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:

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 resources.

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-Paramedic 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 current EMT-Paramedics to become certified at the revised 1998 EMT-Paramedic 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.

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 1998 EMT-Paramedic: 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-Paramedics 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-Paramedic 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?

At the end of each program, the faculty and course medical director must meet to determine if the course met its desired needs. The faculty needs to review content design, measurements, course completion criteria, and participant comments. Adjustments to future programs may be indicated once the evaluation process is complete.

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 paramedic will be able to:

PSYCHOMOTOR OBJECTIVES
At the completion of this unit, the paramedic 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 distention
         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 distention
         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 distention
               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. Non-compliant 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
   12. Translaryngeal cannula ventilation
       1. High volume/ high-pressure ventilation of lungs through cannulation of trachea below the glottis
          1. Oxygen delivery differs from other methods
          2. Delivers a large volume of O₂ through a small port
          3. Delivers a very high pressure to the lungs compared to other methods (50 psi versus less than 1 psi through a regulator)
       2. Indications
          1. Apnea
          2. Delayed or inability to ventilate the patient by other means
       3. Contraindications
          1. Total airway obstruction (both inspiratory and expiratory)
          2. Equipment not immediately available
       4. Advantages
          1. Rapidly performed
          2. Provides adequate ventilation when performed properly
          3. Does not manipulate the cervical spine
          4. Does not interfere with subsequent attempts to intubate
       5. Disadvantages
          1. Requires jet ventilator
          2. Expends high volumes of oxygen more rapidly
          3. May not protect against aspiration
       6. Equipment
          1. Large bore IV catheter (14-16 gauge)
          2. 10 cc syringe
          3. 3 ccs of water or saline (optional)
          4. Oxygen source (50 psi)
          5. Jet ventilator
       7. Method
          1. Prepare equipment
          2. Identify cricothyroid membrane
          3. Insert needle with syringe midline through cricothyroid membrane at a slight angle towards sternum
          4. Withdraw on syringe plunger until air is freely withdrawn (bubbles if fluid is in syringe)
          5. Advance additional 1 cm
          6. Hold needle steady, advance catheter to hub
          7. Attach jet ventilator
          8. Ventilate once per five seconds
          9. Exhalation is passive through the glottis
       8. Complications
          1. Bleeding
             1. From improper catheter placement
          2. Subcutaneous emphysema
             1. From excessive air leak around catheter site or undetected laryngeal trauma
          3. Airway obstruction
             1. Result of excessive bleeding or subcutaneous air which compresses trachea
          4. Barotrauma
             1. Resulting from overinflation
          5. Hypoventilation

    

2. Airway Techniques
   1. Endotracheal intubation techniques
      1. Medical patient
         1. Orotracheal intubation by direct laryngoscopy
      2. Trauma patient
         1. Orotracheal intubation by direct laryngoscopy
         2. Nasotracheal intubation techniques
            1. Indications
      3. Confirming placement
         1. Direct re-visualization
         2. Tube condensation
         3. Auscultation
         4. Palpation of balloon cuff at sternal notch
         5. Pulse oximetry
         6. Expired CO₂
         7. Bag-valve ventilation compliance
      4. Field extubation
      5. Endotracheal tube securing device
   2. Multi-lumen airways
      1. Pharyngo-tracheal lumen airway
         1. Indications
         2. Advantages
         3. Disadvantages
         4. Method
         5. Complications
         6. Special considerations
      2. Combitube
         1. Indications
         2. Advantages
         3. Disadvantages
         4. Method
         5. Complications
         6. Special considerations

• 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 paramedic will be able to:

PSYCHOMOTOR OBJECTIVES
At the completion of this unit, the paramedic will be able to:

1. Management of the patient with arrhythmias
   1. Assessment
   2. Pharmacological
      1. Gases (such as oxygen)
      2. Sympathetic (such as epinephrine)
      3. Anticholinergic (such as atropine)
      4. Antiarrhythmic (such as lidocaine)
      5. Beta blocker
         1. Selective (such as metoprolol)
         2. Non-selective (such as propranolol)
      6. Vasopressor (such as dopamine)
      7. Calcium channel blocker (such as verapamil)
      8. Purine nucleoside (such as adenosine)
      9. Platelet aggregate inhibitor (such as aspirin)
      10. Alkalinizing agents (such as sodium bicarbonate)
      11. Cardiac glycoside (such as digitalis)
      12. Narcotic/ analgesic (such as morphine)
      13. Diuretic (such as furosemide)
      14. Nitrate (such as nitroglycerin)
      15. Antihypertensive (such as sodium nitroprusside)
   3. Electrical
      1. Purpose
      2. Methods
         1. Synchronized cardioversion
         2. Defibrillation
      3. Cardiac pacing
         1. Implanted pacemaker functions
            1. Characteristics
            2. Pacemaker artifact
            3. ECG tracing of capture
            4. Failure to sense
               1. ECG findings
               2. Clinical significance
            5. Failure to capture
               1. ECG findings
               2. Clinical significance
            6. Failure to pace
               1. ECG findings
               2. Clinical significance
            7. Pacer-induced tachycardia
               1. ECG findings
               2. Clinical significance
               3. Treatment
         2. Transcutaneous pacing
            1. Criteria for use
            2. Bradycardia
               1. Patient is hypotensive/ hypoperfusing
               2. No change with pharmacologic intervention
            3. Second degree AV block
               1. Patient is hypotensive/ hypoperfusing
               2. No change with pharmacologic intervention
            4. Complete AV block
               1. Patient is hypotensive/ hypoperfusing
               2. No change with pharmacologic intervention
            5. Asystole
            6. Overdrive
               1. Deter occurrence of recurrent tachycardia
      4. Set-up
         1. Placement of electrodes
         2. Rate and milliampere (mA) settings
         3. Pacer artifact
         4. Capture
         5. Failure to sense
            1. Causes
            2. Implications
            3. Interventions
         6. Failure to capture
            1. Causes
            2. Implications
            3. Interventions
         7. Failure to pace
            1. Causes
            2. Implications
            3. Interventions
         8. Hazards
         9. Complications
            1. Interventions
   4. Transport
      1. Indications for rapid transport
      2. Indications for no transport required
      3. Indications for referral
   5. Support and communications strategies
      1. Explanation for patient, family, significant others
      2. Communications and transfer of data to the physician
2. Myocardial infarction
   1. Epidemiology
   2. Morbidity / Mortality
   3. Initial Assessment Findings
   4. Focused History
   5. Detailed Physical Exam
   6. Management
      1. Position of comfort
      2. Pharmacological
         1. Gases
         2. Nitrates
         3. Platelet aggregate inhibitor
         4. Analgesia
         5. Increase or decrease heart rate
         6. Possible antiarrhythmic
         7. Possible antihypertensives
      3. Electrical
         1. Constant ECG monitoring
         2. Defibrillation/ synchronized cardioversion
         3. Transcutaneous pacing
      4. Transport
         1. Criteria for rapid transport
            1. No relief with medications
               1. Hypotension/ hypoperfusion
               2. Significant changes in ECG
         2. ECG criteria for rapid transport and reperfusion
            1. Time of onset of pain
            2. ECG rhythm abnormalities
         3. Indications for "no transport"
            1. Refusal
            2. No other indications for no-transport
         4. Support and communications strategies
            1. Explanation for patient, family, significant others
            2. Communications and transfer of data to the physician
3. Heart failure
   1. Epidemiology
   2. Morbidity / Mortality
   3. Initial Assessment
   4. Focused History
   5. Detailed Physical Exam
   6. Complications
   7. Management
      1. Position of comfort
      2. Pharmacological
         1. Gases
         2. Afterload reduction
         3. Analgesia
         4. Diuresis
         5. Other
      3. Transport
         1. Refusal
         2. No other indications for no-transport
   8. Support and communications strategies
      1. Explanation for patient, family, significant others
      2. Communications and transfer of data to the physician
4. Cardiac tamponade
   1. Pathophysiology
   2. Morbidity / Mortality
   3. Initial Assessment
   4. Focused History
   5. Detailed Physical Examination
   6. Management
      1. Airway management and ventilation
      2. Circulation
      3. Pharmacological
      4. Non-pharmacological
      5. Rapid transport for pericardiocentesis
   7. Support and communications strategies
      1. Explanation for patient, family, significant others
      2. Communications and transfer of data to the physician
5. Hypertensive Emergencies
   1. Epidemiology and precipitating causes
   2. Mortality / Morbidity
      1. Hypertensive encephalopathy
      2. Stroke
   3. Initial Assessment
      1. Airway/breathing
      2. Circulation
   4. Focused History
      1. Chief complaint
      2. Medication history
      3. Home oxygen use
   5. Detailed Physical Examination
      1. Airway
      2. Breathing
      3. Circulation
      4. Diagnostic signs/symptoms
   6. Management
      1. Non-pharmacologic
         1. Position of comfort
         2. Airway and ventilation
      2. Pharmacological
         1. Gases
         2. Other
      3. Rapid transport
         1. Refusal
         2. No other indications for no transport
   7. Support and communications strategies
      1. Explanation for patient, family, significant others
      2. Communications and transfer of data to the physician
6. Cardiogenic Shock
   1. Pathophysiology
   2. Initial Assessment
   3. Focused History
   4. Detailed Physical Examination
   5. Management
      1. Position of comfort
         1. May prefer sitting upright with legs in dependent position
      2. Pharmacological
         1. Gases
         2. Vasopressor
         3. Analgesia
         4. Diuretics
         5. Glycoside
         6. Sympathetic agonist
         7. Alkalinizing agent
         8. Other
   6. Transport
      1. Refusal
      2. No other indications for no transport
   7. Support and communications strategies
      1. Explanation for patient, family, significant others
      2. Communications and transfer of data to the physician
7. Cardiac arrest
   1. Pathophysiology
   2. Initial assessment
   3. Focused history
   4. Management
      1. Related terminology
         1. Resuscitation - to provide efforts to return spontaneous pulse and breathing to the patient in full 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. For example - rigor; fixed lividity; decapitation
         2. Local protocol
            1. For example - out-of-hospital advance directives
      3. Advanced airway management and ventilation
      4. Circulation
         1. CPR in conjunction with defibrillation
         2. IV therapy
         3. Defibrillation
         4. Pharmacological
            1. Gases (oxygen)
            2. Sympathetic
            3. Anticholinergic
            4. Antiarrhythmic
            5. Vasopressor
            6. Alkalinizing agents
            7. Parasympatholytic
      5. Rapid transport
      6. Support and communications strategies
         1. Explanation for patient, family, significant others
         2. Communications and transfer of data to the physician

1. Anaphylaxis
   1. Epidemiology
   2. Pathophysiology
   3. Assessment findings
      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
      8. Gastrointestinal
         1. Abnormal cramping
         2. Nausea/ vomiting
         3. Diarrhea
      9. Assessment tools
         1. Cardiac monitor
         2. Pulse oximetry low
         3. End tidal CO₂ high
   4. 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
         1. Oxygen
         2. Epinephrine - main stay of treatment
            1. Bronchodilator
            2. Decrease vascular permeability
         3. Antihistamine
         4. Antiinflammatory/ immunosuppressant
         5. Vasopressor
      5. Psychological support
      6. Transport considerations
   5. Management of allergic reaction
      1. Without dyspnea
         1. Antihistamine
      2. With dyspnea
         1. Oxygen
         2. Subcutaneous epinephrine
         3. Antihistamine
2. Near-Drowning
   1. Definition
      1. Submersion episode with at least transient recovery
   2. Pathophysiology
      1. Wet versus dry drownings
         1. Fluid in posterior oropharynx stimulates laryngospasm
         2. Aspiration occurs after muscular relaxation
         3. Suffocation occurs with or without aspiration
         4. Aspiration presents as airway obstruction
      2. Fresh versus saltwater considerations
         1. Despite mechanistic differences, there is no difference in metabolic result
         2. No difference in out-of-hospital treatment
      3. 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
         3. Ventilation
         4. Oxygen
      2. Trauma considerations
         1. Immersion episode of unknown etiology warrants trauma management
      3. 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
3. General toxicology, assessment and management
   1. Types of toxicological emergencies
      1. Unintentional poisoning
         1. Dosage errors
         2. Idiosyncratic reactions
         3. Childhood poisoning
         4. Environmental exposure
         5. Occupational exposures
         6. Neglect and Abuse
      2. Drug/ alcohol abuse
      3. Intentional poisoning/ overdose
         1. Chemical warfare
         2. Assault/ homicide
         3. Suicide attempts
   2. Use of poison control centers
   3. Routes of absorption
      1. Ingestion
      2. Inhalation
      3. Injection
      4. Absorption
   4. Poisoning by ingestion
      1. Examples
      2. Assessment findings
      3. General management considerations
   5. Poisoning by inhalation
      1. Examples
      2. Assessment findings
      3. General management considerations
   6. Poisoning by injection
      1. Examples
      2. Assessment findings
      3. General management considerations
   7. Poisoning by absorption
      1. Examples
      2. Assessment findings
      3. General management considerations
   8. Alcoholism
      1. Epidemiology
      2. Psychological issues
      3. Psycho-social issues
      4. Pathophysiology of long term alcohol abuse
         1. End organ damage
         2. Malnutrition
         3. Withdrawal syndrome
      5. Assessment findings
   9. Toxic syndromes
      1. 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. Management
      2. Anticholinergic
         1. Common causative agents
         2. Assessment findings
         3. Management
      3. Hallucinogens
         1. Common causative agents
            1. lysergic acid diethylamide (LSD)
            2. phenyclicidine (PCP)
            3. Peyote
            4. mushrooms
         2. Assessment findings
            1. Chest pain
         3. Management
      4. Narcotics/ opiates
         1. Common causative agents -
            1. heroin
            2. morphine
            3. codeine
            4. meperidine
            5. propoxyphene
         2. Assessment findings
            1. Euphoria
            2. Hypotension
            3. Respiratory depression/ arrest
            4. Nausea
            5. Pinpoint pupils
            6. Seizures
            7. Coma
         3. Management
      5. Sympathomimetics
         1. Common causative agents
         2. Assessment findings
         3. Management
4. Specific toxicology, assessment and management
   1. Cocaine
      1. Clinical uses
      2. Common causative agents
      3. Common street names
      4. Assessment findings
      5. Management
   2. Marijuana and cannabis compounds
      1. Clinical uses
      2. Common causative agents
      3. Common street names
      4. Assessment findings
      5. Management
   3. Amphetamines and amphetamine-like drugs
      1. Clinical uses
      2. Common causative agents
      3. Common street names
      4. Assessment findings
      5. Management
   4. Barbiturates
      1. Clinical uses
      2. Common causative agents
      3. Common street names
      4. Assessment findings
      5. Management
   5. Sedative-hypnotics
      1. Clinical uses
      2. Common causative agents
      3. Common street names
      4. Assessment findings
      5. Management
   6. Cyanide
      1. Clinical uses
      2. Common causative agents
      3. Common street names
      4. Assessment findings
      5. Management
   7. Narcotics/ opiates
      1. Clinical uses
      2. Common causative agents
      3. Common street names
      4. Assessment findings
      5. Management
   8. Cardiac medications
      1. Clinical uses
      2. Common causative agents
      3. Common street names
      4. Assessment findings
      5. Management
   9. Caustics
      1. Clinical uses
      2. Common causative agents
      3. Common street names
      4. Assessment findings
      5. Management
   10. Common household poisonings
       1. Clinical uses
       2. Common causative agents
       3. Common street names
       4. Assessment findings
       5. Management
   11. Drugs abused for sexual purposes/ sexual gratification
       1. Clinical uses
       2. Common causative agents
       3. Common street names
       4. Assessment findings
       5. Management
   12. Carbon monoxide
       1. Clinical uses
       2. Common causative agents
       3. Common street names
       4. Assessment findings
       5. Management
   13. Alcohols
       1. Clinical uses
       2. Common causative agents
       3. Common street names
       4. Assessment findings
       5. Management
   14. Hydrocarbons
       1. Clinical uses
       2. Common causative agents
       3. Common street names
       4. Assessment findings
       5. Management
   15. Tricyclic antidepressants
       1. Clinical uses
       2. Common causative agents
       3. Common street names
       4. Assessment findings
       5. Management
   16. Newer anti-depressants and serotonin syndromes
       1. Clinical uses
       2. Common causative agents
       3. Common street names
       4. Assessment findings
       5. Management
   17. Lithium
       1. Clinical uses
       2. Common causative agents
       3. Common street names
       4. Assessment findings
       5. Management
   18. Non-prescription pain medications
       1. Clinical uses
       2. Common causative agents
       3. Common street names
       4. Assessment findings
       5. Management
   19. Nonsteroidal anti-inflammatory agents
       1. Salicylates
       2. Clinical uses
       3. Common causative agents
       4. Common street names
       5. Assessment findings
       6. Management
   20. Acetaminophen
       1. Clinical uses
       2. Common causative agents
       3. Common street names
       4. Assessment findings
       5. Management
   21. Metals
       1. Clinical uses
       2. Common causative agents
       3. Common street names
       4. Assessment findings
       5. Management
   22. Plants and mushrooms
       1. Clinical uses
       2. Common causative agents
       3. Common street names
       4. Assessment findings
       5. Management

Module IV: Trauma

• Perform a rapid trauma assessment
• Provide care to a patient with shock (hypoperfusion)
• Assess a patient with a head injury
• Assess a patient with a suspected spinal injury
• Provide care to a patient with a suspected spinal injury
• Provide care to a patient with a chest injury
• Provide care to a patient with a open abdominal injury

Cognitive Objectives
At the completion of this unit, the paramedic will be able to:

Psychomotor Objectives
At the completion of this unit, the paramedic 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
      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) (may use information from the head injury unit 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. 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
         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
            5. Needle chest decompression of tension pneumothorax to improve impaired cardiac output
            6. 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. Head trauma
   1. Review of anatomy and physiology
   2. Mechanisms of injury
   3. General categories of injury
   4. Causes of brain injury
   5. Head injury – broad and inclusive
   6. Brain injury
   7. Pathophysiology of head/brain injury
      1. Increased intracranial pressure
      2. Mechanism
      3. Assessment
         1. Pressure exerted downward
            1. Cerebral cortices and/ or reticular activating system effected
               1. Altered level of consciousness - amnesia of event, confusion, disorientation, lethargy or combativeness, focal deficit or weakness
            2. Hypothalamus - vomiting
            3. Brain stem
               1. Blood pressure elevates to maintain MAP and thus CPP
               2. Vagal nerve pressure - bradycardia
               3. Respiratory centers - irregular respirations or tachypnea
               4. Oculomotor nerve paralysis - unequal/ unreactive pupils
               5. Posturing - flexion/ extension
            4. Seizures - depending on location of injury
         2. Levels of increasing ICP
            1. Cerebral cortex and upper brain stem involved
               1. BP rising and pulse rate begins slowing
               2. Pupils still reactive
               3. Cheyne-Stokes respirations
               4. Initially try to localize and remove painful stimuli
               5. All effects reversible at this stage
            2. Middle brain stem involved
               1. Wide pulse pressure and bradycardia
               2. Pupils nonreactive or sluggish
               3. Central neurogenic hyperventilation (CNH)
               4. Extension
               5. Few patients function normally from this level
            3. Lower portion of brain stem involved/ medulla
               1. Pupil blown - same side as injury
               2. Respirations ataxic (erratic, no rhythm) or absent
               3. Flaccid
               4. Labile pulse rate, irregular often great pulse swings in rate
               5. QRS, S-T and T wave changes
               6. Decreased BP, often labile BP
               7. Not considered survivable
         3. Glasgow coma scale - method to assess level of consciousness
            1. Three independent measurements
               1. Eye opening
               2. Verbal response
               3. Motor response
            2. Numerical score - 3 to 15
            3. Head injury classified according to score
               1. Mild - 13 to 15
               2. Moderate - 8 to 12
               3. Severe - < 8
               4. Vital signs
               5. Pupil size and reaction
               6. Presence of focal deficit
               7. History of unconsciousness or amnesia of event
            4. Management
   8. Specific Injuries - diffuse axonal injury and focal injuries
      1. Diffuse axonal injury - shearing, stretching or tearing of nerve fibers with subsequent axonal damage
         1. Concussion (mild DAI) - physiologic neurologic dysfunction without substantial anatomic disruption which results in transient episode of neuronal dysfunction with rapid return to normal neurologic activity
            1. Epidemiology
            2. Assessment - confusion, disorientation, amnesia of the event
            3. Management
      2. Moderate DAI - shearing, stretching or tearing results in minute petechial bruising of brain tissue, brain stem and reticular activating system may be involved leading to unconsciousness
         1. Epidemiology
         2. Assessment - may result in immediate unconsciousness or persistent confusion, disorientation and amnesia of the event extending to amnesia of moment-to-moment events; may have focal deficit; residual cognitive (inability to concentrate), psychologic (frequent periods of anxiety, uncharacteristic mood swings) and sensorimotor deficits (sense of smell altered) may persist
         3. Management
      3. Severe DAI - formerly called brain stem injury, involves severe mechanical disruption of many axons in both cerebral hemispheres and extending to the brainstem
         1. Epidemiology
         2. Assessment - unconsciousness for prolonged period, posturing common, other signs of increased ICP occur depending on various degrees of damage
         3. Management
      4. Focal injury
         1. Skull fracture - the significance is in the amount of force involved
            1. Epidemiology
            2. Types
               1. Linear (80% of all skull fractures)
               2. Depressed
               3. Basilar
               4. Open skull fractures
            3. Assessment - linear fractures may be missed, depressed and open skull fractures usually found on palpation of head, use balls of fingers to palpate
               1. Airway patency and breathing adequacy a priority
               2. Vomiting and inadequate respirations are common
               3. Assess for signs and symptoms of increased intracranial pressure
            4. Management
         2. Cerebral contusion - a focal brain injury in which brain tissue is bruised and damaged in a local area; may occur at both the area of direct impact (coup) and/or on the opposite side (contrecoup) of impact
            1. Epidemiology
            2. Assessment
               1. Airway patency and breathing adequacy a priority
               2. Alteration in level of consciousness
               3. May complain of progressive headache and/ or photophobia
               4. May be unable to lay down memory - repetitive phrases common
               5. Assess for signs and symptoms of increased intracranial pressure
            3. Management
         3. Intracranial hemorrhage
            1. Types
               1. Epidural
               2. Subdural
               3. Intracerebral
               4. Subarachnoid
            2. Epidemiology
            3. Assessment
               1. May be impossible to tell which type of hematoma is present
               2. More important to recognize the presence of brain injury
               3. Signs/ symptoms of increasing intracranial pressure
               4. Signs/ symptoms of neurolog