Mosby ’ s Paramedic Textbook ABOUT THE AUTHOR AND CONTRIBUTORS Mick J. Sanders, EMT-P, MSA, received his paramedic project and is currently a Board of Director for the National training in 1978 from St. Louis University Hospitals. He Association of EMS Educators. earned a Bachelor of Science degree and a Master of Science degree from Lindenwood University in St. Charles, Mis- Lawrence M. Lewis, MD, FACEP, is Professor of Emergency souri. He has worked in various health care systems as a Medicine in Medicine at Washington University School fi eld paramedic, emergency department paramedic, and of Medicine and Barnes-Jewish Hospital in St. Louis, EMS instructor. For 12 years, Mr. Sanders served as Train- Missouri. He completed his medical school training at the ing Specialist with the Bureau of Emergency Medical Ser- University of Miami School of Medicine before attending a vices, Missouri Department of Health, where he oversaw residency at Washington University. Dr. Lewis is an active EMT and paramedic training and licensure in St. Louis city researcher in emergency medicine with more than 60 pub- and the surrounding metropolitan areas. lications and serves on several national and state emergency medicine committees. Kim D. McKenna, MEd, RN, CEN, EMT-P is the Director of Education for the St. Charles County Ambulance Dis- Gary Quick, MD, FACEP retired as Medical Director at trict and Adjunct Professor at Lindenwood University, Southwestern Medical Center, Lawton, Oklahoma in located in the metropolitan St. Louis, Missouri area. There December, 2010. Previously he served as an Associate Pro- she is primary instructor for the paramedic program, fessor and Chair of the Department of Emergency Medicine program director for the district’ s emergency medical tech- at the University of Oklahoma Health Sciences Center in nician programs, and leads a training staff that provides Oklahoma City, Oklahoma. Dr. Quick is a career emer- education for district paramedics and for fi refi ghters and gency physician with 40 years in clinical practice, as well as emergency personnel within St. Charles County. Kim has extensive educational and research experience. He is widely been teaching in EMS for more than 25 years. She formerly published with more than 100 articles and book chapters worked as an emergency and intensive care nurse, and to his credit. Before his retirement, he served the specialty served as Chief Medical Offi cer for the Florissant Valley Fire of emergency medicine in several capacities at the national Protection District for 6 years. Kim was the EMR Project and state level for the American College of Emergency Level Leader for the National EMS Education Standards Physicians.. Mosby’s Paramedic Textbook FOURTH EDITION MICK J. SANDERS, EMT-P, MSA PHYSICIAN ADVISERS Lawrence M. Lewis, MD, FACEP Professor of Emergency Medicine Washington University School of Medicine/Barnes-Jewish Hospital St. Louis, Missouri Gary Quick, MD, FACEP Attending Emergency Physician Oklahoma Heart Hospital Prior Associate Professor and Chief of Emergency Medicine University of Oklahoma Oklahoma City, Oklahoma CONTRIBUTING EDITOR Kim D. McKenna, MED, RN, CEN, EMT-P Director of Education St. Charles County Ambulance District Adjunct Professor, Lindenwood University St. Charles, Missouri With more than 1500 illustrations World Headquarters Jones & Bartlett Learning 5 Wall Street Burlington, MA 01803 978-443-5000 [email protected] www.jblearning.com Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com. 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This textbook is intended solely as a guide to the appropriate procedures to be employed when rendering emergency care to the sick and injured. It is not intended as a statement of the standards of care required in any particular situation, because circumstances and the patient’s physical condition can vary widely from one emergency to another. Nor is it intended that this textbook shall in any way advise emergency personnel concerning legal authority to perform the activities or procedures discussed. Such local determination should be made only with the aid of legal counsel. Production Credits Chief Executive Officer: Ty Field President: James Homer SVP, Editor-in-Chief: Michael Johnson SVP, Chief Marketing Officer: Alison M. Pendergast Executive Publisher: Kimberly Brophy Executive Acquisitions Editor—EMS: Christine Emerton Vice President of Sales, Public Safety Group: Matthew Maniscalco Director of Sales, Public Safety Group: Patricia Einstein Production Editor: Tina Chen Director of Marketing: Alisha Weisman VP, Manufacturing and Inventory Control: Therese Connell Director of Photo Research and Permissions: Amy Wrynn Printing and Binding: Courier Companies Cover Printing: Courier Companies ISBN: 978-1-284-02954-3 6048 Printed in the United States of America 17 16 15 14 13 13 10 9 8 7 6 5 4 3 2 1 To my family, and in loving memory of my father, James H. Sanders Preface As a paramedic student, you have chosen to work in an Part Three introduces the paramedic student to pharma- exciting and rewarding area of health care prehospital cology, methods of venous access, and medication admin- emergency care. Few professions can provide the same type istration. The pharmacology chapter has been enhanced to of opportunities that lie before you. Through your training, include new emergency drugs. It also has an expanded you will meet the educational demands of a profession that appendix on herbal products, their common uses, indica- requires knowledge in anatomy and physiology, mathemat- tions, and possible interactions with medications. ics, pharmacology, advanced education in the health sci- Part Four is devoted to airway management and ventila- ences, and physical skills in using highly technical and tion. The physiology of the respiratory system is presented sophisticated equipment. You will have an opportunity to in depth, and basic and advanced methods of managing a play an important role in injury prevention, to participate patient ’ s airway with new equipment and techniques are in research, and to be a role model in your community. And illustrated in this chapter. most importantly, you will be entrusted with the lives of Part Five focuses on patient assessment and the impor- the people you serve. This describes today ’ s paramedic – a tance of caring for both the physical and emotional needs member of a unique profession composed of highly trained of the patient. New chapters devoted to Scene Size-Up men and women dedicated to making a difference in peo- ( Chapter 16) , Primary Assessment ( Chapter 19 ), and Sec- ple ’ s lives. ondary Assessment (C hapter 20 ) are included in this edition. Separate chapters address therapeutic communica- CONTENT AND ORGANIZATION tions, history taking, and clinical decision making. The fourth edition of M osby ’ s Paramedic Textbook has been Part Six covers cardiology in detail. Electrophysiology of extensively reviewed by physicians, nurses, paramedics, edu- the heart and electrocardiogram (ECG) interpretation is cators, and national and international experts in the fi eld presented fi rst and is followed by cardiovascular emergen- of emergency care people who know and value the impor- cies such as cardiac rhythm disturbances, myocardial tant role of the paramedic in health care delivery. The text infarction, and stroke. Techniques in managing cardiac was developed from the 2008 National Highway Traffi c emergencies, including basic and advanced cardiac life Safety Administration ’ s National EMS Education Stan- support, follow the 2010 guidelines established by the dards Instructional Guidelines for Paramedics. Every effort American Red Cross (ARC) and the American Heart Asso- was made to meet all educational components as defi ned in ciation (AHA). that document. The fourth edition has also been enhanced Part Seven addresses the many types of medical condi- to address recent advances and important issues in emer- tions that can lead to an emergency response. New chapters gency medical services (EMS), including new equipment to this edition are Diseases of the Eyes, Ears, Nose, and and procedures; critical care transport (CCT); and special Throat ( Chapter 23 ), Immunology ( Chapter 27 ), and Non- considerations for dealing with bioterrorism and weapons traumatic Musculoskeletal Disorders ( Chapter 33 ). Sepa- of mass destruction (WMD). rate chapters are included for disorders of specifi c body Part One explains the paramedic ’ s role and the unique systems. Discussed in depth here are respiratory, neurology, aspects of the profession, such as an overview of EMS endocrinology, gastrointestinal, genitourinary, gynecology, systems and the importance of personal well-being. It also and hematology disorders. In addition, infectious and com- introduces the paramedic student to medical/legal issues, municable diseases, toxicology, and behavioral and psychi- ethics, documentation, and EMS communications. New atric disorders are covered in detail. chapters included in this section include Injury Prevention Part Eight is a complete discussion of the Pathophysio- and Public Health ( Chapter 3 ) and Research Principles logy and Management of Shock, a complicated disease and Evidence-Based Practice ( Chapter 8 ). Personal safety is process that can affect both medical and trauma patients. emphasized in Part One and throughout the text. Part Nine is devoted to a thorough presentation of Part Two provides a review of human systems and is an trauma. It begins with a discussion of trauma systems and easily located reference for anatomical structures and their mechanism of injury. This is followed by separate chapters functions. This section begins with a new chapter to explain on bleeding and soft tissue trauma; burns; head, face, and Medical Terminology ( Chapter 9 ). The general principles of neck trauma; and injury to the spine, chest, abdomen, and pathophysiology lay the foundation for the textbook and musculoskeletal system. A separate chapter on Environ- are presented here as well. Chapters that map lifespan mental Conditions ( Chapter 45 ) describes illness and development and special considerations for specifi c age injury that can result from exposure to elements in the groups are included in this section. environment. vii vviiiiii PREFACE Part Ten describes special considerations for select ■ Critical Thinking Questions. Critical thinking questions patient groups such as pregnant women, neonates, pediat- are found in each chapter to aid in understanding con- rics, and geriatrics. It also addresses the needs of patients cepts and how information presented in the text can who have been victims of abuse and neglect, those with impact day-to-day activities and “ real life ” patient care. special challenges, and home care patients who may require ■ Advanced ECG Rhythm Interpretation. All cardiac acute interventions. rhythms and dysrhythmias are presented in lead I, II, III, Part Eleven deals with the various aspects of advanced and MCL to enhance assessment of the cardiac patient. 1 EMS systems, such as ambulance operations, medical inci- In addition, the text includes advanced electrophy- dent command, rescue operations, crime scene awareness, siology, 12-lead monitoring, fi brinolytic therapy, and and hazardous materials incidents. A separate chapter that current treatment modalities as recommended by the provides an overview of bioterrorism and weapons of mass American Heart Association. destruction is included here, refl ecting the hazards and ■ Full-Color Illustrations. More than 1500 tables, charts, responsibilities important to today’ s paramedic. The last line drawings, and photographs are included in the text chapter in this section ( Chapter 59 ) “ puts it all together ” to illustrate anatomy, physiology, and patient manage- for the student. It serves as a review of the important con- ment guidelines. State-of-the-art equipment and cepts in providing emergency care that have been presented step-by-step demonstrations of practical skills also are throughout the text. Finally, a new appendix has been presented in full color to demonstrate emergency care included to provide an overview of advanced practice pro- procedures. cedures for the critical care paramedic. ■ “ Did You Know? ” The new “ Did You Know? ” boxes are Each chapter of Mosby ’ s Paramedic Textbook begins with included throughout the text to expand on interesting an introduction and a list of objectives that provide an and relevant information, such as unusual facts and overview of the material to be presented. This allows the fi gures, “ nice-to-know ” data, and “ need-to-know ” mate- student to review the content and progression of each rial, such as the rights of terminally ill patients and the chapter in an easy-to-follow format. Key terms are included possible effects of biological terrorism. to highlight terminology and concepts critical to providing ■ Box Notes. Box notes are presented in each chapter to emergency care, and boldfaced items identify terms that are highlight vital information and words of warning. included in the glossary. Each chapter concludes with ■ “ Look Again. ” The new “ Look Again ” feature prevents current references that can be used as a resource for supple- text information from being repeated in numerous mental reading and a bulleted summary that reviews the chapters. This feature directs the student to the chapters most important material presented in the chapter. The text- and page numbers where the material was fi rst presented book also is accompanied by a student workbook to help for easy reference and review. measure understanding of the core material. Included in ■ “ Show Me the Evidence. ” Each new “ Show Me the the workbook are questions, activities, and case studies Evidence ” feature summarizes a research study related designed to enhance understanding, promote refl ection on to the chapter content. This feature familiarizes the learning, and integrate key concepts and knowledge. paramedic with the research process, its language, and The fourth edition of M osby ’ s Paramedic Textbook also its fi ndings. “ Show me the Evidence ” will encourage stu- includes the following features that help make this text- dents to look for information throughout their careers book a leader in EMS education: to promote evidence-based practice. ■ Emergency Drug Index. The Emergency Drug Index ■ Expanded Glossary. The glossary has been expanded to (EDI) details specifi c information on more than 70 include defi nitions on hundreds of medical terms and emergency drugs. It provides a quick source of reference key terms presented in the textbook chapters. for a drug ’ s description, onset and duration, indications, ■ Index. The thorough and detailed index makes it easy to contraindications, adverse reactions, drug interactions, fi nd information that was presented in the text. packaging, dosage and administration for adult and I hope reading this preface reinforces the decision you pediatric patients, and special considerations. Drugs in made to choose this textbook. Whether you ’ re a paramedic the textbook that are found in the EDI are denoted with student, practicing paramedic, nurse, physician, adminis- a bold italic font as a reminder to the reader of their trator, or educator, I think you will fi nd this textbook to be importance and easy location of reference. a valuable EMS resource. Mick J. Sanders