Steve Carlson; President/CEO, Flagstaff Medical Center

Field Test Sites

Center for Emergency Medicine

Paul M. Paris, MD, FACEP; Chief Medical Director

UPMC Health System Printing Services

EMT-INTERMEDIATE CURRICULUM - COURSE TOPICS

Lesson Lesson Topic

Lesson 1-2 Medical/Legal Issues/ Ethics

Lesson 1-3 Documentation

Lesson 2-2 Patient Assessment

Lesson 2-3 Clinical Decision Making

Lesson 2-4 Airway Management and Ventilation - ILS Technicians only

Lesson 2-5 Airway Management and Ventilation - AW or ILS/AW Technicians only

Lesson 2-6 Assessment and Management of Shock

Lesson 2-7 Intravenous & Intraosseous Line Placement and Infusion

Section 3 -Pharmacology and Emergency Care

Lesson 3-2 Cardiology

Lesson 3-3 Medical

Section 4 - Special Considerations

Lesson 4-2 Geriatrics

Required Initial Instruction for the Intravenous Therapy Certification

Clinical Internship Requirements 10 IV insertions on Humans. . At

Field internship Competency Determined By the

Required Initial Instruction for Airway Certification

Clinical Internship Requirements 10 ET intubations on Humans. .

Field internship Competency Determined By the

Required Initial Instruction for IV/Airway Certification

Lab skill proficiency required in:

Required Initial Instruction for ILS Certification

Required Initial Instruction for ILS/Airway Certification

Clinical Internship Requirements Lab skill Lab skill Lab skill

The Curriculum Development Process

and review of the material.

Curriculum Goal and Approach

Description of the Profession

Continuum of Life Long Learning

Basic Education ÎCompetencies/Prerequisites Î Professional Education Î

The EMT-Intermediate: National Standard Curriculum Diagram of Educational Model

Because of the variability in the roles and responsibilities of EMT-Intermediates throughout

The emphasis of EMT-Intermediate education should be competence of the graduate, not

Prerequisites as Identified for the Washington State Amended curriculum

Although this curriculum identifies EMT-Basic as a prerequisite, we have done so in the

Life Long Learning/Continuing Education

Student records shall be maintained for student admissions, attendance, academic

Program Planning/Communities of Interest

Every professional education program is designed and conducted to serve a number of

The goal of the ABC EMT-Intermediate Education program is to produce