HISTORY AND DEVELOPMENT PHILOSOPHY

As part of the revision project for the EMT-Intermediate and EMT-Paramedic: National Standard Curricula (NSC), the contractor was directed to develop the EMT-Paramedic and EMT-Intermediate Continuing Education, National Guidelines. The guidelines document, developed as a substitute for traditional refresher courses, gives the reader an overview of competency assurance mechanisms to promote the delivery of medically appropriate patient care. The guidelines document defined refresher programs as follows:

Although the guidelines document is widely used by the EMS community, the definition for refresher programs caused the EMS community to ask that refresher courses be developed. A contract to develop the refresher courses went to the National Association of EMS Educators (NAEMSE) and they convened a task force of EMS stakeholders inclusive of regulators, physicians, association representatives, providers, and educators.

Some challenges undertaken by the task force were:

1. The development of a refresher program based on scientific data.
2. A program that could be delivered in different formats.
3. A program flexible enough to meet the specific needs of different systems while maintaining the intent of a refresher program.
4. The need to incorporate relevant contemporary material.

The task force used EMS provider practice data, an EMS literature review, expert opinion, and a final EMS community review to develop the refresher programs. Previous versions of EMS refresher programs have been based on a perceived need and not on scientific evidence. With this in mind, the Refresher Development Task Force relied heavily on the findings of the 1999 NREMT Practice Analysis and the following documents:

1. The EMS Agenda for the Future
2. The EMS Education Agenda for the Future, A Systems Approach
3. The National EMS Education and Practice Blueprint
4. EMT-Paramedic and EMT-Intermediate Continuing Education, National Guidelines
5. 1999 EMT-Intermediate National Standard Curriculum

Each of the above documents was created as individual projects, but they are designed to work as a systems approach to EMS and integrate with one another. Contact the NHTSA EMS Division to obtain copies of these documents.

In 1994, the National Registry of Emergency Medical Technicians (NREMT) performed the first nationally conducted practice analysis of EMS. The information obtained in the first analysis was used in the development of the 1998 EMT-Paramedic and 1999 EMT-Intermediate: NSC. In 1999, the NREMT conducted its second practice analysis.

The 1999 NREMT Practice Analysis is a scientific, randomized national sampling of practicing EMT-Paramedic and EMT-Intermediates. The EMT’s participating in the practice analysis provided data on 123 various patient assessments focusing on patient care and operational tasks that make up the day-to-day functions of the providers. Each provider indicated the frequency they performed each task and the potential for harm they experienced accomplishing each task. A Practice Analysis Committee reviewed the data, validated the responses, and published the data in a peer reviewed medical journal. The NREMT Practice Analysis Committee used this data to develop a plan that grouped the identified tasks into the following six content areas:

• Airway and Breathing
• Cardiology
• Medical
• Trauma
• Pediatrics/Obstetrics
• Operations

The specific tasks from the practice analysis are listed in appendix A. The NREMT supplied the data from their practice analysis to the EMT-Intermediate refresher development task force. This information was used to help determine specific content for the refresher course.

The refresher task force used the NREMT data to identify tasks that are infrequent and may cause potential harm to the patient if delayed, performed improperly, or omitted when providing care. The panel decided to "refresh" these tasks since patient outcome is jeopardized if the task is not correctly performed. An example of this would be "Provide care to an infant or child with cardiac arrest." The practice analysis categorizes this task as number 113 of 123 for frequency, but lists it as the number one task for potential for harm. The panel agreed and decided to include this task as a mandatory part of the refresher program.

Likewise, a task such as "Provide care to a patient with a painful, swollen, deformed extremity" is listed as task number 98 in frequency and number 100 as potential for harm. This task is not included as a mandatory part of the refresher program. Other tasks that are performed frequently and lack potential for harm are not included as a mandatory part of this refresher program. Again, the refresher course only targets infrequently performed tasks with a high potential for harm.

Upon further review of the practice analysis, the task force identified a few frequently performed tasks that have a very high potential for harm. The task force decided to also include all tasks with a high potential for harm, regardless of their frequency of performance.

Another tool used in the development of this refresher program was an EMS literature review. The literature review found issues not identified by the data from the NREMT Practice Analysis. The task force also sought expert opinion and feedback from the EMS community to identify additional course content.

Traditional refresher programs refresh material already known by the students. The intent of these programs is to maintain a student’s competence in knowledge and skill performance. This refresher program embraces the same concept, but it also encourages the inclusion of new and expanded information. New and expanded information may be added to the course but not at the expense of content that is core material for the program. This course is not designed to be continuing education for the participants. If a system wishes to incorporate additional information or a new intervention that requires a substantial amount of time to teach, the information must be offered in addition to the content of the refresher program. Moreover, this course is not a transition or bridge course for EMT-Intermediates to become certified at the revised 1999 EMT-Intermediate level.

The participant make-up in a refresher program may challenge the instructional staff. Participants who attend a refresher program may do so for a variety of reasons. Some students may not have practiced for a period of time and are attending to gain back their level of competence prior to practicing again. Others may attend to remediate or gain refresher or continuing education hours. Knowledge of the participant make-up will help the instructors meet the participant’s needs. A thorough knowledge of the re-credentialing requirements and approval process is a must for any organization sponsoring a refresher program.

NREMT PRACTICE ANALYSIS TASK ITEMS

The NREMT Practice Analysis task items are listed at the beginning of each module. These tasks are included based upon their performance frequency and potential for harm.

The objectives and declarative material are extracted from the 1999 EMT-Intermediate: NSC and they support the identified practice analysis tasks. The objectives and declarative material are renumbered for formatting purposes; however, the original objective number from the NSC is found at the end of each objective. The declarative material provides guidance for programs to use to establish their own individual lesson plans.

The objectives in modules 1-5 are mandatory objectives and must be included in every refresher program. The objectives for the operational section should be considered recommended content for the refresher course. Any other objectives and declarative information has not been included and should be developed by the sponsoring agency.

The length of this refresher program will vary according to a number of factors. Some of these factors are as follows:

• The student’s basic academic skills competence
• The student’s EMS knowledge and skills
• The faculty to student ratio
• The student’s motivation
• The student’s prior emergency/health care experience
• The student’s prior academic achievements
• The clinical and academic resources available
• The quantity of patient contacts

The recommended time to instruct the mandatory objectives for the refresher program is 40 to 80 hours. Training institutes will need to adjust these times based on their individual needs. The agencies responsible for program oversight are cautioned against using these hours as a measure of program quality. Competence of the participants, not adherence to arbitrary time frames, is the true measurement of program quality.

The first step for the needs assessment is the performance of a comprehensive analysis of the factors that influence the local pre-hospital emergency care delivery system. Some factors included in this analysis are:

• Recertification requirements (local, state, national, professional).
• System structure.
• Call characteristics (i.e., volume, type).
• Community demographics.
• Community hazard assessment.

The second step of the needs assessment is an analysis of the education needs of the course participants. This assessment may include the following:

• Pre-testing
• Surveys
• Observations
• Expert Judgments
• Data Analysis

The information collected during the assessment process may be used as a guide to select specific material for the classroom. The assessment results can determine the course format, course schedule, and course methods. The selected material may be subjected to national, State, and local standards.

The following steps will assist with the design and implementation of the course design.

Determine regulatory requirements for course conduct:
The refresher course will be approved or accredited by the appropriate local or state agency. A part of this approval process will be the length of the course, the course content, and the faculty requirements or restrictions.

Develop schedule:
The course is designed to allow programs to present the material in a variety of formats. The program may be delivered in class sessions that might include 8 hour consecutive days or may be taught in a shorter sessions extended over a period of months.

Determine class size:
The course emphasizes the evaluation of participant skills. Class size should be manageable and allow students an opportunity to ask questions and receive answers or assistance from the instructor.

Since the instructor must observe and evaluate student performance, it is essential that the group’s size not be too large when evaluating practical skills. Consider segmenting the class into smaller groups, such as 6:1 (students to instructor) when doing the practical skills session.

Instructing a refresher program for practicing EMT-Intermediates is a challenge. We often hear that refresher programs lack challenge, cover material already well known, and are not deemed as useful for the participants. Faculty members must possess expertise in both the content area they instruct and in multiple delivery styles. Instructors must be proficient in performing the skills that they are instructing. Knowing your student’s abilities and the local EMS system’s expectations is essential for a successful program.

Instructional staff must be appropriately credentialed according to local or state requirements. The course medical director must be available throughout the program and be aware of the course design and evaluation instruments being used. The course medical director may be utilized for medical expertise.

Given the repetitive nature of refresher education, it is easy for participants to become bored and lack enthusiasm about the program. The overuse of lecturing is ineffective as the sole method of learning. To improve the quality of the educational experience for instructors and participants, creative and innovative instructional activities are strongly recommended. Consider using some of the following:

Case Presentation
Case presentation and discussion helps participants apply and understand the content by relating to their field experiences. The instructional staff can generate cases by using actual calls. Instructors should develop case studies to highlight key points of their presentations and the area of content being delivered. The most successful case presentations are those placing the participant(s) in a decision-making role allowing them to see the consequences of their decisions. Case presentations can be used in any format, such as, large classes, small groups, and individual instruction. Several examples and templates for case construction are in Appendix B.

Simulations
Simulations are case presentations incorporating role-playing situations. The role players may be other participants, programmed (standardized) patients, or manikins. Simulations work best when they are realistic and present situations the participant(s) may encounter, highlighting key points of the content area. Instructors and participants may critique simulations if the classroom environment is adequate.

Technology
We live in a time when technology is expanding in development and practical use. Though it is hard to say what will be the state of the art delivery system for education resources in the future, participation by the student will likely enhance the learning process.

Distributed learning includes several alternative methods and media usage. Self-study programs, videotapes, audiotapes, and computer-based instruction are just a few examples of distributed learning. These alternative methods of instruction provide an opportunity to review and learn new cognitive knowledge, but they may not replace the need to practice or demonstrate a psychomotor skill. The use of a distributed learning process may best be applied in the remediation of cognitive knowledge identified in a needs assessment. Course directors and the credentialing agency should evaluate distributed learning products to assure that they meet the course goals and objectives.

In order for the refresher program sponsor to issue a certificate of program completion, an evaluation process must be employed. The evaluation process should measure both cognitive knowledge and psychomotor skills. Individuals who are unsuccessful may be counseled and a course of action for remediation developed.

Authoring a valid written evaluation is both a science and an art. While some instructors possess skills in writing test questions, some others may not. A variety of commercially available test question banks may be useful to the instructional staff during the refresher program. Regardless of the tool used, the purpose of the cognitive measurement tool must be known before a test can be validated. The instructional staff must use basic test construction principles to develop written evaluation instruments.

Written evaluation questions should be balanced to the program content. Items should be based upon what is taught and emphasized throughout the program and should have a difficulty measurement. A test written so each participant can obtain a score of 90% without taking the course lacks measurement ability and validation. Test items must be reviewed by faculty members, including the course medical director, to ensure content validation. Correct answers need to be the best choice or the only correct answer. Incorrect answers and distracters should be plausible to the item and have some attraction to the less than competent participant. Finally, a pass/fail score should be established based upon item analysis and judgment by faculty members responsible for issuing course completion certificates.

The following have been identified as essential items in the 2001 EMT-Intermediate Refresher Program:

Validation of psychomotor performance must be accomplished prior to issuing a certificate of course completion. Three opportunities are available to the instructional staff to validate a participant’s performance.

Pretest
The use of a psychomotor pretest is the best measurement of an individual’s performance. The pretest identifies skills that need to be emphasized during the course. Likewise, if all candidates possess competency in a skill prior to taking the program, it may not be necessary to cover that skill.

Skill Labs
When the sponsoring agency does not administer a pretest, the staff can use the skill labs to measure the competency of each participant. The skill labs ensure validation is sprinkled throughout the refresher program.

End of Program
At the end of the refresher program an evaluation process can be utilized if a pretest and skill labs were not used. If an end of program evaluation process is used, some skills may need to be re-evaluated if participants are unsuccessful.

Participants must have documentation of demonstrating competence for each skill identified during the program regardless of what process is used.

The refresher curriculum is the minimum acceptable content to be covered by education programs. With certifying agency approval, the student may meet some program objectives by satisfactorily completing a nationally recognized trauma life support program, cardiac care program, or pediatric care program. Although some certifying agencies allow providers to attend continuing education programs, it is recommended that providers participate in regularly scheduled group education sessions as well.

Participants who do not complete the program’s objectives or pass the evaluation process should have their performance reviewed by one of the instructional staff members. The participant’s strengths and weaknesses should be identified and a plan developed that helps the participant successfully complete the requirements. This plan may include additional classroom time, clinical time, field time, or repeating the entire program.

Refresher programs are often provided by the same instructional staff in a variety of settings to different groups of participants. The program staff should evaluate each program for its effectiveness when completed. The evaluation can include the participant’s point of view by administering post program evaluation surveys. Some questions to ask when evaluating program effectiveness include:

• Did the program conform to the course design?
• Were the resources adequate?
• Were the skills labs effective?
• Did the test provide valuable information?
• Were the instructors effective in delivering the material?
• Can other instructional methods be incorporated in future courses?
• What were the participant comments?
• Was the course cost effective?

The development of this document would not have been possible without the involvement and help of the following task force members and organizations. Gratitude and thanks are also extended to all the individuals who made comments during the development of this document.

Refresher Curriculum Development Task Force Members

• Provide ventilatory support for a patient.

COGNITIVE OBJECTIVES
At the completion of this unit, the EMT-Intermediate will be able to:

PSYCHOMOTOR OBJECTIVES
At the completion of this unit, the EMT-Intermediate will be able to:

1. Ventilation
   1. Mouth-to-mouth
      1. Most basic form of ventilation
      2. Indications
         1. Apnea from any mechanism when other ventilation devices are not available
      3. Contraindications
         1. Awake patients
         2. Communicable disease risk limitations
      4. Advantages
         1. No special equipment required
         2. Delivers excellent tidal volume
         3. Delivers adequate oxygen
      5. Disadvantages
         1. Psychological barriers from
            1. Sanitary issues
            2. Communicable disease issues
               1. Direct blood/ body fluid contact
               2. Unknown communicable disease risks at time of event
      6. Complications
         1. Hyperinflation of patient's lungs
         2. Gastric distension
         3. Blood/ body fluid contact manifestation
         4. Hyperventilation of rescuer
   2. Mouth-to-nose
      1. Ventilating through nose rather than mouth
      2. Indications
         1. Apnea from any mechanism
      3. Contraindications
         1. Awake patients
      4. Advantages
         1. No special equipment required
      5. Disadvantages
         1. Direct blood/ body fluid contact
         2. Psychological limitations of rescuer
      6. Complications
         1. Hyperinflation of patient's lungs
         2. Gastric distension
         3. Blood/ body fluid manifestation
         4. Hyperventilation of rescuer
   3. Mouth-to-mask
      1. Adjunct to mouth-to-mouth ventilation
      2. Indications
         1. Apnea from any mechanism
      3. Contraindications
         1. Awake patients
      4. Advantages
         1. Physical barrier between rescuer and patient blood/ body fluids
         2. One-way valve to prevent blood/ body fluid splash to rescuer
         3. May be easier to obtain face seal
      5. Disadvantages
         1. Useful only if readily available
      6. Complications
         1. Hyperinflation of patient's lungs
         2. Hyperventilation of rescuer
         3. Gastric distention
      7. Method for use
         1. Position head by appropriate method
         2. Position and seal mask over mouth and nose
         3. Ventilate as appropriate
   4. One person bag-valve-mask
      1. Fixed volume self inflating bag can deliver adequate tidal volumes and O₂ enrichment
      2. Indications
         1. Apnea from any mechanism
         2. Unsatisfactory respiratory effort
      3. Contraindications
         1. Awake, intolerant patients
      4. Advantages
         1. Excellent blood/ body fluid barrier
         2. Good tidal volumes
         3. Oxygen enrichment
         4. Rescuer can ventilate for extended periods without fatigue
      5. Disadvantages
         1. Difficult skill to master
         2. Mask seal may be difficult to obtain and maintain
         3. Tidal volume delivered is dependent on mask seal integrity
      6. Complications
         1. Inadequate tidal volume delivery
         2. Poor technique
         3. Poor mask seal
         4. Gastric distention
      7. Method for use
         1. Position appropriately
         2. Choose proper mask size - seats from bridge of nose to chin
         3. Position, spread/ mold/ seal mask
         4. Hold mask in place
         5. Squeeze bag completely over 1.5 to 2 seconds for adults
         6. Avoid overinflation
         7. Reinflate completely over several seconds
      8. Special considerations
         1. Medical
            1. Observe for
               1. Gastric distension
               2. Changes in compliance of bag with ventilation
               3. Improvement or deterioration of ventilation status (i.e., color change, responsiveness, air leak around mask)
         2. Trauma
            1. Very difficult to perform with cervical spine immobilization in place
   5. Two-person bag-valve-mask ventilation method
      1. Most efficient method
      2. Indications
         1. Bag-valve-mask ventilation on any patient
            1. Especially useful for cervical spine immobilized patients
            2. Difficulty obtaining or maintaining adequate mask seal
      3. Contraindications
         1. Awake, intolerant patients
      4. Advantages
         1. Superior mask seal
         2. Superior volume delivery
      5. Disadvantages
         1. Requires extra personnel
      6. Complications
         1. Hyperinflation of patient's lungs
         2. Gastric distention
      7. Method for use
         1. First rescuer maintains mask seal by appropriate method
         2. Second rescuer squeezes bag
      8. Special considerations
         1. Observe chest movement
         2. Avoid overinflation
         3. Monitor lung compliance with ventilations
   6. Three-person bag-valve-mask ventilation
      1. Indications
         1. Bag-valve-mask ventilation on any patient
            1. Especially useful for cervical spine immobilized patients
            2. Difficulty obtaining or maintaining adequate mask seal
      2. Contraindications
         1. Awake, intolerant patients
      3. Advantages
         1. Superior mask seal
         2. Superior volume density
      4. Disadvantages
         1. Requires extra personnel
         2. "Crowded" around airway
      5. Complications
         1. Hyperinflation of patient’s lungs
         2. Gastric distention
      6. Method for use
         1. First rescuer maintains mask seal by appropriate method
         2. Second rescuer holds mask in place
         3. Third rescuer squeezes bag and monitors compliance
      7. Special considerations
         1. Avoid overinflation
         2. Monitor lung compliance with ventilations
   7. Flow-restricted, oxygen-powered ventilation devices
      1. The valve opening pressure at the cardiac sphincter is approx. 30 cm H₂O
      2. These devices operate at or below 30 cm H₂O to prevent gastric distention
      3. Indications
         1. Delivery of high volume/ high concentration of O₂ (1 L/ sec)
         2. Awake compliant patients
         3. Unconscious patient with caution
      4. Contraindications
         1. Noncompliant patients
         2. Poor tidal volume
         3. Small children
      5. Advantages
         1. Self administered
         2. Delivers high volume/ high concentration O₂
         3. O₂ delivered in response to inspiratory effort (no O₂ wasting)
         4. O₂ volume delivery is regulated by inspiratory effort minimizing overinflation risk
         5. O₂ volume delivery is also restricted to less than 30 cm H₂O
      6. Disadvantages
         1. Cannot monitor lung compliance
         2. Requires O₂ source
      7. Complications
         1. Gastric distention
         2. Barotrauma
      8. Method
         1. Mask is held manually in place
         2. Negative pressure upon inspiration triggers O₂ delivery or medic triggers release button
         3. Patient is monitored for adequate tidal volume and oxygenation
   8. Automatic transport ventilators
      1. Volume/ rate controlled
      2. Indications
         1. Extended ventilation of intubated patients
         2. In situations in which a BVM is used
         3. Can be used during CPR
      3. Contraindications
         1. Awake patients
         2. Obstructed airway
         3. Increased airway resistance
            1. Pneumothorax (after needle decompression)
            2. Asthma
            3. Pulmonary edema
      4. Advantages
         1. Frees personnel to perform other tasks
         2. Lightweight
         3. Portable
         4. Durable
         5. Mechanically simple
         6. Adjustable tidal volume
         7. Adjustable rate
         8. Adapts to portable O₂ tank
      5. Disadvantages
         1. Cannot detect tube displacement
         2. Does not detect increasing airway resistance
         3. Difficult to secure
         4. Dependent on O₂ tank pressure
   9. Cricoid pressure - Sellick’s maneuver
      1. Pressure on cricoid Ring
      2. Occludes esophagus
      3. Facilitates intubation by moving the larynx posteriorly
      4. Helps to prevent passive emesis
      5. Can help minimize gastric distention during bag-valve-mask ventilation
      6. Indications
         1. Unconscious patients receiving BVM ventilations
         2. Patient cannot protect own airway
      7. Contraindications
         1. Use with caution in cervical spine injury
      8. Advantages
         1. Noninvasive
         2. Minimizes risk of aspiration as long as pressure is maintained
      9. Disadvantages
         1. May have extreme emesis if pressure is removed
         2. Second rescuer required for bag-valve-mask ventilation
         3. May further compromise injured cervical spine
      10. Complications
          1. Laryngeal trauma with excessive force
          2. Esophageal rupture from unrelieved high gastric pressures
          3. Excessive pressure may obstruct the trachea in small children
      11. Method
          1. Locate the anterior aspect of the cricoid ring
          2. Apply firm, posterior pressure
          3. Maintain pressure until the airway is secured with an endotracheal tube
   10. Artificial ventilation of the pediatric patient
       1. Flat nasal bridge makes achieving mask seal more difficult
       2. Compressing mask against face to improve mask seal results in obstruction
       3. Mask seal best achieved with jaw displacement (two person bag-valve-mask)
       4. Bag-valve-mask ventilation
          1. Bag size
             1. Full-term neonates and infants - minimum of 450 ml tidal volume (pediatric BVM)
             2. Children up to eight years of age - pediatric BVM preferred but adult-sized BVM (1500 ml) may be used
             3. Children over eight years of age require adult-sized BVM for adequate ventilation
             4. Proper mask fit
             5. Length based resuscitation tape
             6. Bridge of nose to cleft of chin
          2. Proper mask position and seal (EC-clamp)
             1. Place mask over mouth and nose; avoid compressing the eyes
             2. Using one hand, place thumb on mask at apex and index finger on mask at chin (C-grip)
             3. With gentle pressure, push down on mask to establish adequate seal
             4. Maintain airway by lifting bony prominence of chin with remaining fingers forming an "E"; avoid placing pressure on the soft area under chin
             5. May use one or two rescuer technique
          3. Ventilate according to current standards
          4. Obtain chest rise with each breath
             1. Begin ventilation and say "squeeze"; provide just enough volume to initiate chest rise; DO NOT OVERVENTILATE
          5. Allow adequate time for exhalation
             1. Begin releasing the bag and say "release, release"
          6. Continue ventilations using "squeeze, release, release" method
          7. Assess BVM ventilation
             1. Look for adequate chest rise
             2. Listen for lung sounds at third intercostal space, midaxillary line
             3. Assess for improvement in color and/ or heart rate
          8. Apply cricoid pressure to minimize gastric inflation and passive regurgitation
             1. Locate cricoid ring by palpating the trachea for a prominent horizontal band inferior to the thyroid cartilage and cricothyroid membrane
             2. Apply gentle downward pressure using one fingertip in infants and the thumb and index finger in children
             3. Avoid excessive pressure as it may produce tracheal compression and obstruction in infants
   11. Ventilation of stoma patients
       1. Mouth-to-stoma
          1. Locate stoma site and expose
          2. Pocket mask to stoma preferred
             1. Seal around stoma site, check for adequate ventilation
             2. Seal mouth and nose if air leak evident
       2. Bag-valve-mask to stoma
          1. Locate stoma site and expose
          2. Seal around stoma site, check for adequate ventilation
          3. Seal mouth and nose if air leak evident

• Provide care to a patient experiencing cardiovascular compromise.
• Attempt to resuscitate a patient in cardiac arrest.
• Provide post-resuscitation care to a cardiac arrest patient.

COGNITIVE OBJECTIVES
At the completion of this unit, the EMT-Intermediate will be able to:

PSYCHOMOTOR OBJECTIVES
At the completion of this unit, the EMT-Intermediate will be able to:

DECLARATIVE

1. Management of the patient with arrhythmias
   1. Assessment
      1. Symptomatic
      2. Hypotensive
      3. Hypoperfusion
   2. Treatment
      1. Mechanical interventions
         1. Vagal maneuvers - if the heart rate is too fast
         2. Stimulation - if heart rate is too slow
         3. Precordial thump
         4. Cough
      2. Pharmacological interventions (for example)
         1. Aspirin
         2. Atropine
         3. Adenosine
         4. Epinephrine
         5. Furosemide
         6. Lidocaine
         7. Morphine
         8. Nitroglycerin
         9. Oxygen
      3. Electrical
         1. Defibrillation
         2. Transcutaneous pacing
            1. Implanted pacemaker functions
               1. Characteristics
               2. Pacemaker artifact
               3. ECG tracing of capture
               4. Failure to sense
                  1. ECG indications
                  2. Clinical significance
               5. Failure to capture
                  1. ECG indications
                  2. Clinical significance
               6. Failure to pace
                  1. ECG indications
                  2. Clinical significance
      4. Transport considerations
      5. Psychological support / communications strategies
         1. Explanation for patient, family, significant others
         2. Communications and transfer of data to the physician
2. Management of chest pain that may be myocardial infarction
   1. Position of comfort
   2. Pharmacological interventions (for example)
      1. Oxygen
      2. Aspirin
      3. Nitroglycerin
      4. Morphine
   3. ECG
   4. Transport considerations
      1. Sense of urgency for reperfusion
         1. No relief with medications
         2. Hypotension / hypoperfusion
   5. Psychological support / communications strategies
      1. Explanation for patient, family, significant others
      2. Communications and transfer of data to the physician
3. Cardiac Arrhythmias
   1. Common management modalities
      1. Assessment of LOC, airway, breathing and circulation (ABCs)
      2. High flow oxygen
      3. Question medical and medication history, allergies
      4. Communicate with the physician
      5. Intravenous (IV) access
      6. Consider aspirin
      7. Pain management
         1. Nitroglycerin
         2. Morphine
      8. Transport considerations common to all conditions
      9. Psychological support / communications strategies
         1. Explanation for patient, family, significant others
         2. Communications and transfer of data to the physician
   2. Tachycardias, narrow-QRS complex
      1. Sinus tachycardia
         1. Management - ABCs, oxygen (as in III.A)
         2. Identify and treat the cause - e.g., fever, pain, anxiety, anger
         3. Transport and support (as in III.A.8 and .9)
      2. Supraventricular tachycardia
         1. Management - ABCs, oxygen (as in III.A)
            1. Vagal maneuvers
            2. Consider adenosine
               1. Ventricular rate greater than 150
               2. Use with caution, if at all, in atrial flutter
                  1. Fear of catastrophic event resulting from acceleration of ventricular rate, that is, from 2:1 to 1:1 conduction
                  2. Every attempt must be taken to clarify that the patient is not in atrial flutter
               3. When in doubt, do not use adenosine
         2. Transport and support (as in III.A.8 and .9)
      3. Wide-complex (see Ventricular tachycardia)
      4. Bradycardia
      5. Narrow complex
         1. Sinus
         2. Junctional
         3. AV blocks
      6. Management - ABCs, oxygen (as in III.A)
         1. Consider atropine if symptomatic, hypotensive and hypoperfusion
            1. Transport and support (as in III.A.8 and .9)
      7. Wide complex
         1. May have a preexisting complication (identified by history)
            1. Accessory pathway
            2. Bundle branch block
         2. New onset
            1. AV blocks
      8. Management - ABCs, oxygen (as in III.A)
         1. Atropine may be contraindicated
      9. Transport for pacemaker
      10. Support (as in III.A.9)
   3. Ventricular arrhythmias
      1. Ectopics (PVCs)
         1. Management - ABCs, oxygen (as in III.A)
         2. Consider lidocaine
         3. Transport and support (as in III.A.8 and .9)
      2. Ventricular tachycardia
         1. Stable, LOC, blood pressure not impaired
            1. Management - ABCs, oxygen (as in III.A)
            2. Consider lidocaine
            3. Consider adenosine
            4. Transport and support (as in III.A.8 and .9)
         2. Unstable
            1. LOC altered, diminished or unresponsive
            2. Chest pain/pressure
            3. Consider sedation
            4. Consider defibrillation
            5. Transport and support (as in III.A.8 and .9)
         3. Pulseless
            1. Defibrillation as soon as possible
            2. Transport and support (as in III.A.8 and .9)
      3. Ventricular fibrillation
         1. Management
            1. Confirm pulselessness
            2. Cardiopulmonary resuscitation (CPR) until defibrillation is available
               1. Confirm pulses with CPR
               2. High flow oxygen
                  1. Bag-valve-mask
                  2. Intubate
            3. Defibrillation as soon as possible
               1. Energy dosage
                  1. In accordance with local medical protocol
                  2. In accordance with type and model of defibrillator
            4. Pharmacological interventions (for example)
               1. Epinephrine
               2. Lidocaine
            5. Transport and support (as in III.A.8 and .9)
   4. Pulseless electrical activity (PEA)
      1. Management
         1. Confirm pulselessness
         2. Cardiopulmonary resuscitation (CPR)
         3. Confirm pulses with CPR
         4. High flow oxygen
            1. Bag-valve-mask
            2. Intubate
         5. Monitor ECG
            1. Basic ECG rhythm, sinus, atrial, junctional, AV blocks
            2. Ventricular rate
         6. Intravenous (IV) fluids
            1. Fluid challenge
               1. Normal saline
               2. Lactated ringers
         7. Pharmacological interventions (for example)
            1. Epinephrine
            2. Atropine if rhythm is bradycardic
         8. Attempt to identify and treat the cause (for example)
            1. Hypovolemia
            2. Pneumothorax
            3. Tamponade
            4. Hypothermia
            5. Pulmonary embolus
            6. Drug overdose
      2. Transport and support (as in III.A.8 and .9)
   5. Asystole (confirmed in second ECG lead)
      1. Management
         1. Cardiopulmonary resuscitation (CPR)
         2. Confirm pulses with CPR
         3. High flow oxygen
            1. Bag-valve-mask
            2. Intubation
         4. Monitor ECG
            1. Basic ECG rhythm, sinus, atrial, junctional, AV blocks
            2. Ventricular rate
         5. Intravenous (IV) fluids
            1. Fluid challenge
               1. Normal saline
               2. Lactated ringers
         6. Pharmacological interventions (for example)
            1. Epinephrine
            2. Atropine
         7. Attempt to identify and treat the cause (for example)
            1. Hypovolemia
            2. Pneumothorax
            3. Tamponade
            4. Hypothermia
            5. Hyperkalemia
            6. Hypokalemia
            7. Drug overdose
      2. Transport and support (as in III.A.8 and .9)
4. Management of pulmonary edema
   1. Position of comfort
   2. Pharmacological interventions (for example)
      1. Oxygen
      2. Nitroglycerin
      3. Lasix
      4. Morphine
   3. Transport considerations
   4. Psychological support / communications strategies
      1. Explanation for patient, family, significant others
      2. Communications and transfer of data to the physician
5. Management of hypertensive emergencies
   1. Pharmacological interventions (for example)
      1. Oxygen
   2. Non-pharmacological interventions
      1. Position of comfort
      2. Airway and ventilation
   3. Transport considerations
   4. Psychological support / communications strategies
      1. Explanation for patient, family, significant others
      2. Communications and transfer of data to the physician
6. Management of cardiogenic shock
   1. Position of comfort
      1. Patient may prefer sitting upright with legs in dependent position
   2. Pharmacological interventions (for example)
      1. Oxygen
      2. Nitroglycerin
      3. Lasix
      4. Antiarrhythmic as indicated
      5. Fluid therapy
   3. Transport considerations
   4. Psychological support / communications strategies
      1. Explanation for patient, family, significant others
      2. Communications and transfer of data to the physician
7. Management of cardiac arrest
   1. Related terminology
      1. Resuscitation - to provide efforts to return spontaneous pulse and breathing to the patient in cardiac arrest
      2. Survival - patient is resuscitated and survives to hospital discharge
      3. Return of spontaneous circulation (ROSC) - patient is resuscitated to the point of having pulse without CPR; may or may not have return of spontaneous respirations; patient may or may not go on to survive
   2. Indications for NOT initiating resuscitative techniques
      1. Signs of obvious death
         1. Rigor, fixed lividity, decapitation
      2. Local protocol
         1. Out of hospital advance directives
   3. Airway and ventilatory support
      1. High flow oxygen
         1. Bag-valve-mask
         2. Intubation
   4. Circulatory support
      1. CPR in conjunction with defibrillation
      2. IV therapy
   5. Pharmacological interventions (for example)
      1. Oxygen
      2. Epinephrine
      3. Lidocaine
   6. Transport considerations
   7. Psychological support / communications strategies
      1. Explanation for patient, family, significant others
      2. Communications and transfer of data to the physician
   8. Termination of resuscitation
      1. Identify local protocols
      2. Criteria for inclusion (for example)
         1. 18 years old or older
         2. Arrest is presumed cardiac in origin and not association with a condition potentially responsive to hospital treatment (e.g., hypothermia, drug overdose, toxicologic exposure)
         3. Endotracheal intubation has been successfully accomplished and maintained
         4. Standard advanced cardiac life support measures have been applied throughout the resuscitative effort
         5. On-scene ALS resuscitation efforts have been sustained for 25 minutes or the patient remains in asystole through four rounds of appropriate ALS drugs
         6. Patient has a cardiac rhythm of asystole or agonal rhythm at the time the decision to terminate is made and this rhythm persists until the arrest is actually terminated
         7. Victims of blunt trauma in arrest whose presenting rhythm is asystole or who develop asystole while on scene
      3. Exclusion criteria (for example)
         1. Under the age of 18
         2. Etiology for which specific in-hospital treatment may be beneficial
         3. Persistent or recurrent ventricular tachycardia or fibrillation
         4. Transient return of pulse
         5. Signs of neurological viability
         6. Arrest was witnessed by EMS personnel
         7. Family or responsible party opposed to termination
      4. Criteria NOT to be considered as inclusionary or exclusionary
         1. Patient age (e.g., geriatric)
         2. Time of collapse prior to EMS arrival
         3. Presence of a non-official do-not-resuscitate (DNR) order
         4. Quality of life valuations
      5. Procedures (according to local protocol)
         1. Direct communication with on-line medical direction
            1. Medical condition of the patient
            2. Known etiologic factors
            3. Therapy rendered
            4. Family present and apprised of the situation
            5. Communicate any resistance or uncertainty on the part of the family
            6. Maintain continuous documentation to include ECG
            7. Mandatory review after the event
               1. Grief support (according to local protocol)
                  1. EMS assigned personnel
                  2. Community agency referral
               2. Law enforcement (according to local protocol)
                  1. On-scene determination if the event/patient requires assignment of the patient to the medical examiner
                  2. On-scene law enforcement communicates with attending physician for the death certificate
                  3. If there is any suspicion about the nature of the death or if the physician refuses or hesitates to sign the death certificate
                  4. No attending physician is identified (the patient will be assigned to the medical examiner)

1. Assessment findings of allergic reaction
   1. Not all signs and symptoms are present in every case
   2. History
      1. Previous exposure
      2. Previous experience to exposure
      3. Onset of symptoms
      4. Dyspnea
   3. Level of consciousness
      1. Unable to speak
      2. Restless
      3. Decreased level of consciousness
      4. Unresponsive
   4. Upper airway
      1. Hoarseness
      2. Stridor
      3. Pharyngeal edema/ spasm
   5. Lower airway
      1. Tachypnea
      2. Hypoventilation
      3. Labored - accessory muscle use
      4. Abnormal retractions
      5. Prolonged expirations
      6. Wheezes
      7. Diminished lung sounds
   6. Skin
      1. Redness
      2. Rashes
      3. Edema
      4. Moisture
      5. Itching
      6. Urticaria
      7. Pallor
      8. Cyanotic
   7. Vital Signs
      1. Tachycardia
      2. Hypotension
      3. Assessment tools
      4. Cardiac monitor
2. Management of anaphylaxis
   1. Remove offending agent (i.e. remove stinger)
   2. Airway and ventilation
      1. Positioning
      2. Oxygen
      3. Assist ventilation
      4. Advanced airway
   3. Circulation
      1. Venous access
      2. Fluid resuscitation
   4. Pharmacological interventions
      1. Oxygen
      2. Epinephrine - main stay of treatment
         1. Bronchodilator
         2. Decreases vascular permeability
         3. Vasoconstriction
      3. Bronchodilator
   5. Transport considerations
   6. Psychological support / communications strategies
3. Management of acute allergic reaction without dyspnea or hypotension
   1. Remove offending agent (i.e., stinger)
   2. Airway and ventilation
   3. Circulation
   4. Transport considerations
   5. Psychological support / communications strategies
4. Specific pathology, assessment and management - near-drowning
   1. Definitions
      1. Drowning - suffocation due to submersion in water or other fluids.
      2. Near-drowning - near suffocation due to submersion in water or other fluids with a recovery event that lasts at least 24 hours.
   2. Pathophysiology
      1. Hypothermic considerations in near-drownings
         1. Common concomitant syndrome
         2. May be organ protective in cold-water near-drownings
         3. Always treat hypoxia first
         4. Treat all near-drowning patients for hypothermia
   3. Treatment
      1. Establish airway
         1. Conflicting recommendations regarding prophylactic abdominal thrusts
         2. Questionable scientific data to support prophylactic abdominal thrusts
      2. Ventilation
      3. Oxygen
   4. Trauma considerations
      1. Immersion episode of unknown etiology warrants trauma management
   5. Post-resuscitation complications
      1. Adult respiratory distress syndrome (ARDS) or renal failure often occur post-resuscitation
      2. Symptoms may not appear for 24 hours or more, post-resuscitation
      3. All near-drowning patients should be transported for evaluation
5. Specific toxicology, assessment and management
   1. Definition / advantages
      1. Grouping of toxicologically-similar agents
      2. Useful for remembering the assessment and management of toxicological emergencies
      3. Does not consider how or why the toxin has been introduced to the body
      4. Be sure to include the general management on route of entry in addition to specific treatments
   2. Cholinergics
      1. Common causative agents
         1. Pesticides (organophosphates / carbamates)
         2. Nerve agents (sarin, Soman)
      2. Assessment findings
         1. Headache
         2. Dizziness
         3. Weakness
         4. Nausea
         5. SLUDGE (Salivation, Lacrimation, Urination, Defecation, GI upset, Emesis)
         6. Bradycardia, wheezing, bronchoconstriction, myosis, coma, convulsions
         7. Diaphoresis, seizures
   3. Anticholinergics
      1. Common causative agents
      2. Assessment findings
   4. Narcotics / opiates
      1. Common causative agents
         1. Heroin
         2. Morphine
         3. Codeine
         4. Meperidine
         5. Propoxyphene
         6. Fentanyl
      2. Assessment findings
         1. Euphoria
         2. Hypotension
         3. Respiratory depression / arrest
         4. Nausea
         5. Pinpoint pupils
         6. Seizures
         7. Coma
   5. Carbon monoxide
      1. Source
      2. Common causative agents
      3. Pharmacodynamics
      4. Pharmacokinetics
      5. Assessment findings
   6. Psychiatric medications
      1. Tricyclic antidepressants
         1. Clinical use
         2. Common causative agents
            1. Amitriptyline
            2. Amoxapine
            3. Clomipramine
            4. Doxepin
            5. Imipramine
            6. Norptyline
         3. Pharmacodynamics
         4. Pharmacokinetics
         5. Assessment findings
            1. Early findings (dry mouth, confusion, hallucinations)
            2. Late findings (delirium, respiratory depression, hypotension, hyperthermia, seizures, coma)
            3. Cardiotoxicity - dysrhythmias
   7. Bites and stings
      1. Common offendings organisms
         1. Hymenoptera
         2. Spiders
         3. Other anthropods
         4. Snakes
         5. Marine animals
      2. Pharmacodynamics
      3. Pharmacokinetics
      4. Assessment findings

• Perform a rapid trauma assessment
• Provide care to a patient with shock (hypo-perfusion)
• Provide care to a patient with a suspected spinal injury
• Provide care to a patient with a chest injury

Cognitive Objectives
At the completion of this unit, the EMT-Intermediate will be able to:

Psychomotor Objectives
At the completion of this unit, the EMT-Intermediate will be able to:

1. Focused history and physical exam - trauma patients
   1. Re-consider mechanism of injury
      1. Helps to identify priority patients
      2. Helps to guide the assessment
      3. 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
             1. Seat belts
                1. If buckled, may have produced injuries
                2. If patient had seat belt on, it does not mean they do not have injuries
             2. Airbags
                1. May not be effective without seat belt
                2. Patient can hit wheel after deflation
                3. Lift the deployed airbag and look at the steering wheel for deformation
                   1. "Lift and look" under the bag after the patient has been removed
                   2. Any visible deformation of the steering wheel should be regarded as an indicator of potentially serious internal injury, and appropriate action should be taken
                   3. Child safety seats
                      1. Injury patterns with airbags
                      2. Proper use in vehicles with airbags
      4. Additional infant and child considerations
         1. Falls >10 feet
         2. Bicycle collision
         3. Vehicle in medium speed collision
   2. Perform rapid trauma physical examination on patients with significant mechanism of injury to determine life-threatening injuries
      1. In the responsive patient, symptoms should be sought before and during the trauma assessment
      2. Continue spinal stabilization
      3. Reconsider transport decision
      4. Assess mental status
      5. As you inspect and palpate, look and feel for injuries or signs of injury
      6. 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)
         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. Look for medical identification devices
         10. Assess baseline vital signs
         11. Assess patient history
         12. Chief complaint
         13. History of present illness
         14. Past medical history
         15. Current health status
2. Shock
   1. Epidemiology
   2. Pathophysiology
   3. Stages of Shock
   4. Assessment
   5. Management/ treatment plan
      1. Airway and ventilatory support
         1. Ventilate and suction as necessary
         2. Administer high concentration oxygen
         3. Reduce increased intrathoracic pressure in tension pneumothorax
      2. Circulatory support
         1. Hemorrhage control
         2. Intravenous volume expanders
            1. Types
               1. Isotonic solutions
               2. Hypertonic solutions
               3. Synthetic solutions
               4. Blood and blood products
               5. Experimental solutions
               6. Blood substitutes
            2. Rate of administration
               1. External hemorrhage that can be controlled
               2. External hemorrhage that can not be controlled
            3. Internal hemorrhage
               1. Blunt trauma
               2. Penetrating trauma
         3. Pneumatic anti-shock garment
            1. Effects
               1. Increased arterial blood pressure above garment
               2. Increased systemic vascular resistance
               3. Immobilization of pelvis and possibly lower extremities
               4. Increased intra-abdominal pressure
            2. Mechanism
               1. Increases systemic vascular resistance through direct compression of tissues and blood vessels
               2. Negligible autotransfusion effect
            3. Indications
               1. Hypoperfusion with unstable pelvis
               2. Conditions of decreased SVR not corrected by other means
               3. As approved locally, other conditions characterized by hypoperfusion with hypotension
               4. Research studies
            4. Contraindications
               1. Advanced pregnancy (no inflation of abdominal compartment)
               2. Object impaled in abdomen or evisceration (no inflation of abdominal compartment)
               3. Ruptured diaphragm
               4. Cardiogenic shock
               5. Pulmonary edema
         4. Needle chest decompression of tension pneumothorax to improve impaired cardiac output
         5. Recognize the need for expeditious transport of suspected cardiac tamponade for pericardiocentesis
      3. Pharmacological interventions
         1. Hypovolemic shock
            1. Volume expanders
         2. Cardiogenic shock
            1. Volume expanders
            2. Positive cardiac inotropes
            3. Vasoconstrictor
            4. Rate altering medications
         3. Distributive shock
            1. Volume expanders
            2. Positive cardiac inotropes
            3. Vasoconstriction
            4. PASG
         4. Obstructive shock
            1. Volume expanders
         5. Spinal shock
            1. Volume expanders
      4. Psychological support/communication strategies
      5. Transport considerations
         1. Indications for rapid transport
         2. Indications for transport to a trauma center
         3. Considerations for air medical transportation
3. Thoracic trauma
   1. General Introduction
      1. Epidemiology
      2. Mechanism of injury
      3. Anatomy and physiology review of the thorax
      4. Pathophysiology
      5. Assessment findings
      6. Management
         1. Airway and ventilation
            1. Oxygen therapy
            2. Endotracheal intubation
            3. Needle cricothyrotomy
            4. Surgical cricothyrotomy
            5. Positive pressure ventilation
            6. Occlude open wounds
            7. Stabilize chest wall
         2. Circulation
            1. Manage cardiac dysrhythmias
            2. Intravenous access
         3. Pharmacologic
            1. Analgesics
            2. Antiarrhythmics
         4. Non-pharmacologic
            1. Needle thoracostomy
            2. Tube thoracostomy - in hospital management
            3. Pericardiocentesis - in hospital management
         5. Transport considerations
            1. Appropriate mode
            2. Appropriate facility
   2. Chest wall injuries
      1. Rib fractures
         1. Epidemiology
         2. Anatomy and physiology review
         3. Pathophysiology
         4. Assessment findings
         5. Management
            1. Airway and ventilation
               1. Oxygen therapy
               2. Positive pressure ventilation
               3. Encourage coughing and deep breathing
            2. Pharmacological
               1. Analgesics
            3. Non-pharmacological
               1. Splint - but avoid circumferential splinting
            4. Transport consideration
               1. Appropriate mode
               2. Appropriate facility
            5. Psychological support/ communication strategies
      2. Flail segment
         1. Epidemiology
         2. Pathophysiology
         3. Assessment findings
         4. Management
            1. Airway and ventilation
               1. Positive pressure ventilation may be needed
               2. Oxygen (high concentration)
               3. Evaluate the need for endotracheal intubation
               4. Stabilize flail segment (may be controversial locally)
               5. Positive end expiratory pressure (PEEP)
            2. Circulation
               1. Restrict fluids
            3. Pharmacologic
               1. Analgesics
            4. Non-pharmacologic
               1. Positioning
               2. Endotracheal intubation and positive pressure ventilation for internal splinting effect
            5. Transport considerations
               1. Appropriate mode
               2. Appropriate facility
            6. Psychological support/ communication strategies
      3. Sternal fracture
         1. Epidemiology
         2. Pathophysiology
         3. Assessment findings
         4. Management
            1. Airway and ventilation
            2. Circulation
               1. Restrict fluids if pulmonary contusion is suspected
            3. Pharmacologic
               1. Analgesics
            4. Non-pharmacologic
               1. Allow chest wall self-splinting
            5. Transport considerations
               1. Appropriate mode
               2. Appropriate facility
            6. Psychological support/ communication strategies
   3. Injury to the lung
      1. Simple pneumothorax
         1. Epidemiology
         2. Pathophysiology
         3. Assessment findings
         4. Management
            1. Airway and ventilation
               1. Positive pressure ventilation if necessary
               2. Monitor for development of tension pneumothorax
            2. Non-pharmacologic
               1. Needle thoracostomy
            3. Transport consideration
               1. Appropriate mode
               2. Appropriate facility
            4. Psychological support/ communication strategies
      2. Open pneumothorax
         1. Epidemiology
         2. Pathophysiology
         3. Assessment findings
         4. Management
            1. Airway and ventilation
               1. Positive pressure ventilation if necessary
               2. Monitor for development of tension pneumothorax
            2. Non-pharmacologic
               1. Occlude open wound
               2. Tube thoracostomy - in hospital management
            3. Transport consideration
               1. Appropriate mode
               2. Appropriate facility
            4. Psychological support/ communication strategies
      3. Tension pneumothorax
         1. Epidemiology
         2. Pathophysiology
         3. Assessment findings
         4. Management
            1. Airway and ventilation
               1. Positive pressure ventilation if necessary
            2. Circulation
               1. Relieve tension pneumothorax to improve cardiac output
            3. Non-pharmacologic
               1. Occlude open wound
               2. Needle thoracentesis

• Equipment
• Technique
• Assess the need for a second or third needle insertion

1. Tube thoracostomy - in hospital management
2. Transport consideration
   1. Appropriate mode
   2. Appropriate facility
3. Psychological support/ communication strategies

1. Hemothorax
   1. Epidemiology
   2. Pathophysiology
   3. Assessment findings
   4. Management
      1. Airway and ventilation
         1. Positive pressure ventilation if necessary
      2. Circulation
         1. Re-expand the affected lung to reduce bleeding
      3. Non-pharmacological
         1. Needle chest decompression
         2. Tube thoracostomy - in hospital management
      4. Transport considerations
         1. Appropriate mode
         2. Appropriate facility
      5. Psychological support/ communication strategies
2. Hemopneumothorax
   1. Epidemiology
   2. Pathophysiology
   3. Assessment findings
   4. Management
      1. Management is the same as a hemothorax
3. Pulmonary contusion
   1. Epidemiology
   2. Pathophysiology
   3. Assessment findings
   4. Management
      1. Airway and ventilation
         1. Positive pressure ventilation if necessary
      2. Circulation
         1. Restrict intravenous fluids (use caution restricting fluids in hypovolemic patients)
      3. Transport considerations
         1. Appropriate mode
         2. Appropriate facility
      4. Psychological support/ communication strategies

1. Myocardial injuries
   1. Pericardial tamponade
      1. Epidemiolgy
      2. Anatomy and physiology
      3. Pathophysiology
      4. Assessment findings
      5. Management
         1. Airway and ventilation
         2. Circulation
            1. Fluid challenge
         3. Non-pharmacological
            1. Pericardiocentesis - in hospital management
         4. Transport considerations
            1. Appropriate mode
            2. Appropriate facility
         5. Psychological support/ communication strategies
   2. Myocardial contusion (blunt myocardial injury)
      1. Epidemiology
      2. Anatomy and physiology
      3. Pathophysiology
      4. Assessment findings
      5. Management
         1. Airway and ventilation
            1. Oxygen therapy
         2. Circulation
            1. Intravenous fluid volume
         3. Pharmacological
            1. Antiarrhythmics
            2. Vasopressors
         4. Transport considerations
            1. Appropriate mode
            2. Appropriate facility
         5. Psychological support/ communication strategies
   3. Myocardial rupture
      1. Epidemiology
      2. Anatomy and physiology
      3. Pathophysiology
      4. Assessment findings
      5. Management is supportive
2. Vascular injuries
   1. Aortic dissection/ rupture
      1. Epidemiology
      2. Anatomy and physiology
      3. Pathophysiology
      4. Assessment findings
      5. Management
         1. Airway and ventilation
         2. Circulation
            1. Do not over hydrate
         3. Transport considerations
            1. Appropriate mode
            2. Appropriate facility
         4. Psychological support/ communication strategies
   2. Penetrating wounds of the great vessels
      1. Epidemiology
      2. Anatomy and physiology
      3. Pathophysiology
      4. Assessment findings
      5. Management
         1. Manage hypovolemia
            1. PASG not recommended
         2. Relief of tamponade if present
         3. Expeditious transport
3. Other thorax injuries
   1. Diaphragmatic injury
      1. Epidemiology
      2. Pathophysiology
      3. Assessment
      4. Management
         1. Airway and ventilation
            1. Positive pressure ventilation if necessary
            2. Caution IPPB may worsen the injury
         2. Non-pharmacologic
            1. Do not place patient in Trendelenburg position
         3. Transport consideration
            1. Appropriate mode
            2. Appropriate facility
         4. Psychological support/ communication strategies
   2. Esophageal injury
      1. Epidemiology
      2. Pathophysiology
      3. Assessment
      4. Management
         1. Airway and ventilation
         2. Transport consideration
            1. Appropriate mode
            2. Appropriate facility
         3. Psychological support/ communication strategies
   3. Tracheo-bronchial injuries
      1. Epidemiology
      2. Pathophysiology
      3. Assessment
      4. Management
         1. Airway and ventilation
         2. Circulation
         3. Transport consideration
            1. Appropriate mode
            2. Appropriate facility
   4. Traumatic asphyxia
      1. Epidemiology
      2. Pathophysiology
      3. Assessment
      4. Management
         1. Airway and ventilation
         2. Circulation
            1. Expect hypotension once compression is released
         3. Pharmacological
            1. Sodium bicarbonate should be guided by ABGs in hospital
         4. Transport considerations
            1. Appropriate mode
            2. Appropriate facility

• Assess an infant or child w/ cardiac arrest
• Provide care to an infant or child w/ cardiac arrest
• Assess an infant or child w/ respiratory distress
• Provide care to an infant or child in respiratory distress
• Assess an infant or child with shock (hypoperfusion)
• Provide care to an infant or child with shock (hypoperfusion)
• Assess an infant or child with trauma
• Provide care to an infant or child with trauma

Cognitive Objectives
At the completion of this unit, the EMT-Intermediate will be able to:

PSYCHOMOTOR OBJECTIVES
At the completion of this unit, the EMT-Intermediate will be able to: