Updated Reviewer for Finals: 1

BLEEDING
○ Signs and symptoms of shock:
● Important to be able to: Disturbed LOC includes
○ Recognize bleeding Irritability or Altered mental
○ Understand how bleeding status
affects the body ○ Significant blood loss
● Bleeding can be external or internal. ○ Rapid blood loss
● Bleeding can cause weakness, shock, ○ Uncontrollable bleeding
and death.

Blunt (close injury) - internal Characteristics of External Bleeding

bleeding ● Arterial bleeding
Penetrating (open injury) - external ○ Pressure causes blood to spurt
bleeding and makes bleeding difficult to
Look for manifestations of shock control.
and LOC ○ Typically brighter red and spurts
in time with the pulse
External Bleeding ● Venous bleeding
● Hemorrhage means bleeding. ○ Dark red, flows slowly or
● Examples include nosebleeds and severely (oozing)
bleeding from open wounds. ○ Does not spurt and is easier to
● As an EMT, you must understand how to manage
control external bleeding. ● Capillary bleeding
○ Bleeding from damaged
Significance of External Bleeding capillary vessels
● With serious external bleeding, it may ○ Dark red, oozes steadily but
be difficult to tell the amount of blood slowly
loss. - Non-emergency, distal part of
● Presentation and assessment of the body
patient will direct care and treatment.
● Body will not tolerate a blood loss
greater than 20% of blood volume.
● Significant changes in vital signs may
occur if the typical adult loses more than
1 L of blood.
(In blood donation only 450mL)
Early indications:
○ Increase in heart rate Clotting
○ Increase in respiratory rate ● Bleeding tends to stop rather quickly,
○ Decrease in blood pressure is a within about 10 minutes.
late sign ○ When a person is cut, blood
● How well people compensate for blood flows rapidly.
loss is related to how rapidly they bleed. ○ The cut end of the vessel begins
○ An adult can comfortably donate to narrow, reducing the amount
1 unit (500 mL) of blood over of bleeding.
15 to 20 minutes. ○ Then a clot forms.
○ If a similar blood loss occurs in ○ Bleeding will not stop if a clot
a much shorter time, the person does not form.
may rapidly develop ● Despite the efficiency of the system, it
hypovolemic shock. may fail in certain situations.
○ Consider age and preexisting ○ Movement
health. ○ Medications
● Serious conditions with bleeding: ○ Removal of bandages
○ Significant MOI ○ External environment
○ Patient has a poor general ○ Body temperature
appearance and is calm. ○ Severe injury
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● Frequent signs
○ Abdominal tenderness
Hemophilia ○ Guarding
● Patient lacks blood clotting factors. ○ Rigidity
● Bleeding may occur spontaneously. ○ Pain - main sign
● All injuries, no matter how trivial, are ○ Distention
potentially serious. ● In older patients, signs include:
● Patients should be transported ○ Dizziness
immediately. ○ Faintness
○ Weakness
● Ulcers or other GI problems may cause:
○ Vomiting of blood
Internal Bleeding ○ Bloody diarrhea or urine
● Bleeding in a cavity or space inside the
body Signs and Symptoms of Internal Bleeding
● Can be very serious, yet with no ● Pain (most common)
outward signs ● Swelling in the area of bleeding
○ Injury or damage to internal ● Distention
organs commonly results in ● Bruising
extensive internal bleeding. ● Dyspnea, tachycardia, hypotension
○ Can cause hypovolemic shock ● Hematoma
● Possible conditions causing internal ● Bleeding from any body opening (Halo
bleeding: Test - common performed in head injury;
○ Stomach ulcer Raccoon eyes - dark circles in eyes;
○ Lacerated liver Battle sign - large bruise extends at the
○ Ruptured spleen - most fatal, back of ears)
massive blood loss
○ Broken bones, especially the
ribs or femur
○ Pelvic fracture

Mechanism of Injury for Internal Bleeding

● High-energy MOI
● Internal bleeding is possible whenever
the MOI suggests that severe forces
affected the body.
○ Blunt trauma
○ Penetrating trauma
● Signs of injury (DCAP-BTLS) ● Hematemesis
○ Deformities ● Melena
○ Contusions ● Hemoptysis
○ Abrasions ● Broken ribs, bruises over the lower part
○ Punctures/penetrations of the chest, or a rigid, distended
○ Burns abdomen
○ Tenderness ● Hypoperfusion
○ Lacerations ● Later signs of hypoperfusion:
○ Swelling ○ Tachycardia
○ Weakness, fainting, or
Nature of Injury for Internal Bleeding dizziness at rest
● Bleeding is not always caused by ○ Thirst
trauma. ○ Nausea and vomiting
● Nontraumatic causes include: ○ Cold, moist (clammy) skin
○ Bleeding ulcers ○ Shallow, rapid breathing
○ Bleeding from colon ○ Dull eyes
○ Ruptured ectopic pregnancy ○ Slightly dilated pupils
○ Aneurysms
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○ Capillary refill of more than 2 ● You should still be able to palpate a

seconds in infants and children distal pulse.
○ Weak, rapid (thready) pulse ● Do not remove a dressing until a
○ Decreasing blood pressure physician has evaluated the patient.
○ Altered level of consciousness ● Bleeding will almost always stop when
the pressure of the dressing exceeds
Emergency Medical Care for External Bleeding arterial pressure.
● Follow standard precautions. ● Follow the steps in Skill Drill 23-1.
○ Wear gloves, eye protection, - Pulse, motor, and sensory always check
and possibly a mask or gown. before and after.
○ Make sure the patient has an
open airway and is breathing Tourniquet
adequately. (Jaw-thrust) ● If direct pressure fails, apply a
○ Provide high-flow oxygen. tourniquet above the level of bleeding.
● Several methods are available to control ● It should be applied quickly and not
external bleeding. released until a physician is present.
○ Direct, even pressure and ● Follow the steps in Skill Drill 23-2 to
elevation apply a commercial tourniquet.
○ Pressure dressings and/or ● Observe the following precautions:
splints ○ Do not apply a tourniquet
○ Tourniquets directly over any joint.
● It will often be useful to combine these ○ Make sure the tourniquet is
methods tightened securely.
○ Never use wire, rope, a belt, or
Direct Pressure any other narrow material.
● Most effective way to control external ○ Use wide
bleeding - bulky dressing, should be padding
sterile under the
● Pressure stops the flow of blood and tourniquet.
permits normal coagulation to occur. ○ Never cover
● Apply pressure with your gloved a tourniquet
fingertip or hand over the top of a sterile with a
dressing. bandage.
● Never remove an impaled object from a ○ Do not
wound. loosen the
● Hold uninterrupted pressure for at least tourniquet
5 minutes. after you
have
Elevation applied it.
● Elevate a bleeding extremity by as little - Ideally, an hour
as 6" while applying direct pressure. - Only for external bleeding
● Never elevate an open fracture to
control bleeding. Splints
● Fractures can be elevated after ● Air splints
splinting. ○ Can control internal or external
● Splinting helps control bleeding. bleeding associated with severe
injuries
Pressure Dressing ○ Stabilize fractures
- bandaging ○ Act like a pressure dressing
● Firmly wrap a sterile, self-adhering roller ○ Commonly referred to as soft
bandage around the entire wound. splints or pressure splints
● Cover the entire dressing above and ○ Once the splint is applied,
below the wound. monitor circulation in the distal
● Stretch the bandage tight enough to extremity.
control bleeding. ○ Use only approved, clean, or
disposable valve stems.
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● Rigid splints ● If spinal injury is not suspected, place

○ Can help stabilize fractures the patient in the shock position.
○ Reduce pain ● Provide high-flow oxygen.
○ Prevent further damage to ● Maintain body temperature.
soft-tissue injuries ● Splint the injured extremity (usually with
○ Once the splint is applied, an air splint).
monitor circulation in the distal ● Never use a tourniquet to control
extremity. bleeding from closed, internal,
● Traction splints soft-tissue injuries.
○ Designed to stabilize femur ● Follow the steps in Skill Drill 23-4.
fractures
○ When the EMT pulls traction to Summary:
the ankle, countertraction is ● Perfusion is the circulation of blood in
applied to the ischium and groin. adequate amounts to meet the cells’
○ Once the splint is applied, current needs for oxygen, nutrients, and
monitor circulation in the distal waste removal.
extremity. ● The cardiovascular system has three
main components:
Bleeding from the Nose, Ears, and Mouth ○ Pump (heart)
● Several conditions: ○ Container (blood vessels)
○ Skull fracture ○ Fluid (blood and bodily fluids)
○ Facial injuries ● Hypoperfusion (shock) occurs when the
○ Sinusitis, infections, use and cardiovascular system fails to provide
abuse of nose drops, dried or adequate perfusion.
cracked nasal mucosa ● Both internal and external bleeding can
○ High blood pressure cause shock. You must know how to
○ Coagulation disorders recognize and control both.
○ Digital trauma ● The methods to control bleeding, in
● Epistaxis (nosebleed) is a common order, are:
emergency. But is not alarming ○ Direct, even pressure
○ Occasionally it can cause ○ Elevation
enough blood loss to send a ○ Pressure dressings
patient into shock. ○ Tourniquets
○ Can usually be controlled by ○ Splinting device
pinching the nostrils together ● Bleeding around the face always
○ Head tilt slightly downward, cold presents a risk of airway obstruction or
compress (15 mins); apply aspiration.
directly on the patient’s nose ● Any patient you suspect of having
● Follow the steps in Skill Drill 23-3 to internal bleeding or significant external
control epistaxis. bleeding should be transported
● Bleeding from the nose or ears following promptly.
a head injury: ● Signs of serious internal bleeding:
○ May indicate a skull fracture ○ Vomiting blood (hematemesis)
○ May be difficult to control ○ Black tarry stools (melena)
○ Do not attempt to stop blood ○ Coughing up blood (hemoptysis)
flow. ○ Distended abdomen
○ Loosely cover the bleeding site ○ Broken ribs
with a sterile gauze pad.
○ Apply light compression with a
dressing.

Emergency Medical Care for Internal Bleeding

● Usually requires surgery or other
hospital procedures
● Keep the patient calm, reassured, and
as still and quiet as possible.
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SOFT-TISSUE INJURIES • Protective layer of the skin is damaged.

• Wound is contaminated and may become
Introduction infected.
• Soft-tissue injuries are common. • Four types:
– Simple as a cut or scrape – Abrasions
– Serious as a life-threatening – Lacerations
internal injury – Avulsions
• Do not be distracted by dramatic open – Penetrating wounds
wounds.
– Do not forget airway obstructions. An abrasion is a wound of the superficial layer
• Soft tissues of the body can be injured of the skin.
through a variety of mechanisms:
– Blunt injury – Caused by friction when a body
– Penetrating injury part rubs or scrapes across a
– Barotrauma rough or hard surface
– Burns
• Soft-tissue trauma is the leading form of
injury.
• Death is often related to hemorrhage or
infection.
• EMTs can teach children and others
preventive actions.

Closed Injuries
• Characteristics of closed injuries
– History of blunt trauma
– Pain at the site of injury
– Swelling beneath the skin A laceration is a jagged cut.
– Discoloration
• A contusion (bruise) causes bleeding – Caused by a sharp object or blunt
beneath the skin but does not break the force that tears the tissue
skin. • An incision is a sharp, smooth cut.
– Caused by blunt forces
– Buildup of blood produces blue or
black ecchymosis.
• A hematoma is blood collected within
damaged tissue or in a body cavity.
• A crushing injury occurs when a great
amount of force is applied to the body.
• Extent of damage depends on:
– Amount of force
– Length of time force is applied
• When an area of the body is trapped for
longer than 4 hours, crush syndrome can
develop.
• Compartment syndrome results from the
swelling that occurs whenever tissues are An avulsion separates various layers of soft
injured. tissue so that they become either completely
• Severe closed injuries can also damage detached or hang as a flap.
internal organs.
– Assess all patients with closed – Often there is significant bleeding.
injuries for more serious hidden – Never remove an avulsion skin
injuries. flap.
• An amputation is an injury in which part of
Open Injuries the body is completely severed.
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device.
A penetrating wound is an injury resulting from • Treat closed soft-tissue injury using the
a sharp, pointed object. RICES mnemonic:
– Rest
– Can damage structures deep – Ice
within the body – Compression
– Elevation
– Splinting

• Signs of developing shock:

– Anxiety or agitation
– Changes in mental status
– Increased heart rate
– Increased respiratory rate
– Diaphoresis
– Cool or clammy skin
– Decreased blood pressure

Emergency Medical Care for

Open Injuries
• Before caring for the patient, follow
• Stabbings and shootings often result in standard precautions.
multiple penetrating injuries. • Wear gloves and eye protection.
– Assess the patient carefully to – Wear a gown and a mask if
identify all wounds. necessary.
– Count the number of penetrating • Make sure the airway is open and
injuries. count x2 (ex. 5 gunshot, administer high-flow oxygen.
you should check 10 penetrating - Scene safety, position airway, administer
injuries) oxygen, control bleeding
– Determine the type of gun and
rounds fired, and document your
care. • Control life-threatening bleeding using:
– You may have to testify in court. – Direct, even pressure and
elevation
• Blast injuries – Pressure dressings and/or splints
– Primary blast injury – Tourniquets
• Damage caused by • Follow the steps in Skill Drill 24-1 to
pressure of explosion control bleeding from an extremity.
– Secondary blast injury • All open wounds are assumed to be
• Damage results from flying contaminated and present a risk of
debris infection.
– Tertiary blast injury • Often, you can better control bleeding
• Victim is thrown by from an open soft-tissue wound by
explosion, perhaps into an splinting the extremity, even if there is no
object fracture.
• Abdominal wounds
Emergency Medical Care for
Closed Injuries
• No special emergency care for small
contusions
• Soft-tissue injuries may look rather
dramatic.
– Still focus on airway and
breathing first
– You may have to assist
ventilations with a bag-mask
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– An open wound in the abdominal – Prevented by a series of special

cavity may expose internal vaccine injections
organs. • Human bites
– The organs may even protrude – The human mouth contains an
through the wound, an injury exceptionally wide range of
called evisceration. virulent bacteria and viruses.
– Cover the wound with sterile – Regard any human bite that has
gauze. penetrated the skin as a very
– Secure with an occlusive serious injury.
dressing. – Can result in a serious, spreading
– Keep the organs moist and warm. infection
• Emergency treatment:
– Apply a dry, sterile dressing.
• Impaled objects – Promptly immobilize the area with
– To treat an impaled object, follow a splint or bandage.
the steps in Skill Drill 24-2. – Provide transport to the ED.
– Only remove an impaled object
when:
• The object is in the cheek
and obstructs breathing. Burns
• The object is in the chest • Account for over 10,000 deaths a year
and interferes with CPR. • Among the most serious and painful of all
injuries
• A burn occurs when the body receives
• Neck injuries more radiant energy than it can absorb.
– Open neck injuries can be life – Sources of this energy include
threatening. heat, toxic chemicals, and
– Open veins may suck in air and electricity.
cause cardiac arrest. • Always perform a complete assessment to
– Cover the wound with an determine whether there are other serious
occlusive dressing. injuries.
– Apply pressure but do not
compress both carotid arteries at Complications of Burns
the same time. • When a person is burned, the skin that
acts as a barrier is destroyed.
• The victim is now at high risk for:
• Small-animal bites
– Infection
– A small animal’s mouth is heavily
– Hypothermia
contaminated with virulent
– Hypovolemia
bacteria.
– Shock
– Wounds may require:
• Burns to the airway are of significant
• Antibiotics
importance.
• Tetanus prophylaxis
• Circumferential burns of the chest can
• Suturing
compromise breathing.
– Bites should be evaluated by a
• Circumferential burns of the extremity
physician.
can lead to neurovascular compromise
- Wash the area
and irreversible damage.

• A major concern is the spread of rabies.

– Acute, potentially fatal viral
Burn Severity
infection of the central nervous
• Burn severity depends on:
system
– Depth of burn
– Can affect all warm-blooded
– Extent of burn
animals
– Critical areas involved
– Transmitted through biting or
• Face, upper airway, hands,
licking an open wound
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feet, genitalia
– Pre-existing medical conditions
– Patient younger than 5 or older
than 55

• Depth
– Superficial (first-degree) burns
• Only the top layer of skin
- (Sunburn)
– Partial-thickness
(second-degree) burns
• Epidermis and some portion
of the dermis
• Blisters are present.
- Most painful
– Full-thickness (third-degree)
burns
• Extend through all skin Chemical Burns
layers. • Can occur whenever a toxic substance
- Painless (damage of contacts the body
nerve endings) • Generally caused by strong acids or
strong alkalis
• The eyes are particularly vulnerable.
- powder or liquid

• The severity of the burn is directly related

to the:
– Type of chemical
– Concentration of the chemical
– Duration of the exposure
• Wear appropriate chemical-resistant
gloves and eye protection.

• Management
– Remove any chemical from the
patient.
• Extent – Always brush dry chemicals off
– Can be estimated using the rule of the skin and clothing before
nines flushing with water.
– Divides the body into sections, – Remove the patient’s clothing.
each representing approximately – For liquid chemicals,
9% of the total body surface area immediately begin to flush the
– Proportions differ for infants, burned area with lots of water.
children, and adults – Continue flooding the area for 15
to 20 minutes after the patient
says the burning pain has
stopped.
– If the patient’s eye has been
burned, hold the eyelid open while
flooding the eye.

Electrical Burns
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• May be the result of contact with high- or • Most commonly, they are caused by
low-voltage electricity scalds or an open flame.
• For electricity to flow, there must be a – A flame burn is very often a deep
complete circuit between the source and burn.
the ground. – Hot liquids produce scald injuries.
– Any substance that prevents this • Coming in contact with hot objects
circuit is called an insulator. produces a contact burn.
– Any substance that allows a • A steam burn can produce a topical burn.
current to flow is called a • A flash burn is produced by an explosion.
conductor. – May briefly expose a person to
very intense heat
• The human body is a good conductor. – Lightning strikes can cause a flash
• The type of electric current, magnitude of burn.
current, and voltage have effects on the • Management
seriousness of the burn. – Stop the burning source, cool the
• Your safety is of particular importance. burned area, and remove all
– Never attempt to remove jewelry.
someone from an electrical source – Increased exposure time will
unless you are specially trained to increase damage to the patient.
do so. – All patients should have a dry
dressing applied to:
• A burn injury appears where the electricity • Maintain body temperature
enters and exits the body. • Prevent infection
• Two dangers: • Provide comfort
– There may be a large amount of
deep tissue injury. Inhalation Burns
– The patient may go into cardiac or • Can occur when burning takes place in
respiratory arrest from the electric enclosed spaces without ventilation
shock. – Upper airway damage is often
associated with the inhalation of
superheated gases.
– Lower airway damage is more
often associated with the
inhalation of chemicals and
particulate matter.
• You may encounter severe upper airway
swelling, requiring intervention
immediately.
– Consider requesting ALS backup.
• The combustion process produces a
variety of toxic gases.
• Management • Carbon monoxide intoxication should
– If indicated, begin CPR on the be considered whenever a group of
patient and apply an AED. people in the same place all report a
– Be prepared to defibrillate if headache or nausea.
necessary. • Management
– Give supplemental oxygen and – First ensure your own safety and
monitor. the safety of your coworkers.
– Treat soft-tissue injuries with dry, – Prehospital treatment for a patient
sterile dressings. with suspected hydrogen cyanide
– Provide prompt transport. poisoning includes
decontamination and supportive
care.
Thermal Burns – Care for any toxic gas exposure
includes:
• Caused by heat • Recognition
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• Identification
• Supportive treatment

Radiation Burns
• Potential threats include:
– Incidents related to the use and
transportation of radioactive
isotopes
– Intentionally released radioactivity
in terrorist attacks
• You must determine if there has been a
radiation exposure and then whether
ongoing exposure continues to exist. • Dressings and bandages have three
• Three types of ionizing radiation: functions:
– Alpha – To control bleeding
• Little penetrating energy, – To protect the wound from further
easily stopped by the skin damage
– Beta – To prevent further contamination
• Greater penetrating power, and infection
but blocked by simple
protective clothing Sterile Dressings
– Gamma • Most wounds will be covered by:
• Very penetrating, easily – Universal dressings
passes through the body – Conventional 4″ × 4″ and 4″ × 8″
and solid materials gauze pads
– Assorted small adhesive-type
• Most ionizing radiation accidents involve dressings and soft self-adherent
gamma radiation, or x-rays. roller dressings
• Management • Universal dressings are ideal for covering
– Patients with a radioactive source large open wounds.
on their body must be initially • Gauze pads are appropriate for smaller
cared for by a HazMat responder. wounds.
– Irrigate open wounds. • Adhesive-type dressings are useful for
– Notify the emergency department. minor wounds.
– Identify the radioactive source and • Occlusive dressings prevent air and
the length of the patient’s liquids from entering (or exiting) the
exposure to it. wound.
– Limit your duration of exposure.
– Increase your distance from the
source. Bandages
– Attempt to place shielding • To keep dressings in place during
between yourself and the source transport, you can use:
of gamma radiation. – Soft roller bandages
– Rolls of gauze
– Triangular bandages
Dressing and Bandaging – Adhesive tape
• All wounds require bandaging. • The self-adherent, soft roller bandages are
– Sometimes splints can help easiest to use.
control bleeding and provide firm • Adhesive tape holds small dressings in
support for dressing. place and helps to secure larger
– There are many different types of dressings.
dressings and bandages. • Do not use elastic bandages to secure
dressings.
– The bandage may become a
tourniquet and cause further
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damage.
• Splints are useful in stabilizing broken
extremities.
– Can be used with dressings to
help control bleeding from
soft-tissue injuries
• If a wound continues to bleed despite the
use of direct pressure, quickly proceed to
the use of a tourniquet.

Summary
• The skin protects the body by keeping
pathogens out, water in, and assisting in
body temperature regulation.
• There are three types of soft-tissue
injuries: closed injuries, open injuries, and
burns.
• Closed soft-tissue injuries are
characterized by a history of blunt trauma,
pain at the site of injury, swelling beneath
the skin, and discoloration.
• Treat a closed soft-tissue injury with the
mnemonic RICES: Rest, Ice,
Compression, Elevation, and Splinting.
• Open injuries differ from closed injuries in
that the protective layer of skin is
damaged. Abrasions, lacerations,
avulsions, and penetrating wounds are
classified as open injuries.
• The assessment of an open injury is
generally easier than the assessment of a
closed injury because you can see the
injury.
• Burns are serious and painful soft-tissue
injuries caused by heat (thermal),
chemicals, electricity, or radiation.
• Burns are classified primarily by the depth
and extent of the burn injury and the body
area involved.
• Burns are considered to be superficial,
partial-thickness, or full-thickness based
on the depth involved.
• Small animal and human bites can lead to
serious infection and must be evaluated
by a physician. Small animals can carry
rabies.
• Dressings and bandages are designed to
control bleeding, protect the wound from
further damage, prevent further
contamination, and prevent infection.
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Chest Injuries ○ Localized pain aggravated or

increased with breathing
● Each year in the United States, chest ○ Bruising to the chest wall
trauma causes more than: ○ Crepitus with palpation of the
○ 700,000 emergency department chest
visits ○ Penetrating injury to the chest
○ 18,000 deaths ○ Dyspnea
● Chest injuries can involve the heart, ○ Hemoptysis
lungs, and great blood vessels. ○ Failure of one or both sides of
● Immediately treat injuries that interfere the chest to expand normally
with normal breathing function. with inspiration
○ Internal bleeding can compress ○ Rapid, weak pulse
the lungs and heart. ○ Low blood pressure
○ Air may collect in the chest, ○ Cyanosis around the lips or
preventing lung expansion. fingernails
● Chest injury patients often have rapid
and shallow respirations.
○ Hurts to take a deep breath
Injuries of the Chest
○ The patient may not be moving
● Two types: open and closed air.
● In a closed chest injury, the skin is not ○ Auscultate multiple locations to
broken. assess for adequate breath
○ Generally caused by blunt sounds.
trauma
● Closed Chest Injury
○ Can cause significant cardiac Pneumothorax
and pulmonary contusion
○ If the heart is damaged, it may ● Commonly called a collapsed lung
not be able to refill with or ● Accumulation of air in the pleural space
receive blood. ○ Blood passing through the
○ Lung tissue bruising can result collapsed portion of the lung is
in exponential loss of surface not oxygenated.
area. ○ You may hear diminished,
○ Rib fractures may cause further absent, or abnormal breath
damage. sounds.
● In an open chest injury, an object
penetrates the chest wall itself.
○ Knife, bullet, piece of metal, or
broken end of fractured rib
○ Do not attempt to move or
remove objects.

○
● Open chest wound
○ Often called an open
● Blunt trauma to the chest may cause: pneumothorax or a sucking
○ Rib, sternum, and chest wall chest wound
fractures
○ Bruising of the lungs and heart
○ Damage to the aorta
○ Vital organs to be torn from their
attachment in the chest cavity
● Signs and symptoms:
○ Pain at the site of injury
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- Classic sign: you cannot hear breath

○ Wounds must be rapidly sealed sounds upon auscultation
with a sterile occlusive
dressing.
○ A flutter valve is taped on only
three sides. Hemothorax
○ Carefully monitor the patients
for tension pneumothorax. ● Blood collects in the pleural space from
● Spontaneous pneumothorax bleeding around the rib cage or from a
○ Caused by structural weakness lung or great vessel.
rather than trauma
○ Weak area (“bleb”) can rupture
spontaneously, letting air into
the pleural space.
○ Suspect it in patients with
sudden, unexplained chest pain
and shortness of breath.
● Simple pneumothorax
○ Does not result in major
changes in the patient’s
physiology
○ Commonly due to blunt trauma
that results in fractured ribs
○ Can often worsen, deteriorate
into tension pneumothorax, or ● Signs and symptoms
develop complications ○ Shock
● Tension pneumothorax ○ Decreased breath sounds on
○ Results from significant air the affected side
accumulation in the pleural ● Prehospital treatment:
space ○ Rapid transport
○ Increased pressure in the chest ● The presence of air and blood in the
causes: pleural space is a hemopneumothorax.
■ Complete collapse of
the unaffected lung
■ Mediastinum to be
pushed into the Cardiac Tamponade
opposite pleural cavity
● Protective membrane (pericardium)
○ Commonly caused by a blunt
around the heart fills with blood or fluid
injury in which a fractured rib
● The heart cannot adequately pump the
lacerates the lung or bronchus
blood.
 14

○ Maintain the airway.

○ Provide respiratory support, if
needed.
○ Give supplemental oxygen.
○ Reassess for complications.
● To immobilize a flail segment:
○ Tape a bulky dressing or pad
against that segment of the
● Signs and symptoms chest.
○ Beck’s triad (JVD, Narrowing ○ Have the patient hold a pillow
pulse pressure, muffled heart against the chest wall.
sounds) ● Flail chest may indicate serious internal
○ Altered mental status damage or spinal injury. - may puncture
● Prehospital treatment site and lead to hemothorax
○ Support ventilations.
○ Rapidly transport. Other Chest Injuries

● Pulmonary contusion
○ Should always be suspected in
Rib Fractures a patient with a flail chest
○ Pulmonary alveoli become filled
● Common, particularly in older people with blood, leading to hypoxia
● A fracture of one of the upper four ribs is ● Prehospital treatment
a sign of a very substantial MOI. ○ Respiratory support and
● A fractured rib may cause a supplemental oxygen
pneumothorax or a hemothorax. ○ Rapid transport
● Signs and symptoms
○ Localized tenderness and pain Other fractures
when breathing
○ Rapid, shallow respirations ● Sternal fractures
○ Patient holding the affected ○ Increased index of suspicion for
portion of the rib cage organ injury
● Prehospital treatment includes ● Clavicle fractures
supplemental oxygen. ○ Possible damage to
neurovascular bundle
○ Suspect upper rib fractures in
medial clavicle fractures.
Flail chest ○ Be alert to pneumothorax
development.
● Caused by compound rib fractures that ● Traumatic asphyxia
detach a segment of the chest wall ○ Characterized by distended
● Detached portion moves opposite of neck veins, cyanosis in the face
normal and neck, and hemorrhage in
the sclera of the eye
○ Sudden, severe compression of
the chest, producing a rapid
increase in pressure
○ Suggests an underlying injury to
the heart and possibly a
pulmonary contusion
○ Prehospital treatment:
■ Ventilatory support and
supplemental oxygen
■ Monitor vital signs
during immediate
transport.
● Prehospital treatment
 15

● Blunt myocardial injury pneumothorax or sucking chest wound.

○ Bruising of the heart muscle ● A spontaneous pneumothorax may be
○ The heart may be unable to the result of rupture of a weak spot on
maintain adequate blood the lung, allowing air to enter the pleural
pressure. space and accumulate.
○ Signs and symptoms ● A simple pneumothorax is a result of
■ Irregular pulse rate blunt trauma resulting in fractured ribs.
■ Chest pain or ● A pneumothorax may progress to a
discomfort tension pneumothorax and cause
○ Suspect it in all cases of severe cardiac arrest.
blunt injury to the chest. ● Hemothorax is the result of blood
○ Prehospital treatment accumulating in the pleural space. A
■ Carefully monitor the hemopneumothorax is the presence of
pulse. air and blood in the pleural space.
■ Note changes in blood ● A flail chest segment (two or more ribs
pressure. broken in two or more places) should be
● Commotio cordis immobilized with a large bulky dressing.
○ Injury caused by a sudden, ● All patients with chest injuries should
direct blow to the chest during a receive high-flow oxygen or ventilation
critical portion of the heartbeat with a bag-mask device.
○ May result in immediate cardiac ● Pulmonary contusion, which is bruising
arrest of or injury to lung tissue after traumatic
○ Ventricular fibrillation responds injury, may interfere with oxygen
to defibrillation within the first 2 exchange in the lung tissue.
minutes of the injury. ● Traumatic asphyxia is sudden, severe
● Laceration of the great vessels compression of the chest.
○ May result in rapidly fatal ● Myocardial contusion describes bruising
hemorrhage of the heart muscle.
○ Prehospital treatment
■ Ventilatory support, if
needed
■ Immediate transport
■ Be alert for shock.
■ Monitor for changes in
baseline vital signs.

Summary:

● A penetrating chest injury can penetrate

the lung and diaphragm and injure the
liver or stomach.
● Closed chest injuries are often the result
of blunt force trauma, and open injuries
are the result of some object penetrating
the skin and/or chest wall.
● Blunt trauma may result in fractures to
the ribs and the sternum.
● Injuries that interfere with the ability of
the patient to ventilate or oxygenate
must be addressed quickly.
● Penetrating injury to the chest may allow
air to enter the pleural space, causing
pneumothorax. Cover the wound with an
occlusive dressing.
● A penetrating injury that creates a hole
in the chest wall is called an open
 16

Incident Management ○ Tagging patients (red, yellow,

green, black)
Introduction - Primary triage
● Disasters and mass-casualty incidents ● Treatment supervisor
can be overwhelming. ○ Locates and sets up the
- Most common human-induced is treatment area with a tier for
terrorism each priority of patient
○ Large number of patients ○ Ensures that secondary triage is
○ Lack of specialized equipment performed and that adequate
and/or adequate help patient care is given
● Incident command system (ICS) ○ Assists with moving patients to
(managerial) the transportation area
○ Makes it possible to do the ■ Ex. Patients are moved
greatest good for the greatest to a safe area and are
number - Golden rule sorted out according to
● National Incident Management System color tags.
(NIMS) - Only physicians can declare
○ Promotes efficient coordination patients who are expired
of emergency incidents at the - In here patients will be re-triage
regional, state, and national or re-tag by the physician
levels (Secondary triage)
● Transportation supervisor
Medical Incident Command ○ Coordinates the transportation
● Medical incident command is also and distribution of patients to
known as the medical (or EMS) branch appropriate receiving hospitals
of the ICS. ○ Communicates with the area
○ Primary roles of triage, hospitals
treatment, and transport of ○ Documents and tracks the
injured people number of vehicles transporting,
patients transported, and the
facility destination
● Staging supervisor
○ Should be assigned when
scenes require response by
numerous emergency vehicles
or agencies
○ The staging area should be
established away from the
scene.
- (hot zone, warm zone, cool
- All of these are manned by supervisors
zone)
● Triage supervisor
● Physicians on scene
○ In charge of counting and
○ Make difficult triage decisions
prioritizing patients
○ Provide secondary triage
○ Ensures that every patient
decisions in the treatment sector
receives initial assessment of
○ Provide on-scene medical
his or her condition
direction for EMTs
○ Do not begin treatment until all
○ Provide care in the treatment
patients are triaged.
sector as appropriate
 17

● Rehabilitation supervisor
○ Establishes an area that
provides protection from the
elements and situation
○ Monitors responders for signs of
stress
○ Rehabilitation is where a
responder’s needs for rest,
fluids, food, and protection from ● All systems have different protocols for
the elements are met. when to declare an MCI and initiate the
● Extrication and special rescue ICS.
○ Determines the type of ○ You and your team cannot treat
equipment and resources and transport all injured patients
needed for the situation at the same time.
○ Usually function under the EMS ○ Never leave the scene with
branch of the ICS patients if there are still other
patients who are sick or
● Morgue supervisor wounded.
○ Works with area medical ● If there are multiple patients and not
examiners, coroners, disaster enough resources to handle them
mortuary assistance teams, and without abandoning victims, you should:
law enforcement agencies to ○ Declare an MCI.
coordinate removal of bodies ○ Request additional resources.
and body parts ○ Initiate the ICS and triage
○ The morgue area should be out procedures.
of view of the living patients and
other responders. TRIAGE
○ There should be an allotted area ● “Triage” means “to sort” patients based
for black tag patients and must on the severity of their injuries.
be far away from other patients ○ Assessment is brief and patient
(can cause hysteria) condition categories are basic.
- 30 seconds - 1 minute
Mass Casualty Incidents ○ Primary triage is done in the
● A mass-casualty incident (MCI) is: field.
○ Any call involving three or more - Quick, brief
patients ○ Secondary triage is done as
○ Any situation that requires a patients are brought to the
mutual aid response treatment area.
○ Any incident that has the ● Four common categories give the order
potential for one of these of treatment and transport.
situations (may progress or ○ Immediate (red)
de-escalates on its own) ○ Delayed (yellow)
● Bus or train crashes and earthquakes ○ Minor or minimal (green; hold)
are examples. ○ Expectant (black; likely to die or
○ Other causes, smaller in scope, dead)
are more common.
 18

appear to weigh less than 100 lb

○ Begin by identifying the walking
wounded.
○ If a child has no pulse or does
not begin to breathe after
rescue breaths, label him or her
as expectant.

● Tagging patients early assists in tracking

them and can help keep an accurate
record of their condition.
○ Tags should be weatherproof,
easily read, and color-coded.
● START triage
○ Simple Triage And Rapid
Treatment
○ Call out to patients and direct
them to an easily identifiable
landmark. ● Triage special considerations
○ Injured persons are the walking ○ Patients who are hysterical and
wounded. disruptive to rescue efforts may
○ Assess the respiratory, need to be made an immediate
hemodynamic, and neurologic priority.
status of the nonambulatory ○ A rescuer who becomes sick or
patients. injured during the rescue effort
- RPM - Respiration (15 secs x 4 should be handled as an
in emergency cases), Perfusion immediate priority.
(radial pulse/capillary refill), ○ Identify patients as
Mental Status contaminated or
decontaminated in HazMat
incidents.
● Destination decisions
○ All patients triaged as
immediate or delayed should be
transported by ground or air
ambulance.
○ In large situations, a bus may
transport the walking wounded.
○ Immediate-priority patients
should be transported two at a
time until all are gone.
○ Then patients in the delayed
● JumpSTART triage for pediatric category can be transported two
patients or three at a time.
○ Artificial ventilation is applied ○ Finally, the slightly injured are
○ Intended for use in children transported.
younger than 8 years or who ○ Expectant patients who are still
 19

alive would receive treatment it is not properly controlled during

and transport last. handling, storage, manufacture,
○ Dead victims are handled or processing, packing, use and disposal,
transported according to the and transportation.
SOP for the area.. ● Take time to look at the whole scene.
● Identify critical visual indicators.
SALT (Sort, Assess, Life-Saving Intervention, ● Approach from a safe location and
Treatment/Transport) Triage direction.
● Developed by the Centers for Disease ○ Uphill and upwind (away from
Control and Prevention (CDC) to reduce harmful smokes and hazards)
triage time and to better utilize ● Hazardous materials may be involved in
resources. any of the following situations:
● This system had been adopted by ○ A truck or train crash in which a
pre-hospital providers in the Greater substance is leaking from a tank
Dayton area as a standard triage truck or tank car
system to be used in the event of a MCI. ○ A leak, fire, or other emergency
at an industrial plant, refinery, or
Gray - Expectant (not dead, but expected to not other complex
survive given current circumstances). These ○ A leak or rupture of an
patients might include TBI with exposed brain, underground natural gas pipe
90% ● Hazardous materials may be involved in
any of the following situations (cont’d):
Black - Patient is deceased (black/white stripes ○ Deterioration of underground
used for low light situations) fuel tanks and seepage of oil or
gasoline into the ground
Orange - used in addition to one of the above ○ Buildup of methane or other
by-products of waste
Quiz decomposition in sewers
● The first is to ○ A motor vehicle crash resulting
○ stop, look, listen and think in a ruptured gas tank
● Triage which victim first ● Occupancy and location
○ the closest victim ○ A wide variety of chemicals are
● A victim has a capillary refill of 4 stored in:
seconds. What do you do next? ■ Warehouses
○ Tag immediate and treat for ■ Hospitals
shock ■ Laboratories
● A 50 y.o. male with 2nd degree burns ■ Industrial occupancies
over 70% of the body. Respiratory rate ■ Residential garages
of 35 bpm, capillary refill lf more than 2 ■ Bowling alleys
seconds and unconscious ■ Home improvement
○ RED centers
● 42 year old female with an open fracture ● Senses
left ankle. Respiratory rate 24, Capillary ○ The senses that can be safely
refill less than 2 sec. Alert and oriented used are those of sight and
○ YELLOW sound.
○ Using any of your senses that
Recognizing Hazardous Materials bring you in proximity to the
● A hazardous material poses an chemical should be done with
unreasonable risk of damage or injury if caution or avoided.
 20

monitoring, support, and/or

HazMat Scene Operation treatment after decontamination
● Use the ambulance’s public address ● Role of the EMT
system. ○ Your job is to report to a
○ Alert individuals near the scene designated area outside of the
and direct them to move. hot and warm zones and
● Establish control zones. provide:
○ Securing access helps ensure ■ Triage
that no one will accidentally ■ Treatment
enter the contaminated area. ■ Transport
○ You should be prepared to ■ Rehabilitation
expand or contract the control
zones if necessary. Personal Protective Equipment Level
● PPE levels indicate the amount and type
of protective gear that you need to
prevent injury from a substance.
- All level requires use of gloves

Level A
● Most hazardous
● Requires fully encapsulated,
chemical-resistant protective clothing
● Hot zone that provides full-body protection, as
○ Area immediately surrounding well as SCBA
the release Level B
○ Most contaminated area ● Requires nonencapsulated protective
○ All personnel must be clothing or clothing that is designed to
decontaminated when they protect against a particular hazard
leave the hot zone. ● Requires breathing devices that contain
● Warm zone their own air supply, such as SCBA, and
○ Where personnel and eye protection
equipment transition into and Level C
out of the hot zone ● Requires the use of nonpermeable
○ Contains control points for clothing and eye protection
access to the hot zone and the ● Face masks that filter all inhaled outside
decontamination area air
○ Decontamination is the process Level D
of removing or neutralizing and ● Requires a work uniform, such as
properly disposing of hazardous coveralls, that affords minimal protection
materials. ● All levels require the use of gloves.
● Cold zone
○ Safe area where personnel do
not need to wear any special
protective clothing for safe
operation
○ Includes personnel staging, the
command post, EMS providers,
and the area for medical
 21

dead)
● A disaster is a widespread event that
disrupts functions and resources of a
community and threatens lives and
property.
● When you arrive at the scene of a
HazMat incident, you must first step
back and assess the situation.

Summary:
● The NIMS is used to prepare for,
prevent, respond to, and recover from
domestic incidents, regardless of cause,
size, or complexity, including acts of
catastrophic terrorism and hazardous
materials (HazMat) incidents.
● The major NIMS components are
command and management,
preparedness, resource management,
communications and information
management, supporting technologies,
and ongoing management and
maintenance.
● The purpose of the incident command
system is ensuring responder and public
safety; achieving incident management
goals; and ensuring the efficient use of
resources.
● At incidents, the medical group or
branch leader will supervise the primary
roles of the medical group: triage,
treatment, and transport of the injured.
● A mass-casualty incident refers to any
call that involves three or more patients,
any situation that places such a great
demand on available equipment or
personnel that the system would require
a mutual aid response, or any incident
that has a potential to create one of
these situations.
● The goal of triage is to do the greatest
good for the greatest number.
● There are four basic triage categories:
○ Immediate (red)
○ Delayed (yellow)
○ Minimal (green; hold)
○ Expectant (black; likely to die or
 22

MODULE 1: INTRODUCTION TO 2009

ICS - Quirino Grandstand Hostage Taking:
August 2010
LESSONS FROM PAST • WOWOWEE Stampede: an example of
INCIDENTS planned event that resulted into an incident
• Tropical Storm Ondoy: an example of a
disaster caused by natural hazard
Philippines: a country that is at risk • Quirino Grandstand Hostage Taking: an
to disasters example of a human-induced disaster
- As we all know, disasters exist in the
Philippines primarily because of our ISSUES FROM PAST DISASTERS
geographic location. We are located During those past incidents, the
within the Pacific Ring of Fire, an area of following are the issues and
convergence between large tectonic concerns:
plates causing earthquakes, tsunamis ● Lack of reliable incident information –
and volcanic eruptions. Also, our no assigned public information to
disseminate official information
country is located in the Pacific Typhoon
● Inadequate communications –
Belt, which explains the occurrences of agencies rely on their own
typhoons and tropical storms. communication tools
● Too many people reporting to one
World Risk Index Report 2017 supervisor – “span of control” is
overwhelming, eg 1 supervisor
- 3rd in 2011 - 2013 commanding 10-15 responders
- 2nd in 2014 ● Too many responders – too many
- 3rd in 2015-2016 rescuers, EMTs, fire fighters, social
- 3rd in 2017 workers in one incident area but
resources are not properly utilized
● Too many emergency response
organization structures – eg DSWD,
DOH, AFP, PNP, BFP have their own
organization structures, with their
respective chain of commands and
authorities.
● No check-in procedures for
responders – most of the ground
responders act as “freelancer”, respond
on their own without accounting their
actions
● Lack of structure for coordinated
planning between agencies – no
mechanism to harmonize inter-agency
planning
- According to the study by the UN ● Unclear lines of authority – different
“bosses” in one area, too many
University Institute for Environmentand
supervisors
Human Security, the Philippines is ● Terminology differences between
currently the 3rd country at risk to agencies – civilian personnel are
disasters worldwide, based on the World unfamiliar with the terminologies of the
Risk Index Report 2017. uniformed personnel such as ten codes
● Unclear or unspecified incident
objectives – since most of the
- WOWOWEE Stampede: February 2006
responders are freelancer during those
- Tropical Storm “Ondoy”: September past incident, objectives are not
 23

properly disseminated to all responders. especially response groups.

● Lack of clarity on who’s in charge – - Here are the key words that we have to
there are many prominent personalities consider:
and high ranking officials from different
- Standard – it is a universally accepted
agencies in the disaster scene.
● Confusion arising from catastrophic concept , a response mechanism
incidents – as explained earlier, too attuned to international guidelines
many responders, no clear objectives, - On- scene – it is on the spot/ on the
too many chain of command, in addition actual scene
to the pressures of catering to the - All – hazard – can be used for all types,
overlapping demands of the whether natural or human induced
communities (eg requests for rescue
- All response groups – ICS can be
and assistance, instructions of higher
officials, etc). All of these lead to used by practically all stakeholders,
confusion. whether government or
● Political intervention – some take non-government.
advantage of the disaster for political
interests ICS allows users to adopt an
integrated organizational
structure for response.
OVERVIEW OF ICS
- ICS allows users to adopt an integrated
Definition of Incident
organizational structure to match the
Incident is an occurrence, caused
complexities and demands of single or
by either human or natural
multiple incidents without being
phenomena, that requires
hindered by agency or jurisdictional
response actions to prevent or
boundaries. It allows different actors
minimize loss of life, or damage
(government, non-government, private,
to property and the
volunteers, and even international
environment.
groups) to harmonize their efforts, have
- Foremost, let us define incident as
a common objective despite their
prelude to defining Incident Command
differences in mandates, functions and
System (ICS). An incident is an
priorities.
occurrence, caused by either human or
natural phenomena, that requires
response actions to prevent or minimize
loss of life, or damage to property and
the environment.
Institutionalization Timelines
- This means that any situation that will
–+++++
require response intervention or
assistance, whether a simple car
Republic Act 10121
accident or a complex flooding situation,
• Section 9 (g): The Office of Civil Defense
is an “incident”.
(OCD) shall formulate standard operating
procedures for coordination.
ICS is a standard, on-scene,
• Rule 7 (h), Implementing Rules and
all-hazard incident
Regulations: The OCD shall establish
management concept that can
ICS as part of the Philippines’ on- scene
be used by all response
disaster response system.
groups.
- Republic Act 10121
- ICS is a standard, on-scene, all-hazard
- In response to the challenges
incident management concept that can
encountered from past major disasters
be used by all DRRMCs at all levels,
and incidents, ICS was mandated to be
 24

established in the Philippines through crisis level, the responding Crisis

Republic Act 10121, particularly in the Manager activates the Incident
following provisions: Command System (ICS)...”

NDRRMC Memo No. 4 s 2012 OCD Memo No. 758A s 2014

Provides guidelines on the use of
Approves the use of the Philippine
ICS as an on-scene disaster
ICS Field Operations Guide
response and management
mechanism - Issued on 23 October 2014 , this
- On March 28, 2012, the NDRRMC approves the ICS Field Operations
Memorandum Circular No. 4 was Guide for use and dissemination by the
approved, which provides the guidelines OCD.
on use of ICS as an On-Scene Disaster
Response and Management Mechanism
under the Philippine DRRM System.

NDRRMC Memo No. 48, s 2015

Provides for the localization of ICS
Executive Order No. 82 s 2012 forms in the Philippines context
- Issued on 12 November 2015, this
Provides for the activation of ICS provides for the localization of ICS forms
during human-induced crises in the Philippine context.

NDRRMC Memo No. 43, s 2016

- On September 4, 2012, former Provides the guidelines on the
President Aquino signed Executive interoperability of thr Incident
Order No. 82 entitled “Operationalizing Management Teams and
the Practical Guide for National Crisis Response Clusters
Managers and the National Crisis - Issued on August 18, 2016, this
Management Core Manual; Establishing provides the guidelines on the
National and Local Crisis Management interoperability of the Incident
Organizations; and Providing Funds Management Teams and Response
Therefor.” Clusters.
- Specifically, under Section 4D, the
Executive Order states that “as soon as
an incident is declared as approaching
 25

- Approved on 16 August 2017, this

reiterates the training qualifications to
become recognized by the OCD as an
ICS Cadre or Master Trainer. (6 weeks)

NDRRMC Memo No. 44, s 2016

Provides the guidelines on the
mobilization of Incident
Managemet Teams
- Also issued on August 18, 2016, this
provides the guidelines on the
mobilization of Incident Management Regional and Local
Teams. Institutionalization
Regional and local DMRRCs
formulated issuances to
institutionalize ICS in their
respective areas.
- Aside from issuances from the national
government, regional and local
DRRMCS also formulated their
respective issuances to institutionalize
NDRRMC-NSC JMC No. 1, s 2016 ICS in their respective areas.
Requires the use of ICS as an
integral component of
contingency plan for both Purpose of ICS
natural and human-induced Using management best practices,
hazards the purpose of the ICS is to help
- Issued on 30 August 2016, this Joint ensure:
Memorandum Circular of the NDRRMC ● The safety of responders and others.
and the National Security Council – This is the number one priority,
requires the use of ICS as an integral responders first before others. In ICS, a
component of contingency plan for both response operation can be put on hold
natural and human-induced hazards. or even terminated if the site is not safe
for the responders.
● The achievement of tactical
objectives. – Tactical objectives will be
formulated as bases for the actions of
the responders. In other words, when
you are deployed on-scene, you should
know what is your actual role and
contribution for the operations.
● The efficient use of resources. – This
is to prevent wastage of resources and
NDRRMC Memo No. 100, s 2017 overlapping of functions.
Reiterates the training qualifications
to become as an ICS Cadre or Benefits of ICS
Master Trainer ● Meets the needs of incidents of any
 26

kind or size – whether natural or ICS

human induced, small scale or large in Incident Command System
scope, ICS can be applied 1. Common Terminology
● Allows personnel from a variety of
2. Modular Organization
agencies to meld rapidly into a
common management structure – 3. Management by Objectives
whether you are from the government, 4. Incident Action Plan
non-government, or private sector, 5. Span of Control
everyone can work together 6. Incident Facilities & Location
harmoniously using ICS (accountability) 7. Resource Management
● Provides accountability and a 8. Integrated Communications
planning process – there is proper
9. Establishment and Transfer of
documentation and planning of who’s
doing what Command
● Provides logistical and administrative 10. Chain of Command & Unity of
support to operational staff – ICS Command
helps to ensure that responders will not 11. Unified Command
only be provided with equipment and 12. Accountability
tools, but also support in terms of 13. Dispatch/ Deployment
medicine, meals and other needs such
14. Information and Intelligence
as quarters.
● Cost effective by avoiding duplication Management
of efforts. – This is to avoid wastage of 15. ICS Forms and Tools
resources - To ensure the standard use and
application of ICS, the following are the
key principles and features that must be
remembered. We will explain them
one-by-one on the succeeding slides.
Countries using ICS Common Terminology
Full implementation: Organizational Elements.
• United States
- There is a consistent pattern for
• Canada
• Australia designating each level of the
• New Zealand organization (e.g., sections, branches,
• Mexico etc.). ICS incorporates a wide range of
In transition: management features and principles,
• Bhutan one of which is the use of common
• India terminology and clear text.
• Sri Lanka Communication is probably one of the
• Indonesia most essential elements of the ICS. It is
• Philippines important that we know how to
• Thailand communicate.
• Brunei Darussalam
• Ethiopia If the terms that I use mean
• Ghana different things to different
• Latin American Countries people, we are going to have a
- Here are the countries using ICS (as hard time communicating and
shown). Usually the developed countries
doing what needs to be done to
have ICS fully implemented. The
Philippines is still in transition when it accomplish our mission.
comes to implementation.
Resources.
PRINCIPLES AND FEATURES OF - Common designations are assigned to
 27

various kinds of resources. Many kinds management responsibilities are named

of resources may be classified by type and defined. Terminology for the
which will indicate their capabilities (e.g., organizational elements involved is
types of search and rescue teams, standard and consistent.
helicopters, mobile kitchen units, etc.).
For example, in the ICS, a vehicle that is
used in fire suppression is called an
engine. Recognizing that there is a
variety of engines, a type classification
is given based on tank capacity,
pumping capability, staffing and other
factors. The following examples
demonstrate the difference
Incident Facilities. between jargon and clear text:
- The facilities used in incidents are
named and referenced on maps using Jargon: “Railroad Street Command
common terminology and symbols. for Engine 44, you’re 10-1.”
Clear Text: “Railroad Street
Position Titles. Command from Engine 44, you
- People charged with management or are unreadable.”
leadership responsibility in the ICS are - Remember, do not use 10 codes.
referred to by position titles such as
Officer, Chief, Director, Supervisor, etc. Jargon: “OPSEC from Div. A, I
This is done to provide a way to place have you 10- 4.”
the most qualified personnel in Clear Text: “Operations Section
organizational positions in multi-agency Chief Noy Ramos from Division
incidents without confusion caused by Alpha. You are coming in clear.”
various multi- agency rank designations. - Remember, spell-out names and
It also provides a standardized method acronyms.
for ordering personnel to fill positions.

● Use clear text (plain language). Modular Organization

● Do not use radio codes, agency- ∙ ICS organization:
specific codes, acronyms, or other ∙ is flexible and modular.
jargons. ∙ develops in a top- down fashion
- All ICS communications should be done ∙ Form follows function
in plain language. Radio codes, - The ICS organization is flexible and
agency- specific codes, acronyms, and modular. Organization develops in a top-
other jargon should be avoided to down fashion, beginning with the
ensure that radio traffic can be Incident Commander (IC).The IC
understood by everyone on that establishes organization based on
channel. This ensures better incident size, complexity, and specific
communication and a safer work hazards.
environment. - “Form follows function”, i.e., only
- The ICS establishes common functions/positions necessary for the
terminology that allows diverse incident incident will be filled or activated.
management and support entities to
work together. Major functions and
functional units with incident
 28

- All activated units are called Incident

Management Team. The roles,
functions, and responsibilities will be
discussed on the next module.

Management by Objectives
The ICS is managed by objectives.
Incident Complexity, Resource In order to achieve the desired
Needs and ICS Organization goal at the top of the triangle,
there are four essential steps.
These steps take place in every
incident regardless of size or
complexity.
Understand agency policy and
direction
Establish incident objectives
Select appropriate strategy
Perform tactical direction (applying
- As seen in the diagram, if the incident is tactics appropriate to the
less complex, such as a car accident, strategy, assigning the right
only a few resources are needed. The resources, and monitoring
ICS organizational structure will be performance)
simple as well. However, as the
complexity of the incident increases, Once all these steps are conducted,
such as building bombing, more the goal will be achieved.
resources will be needed. This means
that the organizational structure will
have more layers. Incident Action Plan
- As mentioned, “Form follows function.”
Only functions/positions necessary for Used to communicate response
the incident are filled or activated. goals, objectives and support
activities throughout the ICS
organization May be oral or
Large Disaster: All Units written.
Activated Every incident needs an action plan.
● At first, an Incident Briefing Form is
used in smaller incidents to record initial
actions and list assigned and available
resources.
● As incidents grow in complexity and/or
size, the ICS provides a format for a
written action plan, referred to as the
IAP.
● The purpose of the plan is to provide all
incident supervisory personnel with
- Here is an example of an ICS appropriate direction for future actions.
organizational structure, with all units ● An IAP is developed for each
activated for large disasters. operational period. It includes the
following:
 29

- What must be done ● Staging area

- Who is responsible
- How information will be Established based on the
communicated requirements and complexity of
● IAP provides a clear understanding of the incident.
the tactical actions associated with the
next operational period. RESOURCE MANAGEMENT

SPAN OF CONTROL Definition of Resource: Any

personnel, team, equipment,
Ideal span of control for any aircraft, supplies and facilities
supervisor: 3 to 7 subordinates available to support
management and response
Span of control pertains to the activities
number of individuals one ● When it comes to ICS, resource refers
supervisor can effectively to any personnel, team, equipment,
manage. Maintaining an aircraft, supplies and facilities available
effective span of control is to support management and response
particularly important in activities.
incidents where safety and Includes processes for:
accountability have top priority. ● Categorizing
In ICS, the span of control for ● Ordering
any supervisor falls within a ● Dispatching
range of 3 to 7. If a supervisor ● Tracking
has fewer than 3, or more than ● Recovering
7, people reporting to him/her, ● Reimbursing resources (as appropriate)
some adjustments to the
organization should be Resource management includes
considered. processes for categorizing,
ordering, dispatching, tracking,
and recovering resources.
● It also includes processes for
reimbursement of resources, as
appropriate.
● Maintaining an accurate and up-to-date
picture of resource utilization is a critical
component of incident management.
The resource management process
consists of the following:
INCIDENT FACILITIES AND
- Establishment of resource needs
LOCATION
(kind/type/quantity)
- Resource ordering (actually getting what
In ICS, there are several incident
you need)
facilities and locations being
- Check-in process and tracking (knowing
established depending on the
what resources you have and where
needs of the incident.
they are)
● Incident command post
- Resource utilization and evaluation
● Base
(using the resources effectively)
● Camp
- Resource demobilization (releasing
 30

resources that are no longer needed) branch, or for divisions and groups,
depending on hardware and frequency
INTEGRATED COMMUNICATIONS availability, and specific incident needs.
● Support Nets- Established in larger
Every incident needs a incidents to handle logistics traffic and
communications plan. Sample resource status changes.
Communications networks: ● Ground- to- Air- Established to
● Command Net coordinate ground- to- air traffic.
● Tactical Nets ● Air- to- Air- Assigned for coordination
● Support Nets between aircraft assigned to an incident.
● Ground- to- Air
● Air- to- Air An awareness of available
communications systems and
frequencies, combined with an
The ability to communicate within understanding of incident
the ICS is absolutely essential. requirements, will enable the
Communications can be viewed Communications Unit Leader to
in at least three different ways: develop an effective
● The "hardware" systems that transfer Communications Plan for each
information operational period.
● Planning for the use of all available
communications frequencies and An essential part of an effective
resources multi- agency incident
● The procedures and processes for management system is for all
transferring information communications to be in clear
Just as every incident requires an text, i.e., do not use radio
IAP, every incident also needs a codes.
Communications Plan. Like the
action plan, the
Communications Plan can be
very simple and stated orally, or
it can be quite complex, and
form a part of a written IAP. ESTABLISHMENT AND
TRANSFER OF
Several communication networks COMMAND
may be established depending ● Command must be clearly established
upon the size and complexity of from the beginning of response.
the incident. ● Depending on the situation, command
may be transferred.
Communication networks may
include: The command function must be
● Command Net- Established to link clearly established from the
supervisory personnel from the Incident beginning of incident operations.
Commander down to and including The agency with primary
division and group supervisors. jurisdictional authority over the
● Tactical Nets- Established in a variety incident designates the
of ways, e.g., by agency, department, individual at the scene
geographical area, or function. Tactical responsible for establishing
nets may be established for each command.
 31

to, higher levels.

However, the command may also be
transferred from one IC to As incidents expand, the Chain of
another. Depending on the Command is established
situation, transfer of command through an organizational
occurs when: structure which can consist of
● A more qualified person assumes several layers as needed. Unity
command. of Command means that every
● The incident situation changes over individual has a designated
time, resulting in a legal requirement to supervisor. Unity of command is
change command. ensuring unity of effort under
● There is normal turnover of personnel one responsible person (or
on extended incidents. commander) for completing a
● The incident response is concluded and task.
responsibility is transferred to the home
agency. Chain of Command and Unity of
Command help to ensure that
When command is transferred, the clear reporting relationships
process must include a briefing exist. They eliminate the
that captures all essential confusion caused by multiple,
information for continuing safe conflicting directives. Incident
and effective operations. managers at all levels must be
able to control the actions of all
personnel under their
supervision.

UNIFIED COMMAND
Different agencies manage an
CHAIN OF COMMAND AND UNITY incident together by establishing
OF COMMAND a common set of incident
objectives and strategies.

Unified Command enables all

responsible agencies to manage
an incident together by
establishing a common set of
incident objectives and
strategies. It allows Incident
Commanders to make joint
decisions by establishing a
single command structure. In
maintaining unity of command,
each employee only reports to
Chain of Command means that one supervisor. There is shared
there is an orderly line of responsibility and accountability.
authority within the ranks of the
organization with lower levels
subordinate to, and connected ACCOUNTABILITY
 32

Several procedures within the ICS

ensure personnel accountability. Resource Tracking. Resource
Check- In. It is mandatory for all tracking maintains status of all
personnel upon arrival at an assigned resources.
incident to check- in. All Maintaining an accurate and up-
responders, regardless of to- date picture of resource
agency affiliation, must report in utilization is a critical component
order to receive an assignment of incident management.
in accordance with the
procedures established by the DISPATCH / DEPLOYMENT
Incident Commander. Upon Resources should respond only
check-in. You are now part of when requested or when
the Incident Management Team. dispatched by an appropriate
authority through established
Incident Action Plan. Response resource management systems.
operation must be coordinated Resources not requested must
as outlined in the IAP. Having an refrain from spontaneous
IAP enables all responders their deployment to avoid
respective duties and overburdening the recipient and
responsibilities for a given compounding accountability
operational period. challenges.

Unity of Command. Unity of Make sure that you receive a

command ensures everybody complete deployment briefing.
has only one supervisor. It The situation must be assessed
means that each individual and the response must be
involved in incident operations thoroughly planned. Managing
will be assigned, and will report, resources safely and effectively
to only one supervisor. Unity of is the most important
command clears up many of the consideration.
potential communication
problems encountered in
managing incidents or events
because each individual
maintains a formal INFORMATION AND
communication relationship only INTELLIGENCE
with his or her immediate MANAGEMENT
supervisor. Establish a process for gathering,
sharing and managing
Span of Control. Supervisors must information and intelligence.
be able to effectively supervise
their subordinates and manage Information and intelligence are
all resources under their critical to incident response. It
supervision. As explained is important that the incident
earlier, the ICS span of control management organization
for any supervisor is between 3 establishes a process for
and 7 subordinates, and gathering, sharing, and
optimally does not exceed 5 managing incident-related
subordinates. information and intelligence.
 33

Principles such as unity of

Definition of “Information”: command are applied to
Webster defines information as: effectively manage all
“Knowledge of a particular event responders in Metro Manila.
or situation.” In this instance it
could include details related to
your resource order, Typhoon Ruby (2014)
transportation, the incident In response to Typhoon Ruby, the
location, and contacts. Under regional and local IMTs were
the working definition for this mobilized by the different
course, information is primarily DRRMCs. The photos you see
intended for external use. are ICS action photos from
Agusan del Norte and Batangas
Definition of “Intelligence”: City. They developed their IAPs
Webster defines intelligence as: and conducted Operational
“The capacity to acquire and Briefings for the responders.
apply knowledge.” Specific Evacuation procedures, SRR
details related to the physical and clearing operations using
characteristics of the incident ICS were conducted efficiently
and current and expected and effectively.
conditions and how they affect
the actions taken to abate the APEC Meetings (2015)
incident. Intelligence is an During the hosting of the APEC in
aspect of information. In the 2015, several IMTs were
working definition for this deployed to various
course, Intelligence is primarily engagement areas, hotels and
intended for internal use. meeting venues of various
regions to ensure the safety and
ICS FORMS AND TOOLS welfare of the APEC delegates.
Moreover, during the APEC
The ICS has a variety of tools, Economic Leaders Meeting, the
including forms, to help concept of Unified Command
standardize procedures and was applied by the NDRRMC
documentation under the Joint Task Group
Emergency Preparedness.
The importance of standard ICS
forms and tools. Possible Mt. Apo Fire Incident (2016)
answers are: During the Mt. Apo Fire Incident, the
● For standardization RDRRMC XI and XII fully
● For quick planning and decision making applied all the concepts and
● To serve as handy reference guide principles of ICS to facilitate
well- coordinated inter- agency
ICS SUCCESS STORIES response and prevent further
Black Nazarene Traslacion (since spreading of the fire. Moreover,
2013) the ICS was used for proper
ICS methodologies are utilized to coordination with other
ensure the safety of devotees neighboring regions offering
from security threats, stampede, assistance.
and other untoward incidents.
 34

Marawi Crisis (2017)

In response to the Marawi Crisis, HEAD & SPINE INJURIES
the IMTs were mobilized by the Introduction
NDRRMC for consequence ● The nervous system is a complex
management. They developed network of nerve cells that enables all
their IAPs and conducted parts of the body to function.
Operational Briefings for the ● It includes:
responders in providing the - Brain
immediate needs of the affected - Spinal cord
population. - Several billion nerve fibers
● The nervous system is well protected.
ASEAN Meetings (2017) - The brain is protected by the
ICS was also applied during the skull.
conduct of ASEAN related - The spinal cord is protected by
meetings. Several IMTs were the spinal canal.
deployed to various ● Despite this protection, serious injuries
engagement areas, hotels and can damage the nervous system.
meeting venues of various
regions to ensure the safety and Head Injuries
welfare of the ASEAN ● Traumatic insult to the head that may
delegates. result in injury to soft tissue, bony
structures, or the brain
● 52,000 deaths occur annually in the
United States as the result of severe
head injury.
● Account for more than half of all
traumatic deaths
● Closed injuries
- The brain has been injured but
there is no opening into the
brain.
● Open injuries
- An opening from the brain to the
outside world exits.
- Often caused by penetrating
MODULE SUMMARY trauma
● The establishment of ICS is the - May be bleeding and exposed
mandate of the OCD as provided for in brain tissue
Republic Act 10121 and other national ● Motor vehicle crashes are the most
issuances. common MMOI.
● ICS was institutionalized to address - Head injuries also commonly occur:
command issues and concerns ● In victims of assault
regarding response operations. ● When elderly people fall
● During sport-related incidents
● In a variety of incidents involving
FACE & NECK INJURIES children
- Any head injury is potentially serious.
 35

● Linear skull fractures

- Account for about 80% of all
skull fractures
- Radiographs are often required
to diagnose a linear skull
Scalp Lacerations
fracture because there are often
● Can be minor or serious
no physical signs.
● Even small lacerations can lead to
● Compressed skull fractures
significant blood loss.
- Result from high-energy direct
- This blood loss may be severe
trauma to the head with a blunt
enough to cause hypovolemic
object
shock.
- Frontal and parietal bones are
● They are often an indicator of deeper,
most susceptible
more serious injuries.
- Bony fragments may be driven
into the brain
Skull Fracture
● Basilar skull fractures
● Significant force applied to the head
- Associated with high-energy
may cause a skull fracture.
trauma
● May be open or closed, depending on
- Usually occur following diffuse
whether there is an overlying laceration
impact to the head
of the scalp
- Signs include CSF drainage
● Injuries from bullets or other penetrating
from the ears, raccoon eyes,
weapons often result in skull fractures.
and Battle’s sign
● Signs of skull fracture include:
● Open skull fractures
- Patient’s head appears
- Result when severe forces are
deformed
applied to the head
- Visible cracks in the skull
- Often associated with trauma to
- Ecchymosis (bruising) that
multiple body systems
develops under the eyes
- Brain tissue may be exposed to
(raccoon eyes)
the environment
- Ecchymosis that develops
behind one ear over the mastoid
Traumatic Brain Injuries
process (Battle’s sign)
● Most serious of all head injuries
 36

● Two broad categories: primary (direct)

injury and secondary (indirect) injury
- Primary brain injury results
instantaneously from impact to
the head.
- Secondary brain injury
increases the severity of the
primary injury.
Secondary injury may be
caused by:
● Hypoxia
● Hypotension
● Cerebral edema
● Intracranial hemorrhage
● Increased intracranial
pressure
● Cerebral ischemia
● Infection

Intracranial Pressure
● The brain can be injured directly by a
penetrating object or indirectly as a
result of external forces. ● Intracranial hemorrhage
● A coup-countercoup injury can result - Bleeding inside the skull also increases
from striking a windshield. the ICP.
- Initial impact injures front part of - Bleeding can occur:
brain ● Between the skull and dura
- Head falling back against mater
headrest injures rear part of ● Beneath the dura mater but
brain outside the brain
● Accumulations of blood within the skull ● Within the tissue of the brain
or swelling of the brain can rapidly lead itself
to an increase in ICP. ● Epidural hematoma
- Increased ICP squeezes the - Accumulation of blood between the skull
brain against bony prominences and dura mater
within the cranium. - Nearly always a result of a blow to the
head that produces a linear fracture

● Subdural hematoma
- Accumulation of blood beneath the dura
mater but outside the brain
- Occurs after falls or injuries involving
strong deceleration forces
 37

- Disorientation

Contusion
● Far more serious than a concussion
● Involves physical injury to brain tissue
● Intracerebral hematoma
● May sustain long-lasting and even
- Bleeding within the brain tissue itself
permanent damage
- Can occur following a penetrating injury
● A patient may exhibit any or all of the
to the head or because of rapid
signs of brain injury.
deceleration forces

Other Brain Injuries

● Brain injuries can also arise from
medical conditions, such as blood clots
or hemorrhages.
● Subarachnoid hemorrhage ● Signs and symptoms of nontraumatic
- Bleeding occurs into the subarachnoid injuries are often the same as those of
space, where the CSF circulates traumatic brain injuries.
- Results in bloody CSF and signs of - Except that there is no obvious history
meningeal irritation of MOI or any external evidence of
- Common causes include trauma or trauma
rupture of an aneurysm.
Spine Injuries
Concussion ● Compression injuries can result from a
● A blow to the head or face may cause fall.
concussion of the brain. ● Motor vehicle crashes can overextend,
- Closed injury with a temporary loss or flex, or rotate the spine.
alteration of part or all of the brain’s ● The spine can be pulled along its length,
abilities to function without called distraction.
demonstrable physical damage to the ● Subluxation occurs when vertebrae are
brain no longer aligned.
- About 90% of patients do not
experience a loss of consciousness. Emergency Medical Care of Head
● A patient with a concussion may be Injuries
confused or have amnesia. ● Three general principles:
● Usually a concussion lasts only a short - Establish an adequate airway.
time. - Control bleeding, and provide adequate
● Ask about these symptoms: circulation to maintain cerebral
- Dizziness perfusion.
- Weakness ● Begin CPR, if necessary.
- Visual changes ● Follow standard precautions.
- Nausea and vomiting - Assess the patient’s baseline level of
- Ringing in the ears consciousness, and continuously
- Slurred speech monitor.
- Inability to focus ● Managing the airway
- Lack of coordination - The most important steps is establishing
- Delay of motor functions an adequate airway.
- Inappropriate emotional - Perform the jaw-thrust maneuver.
responses - Once the airway is open, maintain the
- Temporary headache head and cervical spine in a neutral,
 38

in-line position. oropharyngeal airway.

- Remove any foreign bodies, secretions, - Have a suctioning unit available.
or vomitus. - Provide high-flow oxygen.
- Make sure a suctioning unit is available. ● Stabilization of the cervical spine
- Check ventilation. - Immobilize the head and trunk
- Give high-flow oxygen to any patient so that bone fragments do not
with suspected head injury. cause further damage.
- Follow the steps in Skill Drill
26-1.
- Assess the pulse, motor
functions, and sensations in all
extremities.
- Assess the cervical spine area
and neck.
- Never force the head into a
neutral, in-line position.

Preparation for Transport

● Supine patients
- Secure to a long backboard.
- The ideal way to move a patient from
the ground to a backboard is the
● Circulation four-person log roll.
- Begin CPR if the patient is in cardiac - You may also slide the patient onto a
arrest. backboard or use a scoop stretcher.
- Active blood loss aggravates hypoxia. - Follow the steps in Skill Drill 26-2.
- You can almost always control bleeding ● Sitting patients
from a scalp laceration by applying - If there is time, use a short backboard to
direct pressure over the wound. immobilize the cervical and thoracic
● Cushing’s triad spine.
- Increased blood pressure (hypertension) - Then secure the short board to the long
- Decreased heart rate (bradycardia) board.
- Irregular respirations (Cheyne-Stokes - Exceptions include situations in which:
respirations, central neurogenic ● You or the patient is in danger
hyperventilation, or Biot respirations) ● You need immediate access to
other patients
Emergency Medical Care of ● The patient’s injuries justify
Spinal Injuries urgent removal
● Follow standard precautions. ● Follow the steps in Skill Drill
● Maintain the patient’s airway while 26-3.
keeping the spine in the proper position. ● Standing patients
● Assess respirations and give - Immobilize the patient to a long
supplemental oxygen. backboard before proceeding with
● Managing the airway assessment.
- Perform the jaw-thrust - This process will require three EMTs.
maneuver. - Follow the steps in Skill Drill 26-4.
- After you open the airway, ● Immobilization devices
consider inserting an - Assume the presence of spinal injury in
 39

all patients who have sustained head baseline level of consciousness.

injuries. ● Treat the patient with a spinal injury by
- Use manual in-line immobilization or a maintaining the airway while keeping the
cervical collar and long backboard spine in proper alignment, assess
● Cervical collars respirations, and give supplemental
- Provide preliminary, partial support oxygen.
- Should be applied to every patient who ● Reduction of on-scene time increases
has a possible spinal injury the critical patient’s chances for survival
- Must be the correct size for the patient or a reduction in the amount of
- Follow the steps in Skill Drill 26-5. irreversible damage.
● Short backboards
- Vest-type device and rigid short board
- Designed to stabilize and mobilize the
head, neck, and torso
- Used to immobilize noncritical patients
found in a sitting position
● Long backboards
- Provide full body spinal immobilization
and motion restriction and
immobilization to the head, neck, torso,
pelvis, and extremities
- Used to immobilize patients found in any
position

SUMMARY
● The nervous system of the human can
be divided into two parts: the central
nervous system and the peripheral
nervous system.
● The central nervous system consists of
the brain and the spinal cord; the
peripheral nervous system consists of a
network of nerve fibers.
● The central nervous system is well
protected by bony structures; the brain
is protected by the skull and the spinal
cord is protected by the bones of the
spinal column.
● A head injury is a traumatic injury to the
head that may result in injury to soft
tissue, bony structures, or the brain.
● Motor vehicle crashes, direct blows, falls
from heights, assault, and sports injuries
are common causes of spinal injury.
● Treat the patient with a head injury
according to three general principles:
establish an adequate airway, control
bleeding, and reassess the patient’s
 40

ORTHOPEDIC INJURIES ● Musculoskeletal injuries are among the

most common reasons why patients
National EMS Education Standard seek medical attention.
Competencies ○ Often easily identified because
of associated pain, swelling, and
Trauma deformity
● Applies fundamental knowledge to ○ Often result in short- or
provide basic emergency care and long-term disability
transportation based on assessment
findings for an acutely injured patient. Anatomy and Physiology of the
Musculoskeletal System
Orthopaedic Trauma ● Three types of muscles: skeletal,
● Recognition and management of: smooth, and cardiac
○ Open fractures ● Skeletal muscle attaches to the bones
○ Closed fractures and usually crosses at least one joint.
○ Dislocations ○ Forms the major muscle mass
○ Amputations of the body
Pathophysiology, assessment, ○ Called voluntary muscle
and management of: because it is under direct
● Upper and lower extremity orthopaedic voluntary control of the brain
trauma
● Open fractures
● Closed fractures
● Dislocations
● Sprains/strains
● Pelvic fractures
● Amputations/replantation

Medicine
● Applies fundamental knowledge to
provide basic emergency care and ○
transportation based on assessment ● Cardiac muscle is a specially adapted
findings for an acutely ill patient. involuntary muscle with its own
regulatory system.
Nontraumatic Musculoskeletal
Disorders The Skeleton
● Anatomy, physiology, pathophysiology, ● Gives us our recognizable human form
assessment, and management of: ● Protects our vital organs
○ Nontraumatic fractures ● Allows us to move
● Produces blood cells
Introduction ● Made up of approximately 206 bones
● The musculoskeletal system provides:
○ Form
○ Upright posture
○ Movement
● System also protects vital internal
organs
○ Bones, muscles, tendons, joints,
and ligaments are still at risk
 41

●
● The skull protects the brain.
● The thoracic cage protects the heart,
lungs, and great vessels.
●
● The pectoral girdle consists of two
● The hand contains three sets of bones:
scapulae and two clavicles.
○ Wrist bones (carpals)
○ Hand bones (metacarpals)
○ Finger bones (phalanges)
● The pelvis supports the body weight and
protects the structures within the pelvis:
the bladder, rectum, and female
reproductive organs.
● The lower extremity consists of the
bones of the thigh, leg, and foot.
● The foot consists of three classes of
●
bones:
○ Ankle bones (tarsals)
○ Foot bones (metatarsals)
○ Toe bones (phalanges)

●
● The upper extremity extends from the
shoulder to the fingertips.
○ Composed of the arm
(humerus), elbow, forearm
(radius and ulna), wrist, hand, ●
and fingers ● The bones of the skeleton provide a
framework to which the muscles and
tendons are attached.
● A joint is formed wherever two bones
come into contact.
○ Joints are held together in a
capsule.
○ Joints are lubricated by synovial
fluid.
 42

Musculoskeletal Injuries ■ A displaced fracture

● A fracture is a broken bone. produces actual
○ A potential complication is deformity, or distortion,
compartment syndrome. of the limb by
● A dislocation is a disruption of a joint in shortening, rotating, or
which the bone ends are no longer in angulating it.
contact. ● Medical personnel often use the
● A subluxation is similar except the following special terms to describe
disruption of the joints is not complete. particular types of fractures.
● A fracture-dislocation is a combination
injury at the joint.
● A sprain is an injury to ligaments,
articular capsule, synovial membrane,
and tendons crossing the joint.
● A strain is a stretching or tearing of the
muscle, causing:
○ Pain ●
○ Swelling ● Greenstick
○ Bruising ○ An incomplete fracture that
● An amputation is an injury in which an passes only partway through the
extremity is completely severed from the shaft of a bone
body. ● Comminuted
● Injury to bones and joints is often ○ A fracture in which the bone is
associated with injury to the surrounding broken into more than two
tissues. fragments
○ Entire area is known as the ● Pathologic
zone of injury ○ A fracture of weakened or
diseased bone
Mechanism of Injury ● Oblique
● Significant force is generally required to ○ A fracture in which the bone is
cause fractures and dislocations. broken at an angle across the
○ Direct blows bone
○ Indirect forces ● Transverse
○ Twisting forces ○ A fracture that occurs straight
○ High-energy forces across the bone
● Spiral
Fractures ○ A fracture caused by a twisting
● Classified as either closed or open force, causing an oblique
● Your first priority is to determine whether fracture around the bone and
the overlying skin is damaged. through the bone
○ Treat any injury that breaks the ● Incomplete
skin as a possible open fracture. ○ A fracture that does not run
○ Fractures are described by completely through the bone
whether the bone is moved from ● Suspect a fracture if one or more of the
its normal position. following signs are present:
■ A nondisplaced fracture ○ Deformity
is a simple crack of the ○ Tenderness
bone. ○ Guarding
○ Swelling
 43

● Signs of fractures (cont’d) ● A sprain occurs when a joint is twisted

○ Bruising or stretched beyond its normal range of
○ Crepitus motion.
○ False motion ○ Alignment generally returns to a
○ Exposed fragments fairly normal position, although
○ Pain there may be some
○ Locked joint displacement.
○ Severe deformity does not
Dislocations typically occur.
● Signs and symptoms
○ Point tenderness
○ Swelling and ecchymosis
○ Pain
○ Instability of the joint

Strain
● A strain is an injury to a muscle and/or
tendon that results from a violent muscle
contraction or from excessive stretching.
○ Often no deformity is present
● Sometimes a dislocated joint will and only minor swelling is noted
spontaneously reduce before your at the site of the injury.
assessment.
○ Confirm the dislocation by Compartment Syndrome
taking a patient history. ● Most often occurs with a fractured tibia
○ A dislocation that does not or forearm of children
reduce is a serious problem. ● Typically develops within 6 to 12 hours
● Signs and symptoms after injury, as a result of:
○ Marked deformity ○ Excessive bleeding
○ Swelling ○ A severely crushed extremity
○ Pain that is aggravated by any ○ The rapid return of blood to an
attempt at movement ischemic limb
○ Tenderness on palpation ● This syndrome is characterized by:
● Signs and symptoms (cont’d) ○ Pain that is out of proportion to
○ Virtually complete loss of normal the injury
joint motion ○ Pain on passive stretching of
○ Numbness or impaired muscles within the compartment
circulation to the limb or digit ○ Pallor
○ Decreased sensation
Sprains ○ Decreased power

Amputations
● Can occur as a result of trauma or a
surgical intervention
● You must control bleeding and treat for
shock.
● Be aware of the victim’s emotional
stress.
 44

Complications
● orthopedic injuries can also lead to
systemic changes or illnesses.
● The likelihood of having a complication
is often related to the:
○ Strength of the force that
caused the injury
○ Injury’s location
○ Patient’s overall health
● To prevent contamination following an
open fracture:
○ Brush away any debris on the
skin
○ Do not enter or probe the site
● Long-term disability is one of the most ●
devastating consequences of an
orthopedic injury. Patient Assessment
● You can help reduce the risk or duration ● Patient assessment steps
of long-term disability by: ○ Scene size-up
○ Preventing further injury ○ Primary assessment
○ Reducing the risk of wound ○ History taking
infection ○ Secondary assessment
○ Minimizing pain by the use of ○ Reassessment
cold and analgesia ● Always look at the big picture.
○ Transporting patients to an ○ Distinguish mild injuries from
appropriate medical facility severe injuries.
○ Severe injuries may
Assessing the Severity of Injury compromise neurovascular
● The Golden Period is critical for life and function, which could be limb
for preserving limb viability. threatening.
○ Prolonged hypoperfusion can
cause significant damage. Scene Size Up
○ Any suspected open fracture or ● Scene safety
vascular injury is a medical ○ Observe the scene for any
emergency. hazards.
● Most injuries are not critical. ○ Identify the forces associated
○ Use a grading system. with the MOI.
○ Standard precautions involve
gloves, a mask, and a gown.
○ Consider that there may be
hidden bleeding.
○ Evaluate the need for additional
support.
● Mechanism of injury/nature of illness
○ Look for indicators of the MOI.
○ Be alert for both primary and
secondary injuries.
○ Consider how the MOI produced
the injuries expected.
 45

Primary Assessment Secondary Assessment

● Focus on identifying and managing life ● Physical examinations (cont’d)
threats. ○ When lacerations are present in
● Form a general impression. an extremity, consider an open
○ Introduce yourself. fracture.
○ Check for responsiveness using ○ Any injury or deformity of the
the AVPU scale. bone may be associated with
○ Ask about the chief complaint. vessel or nerve injury.
● Form a general impression (cont’d). ○ To assess neurovascular status,
○ Administer high-flow oxygen to follow the steps in Skill Drill
all patients whose LOC is less 29-1.
than alert and oriented. Reassessment
○ Perform a rapid scan and ask ● Repeat the primary assessment.
about the MOI. ○ Every 5 minutes for an unstable
○ If there was significant trauma, patient
the musculoskeletal injuries may ○ Every 15 minutes for a stable
be a lower priority. patient
● Circulation ● Interventions
○ Determine whether the patient ○ Assess the overall condition,
has a pulse, has adequate stabilize the ABCs, and control
perfusion, or is bleeding. any serious bleeding.
○ If the skin is pale, cool, or ○ In a critically injured patient,
clammy and capillary refill time secure the patient to a long
is slow, treat for shock. backboard and transport.
○ Maintain a normal body ○ If the patient has no
temperature and improve life-threatening injuries, take
perfusion with oxygen. extra time at the scene to
○ Fractures can break through the stabilize his or her condition.
skin and cause external ○ The main goal is stabilization in
bleeding. the most comfortable position
● Transport decision that allows for maintenance of
○ Provide rapid transport if the good circulation distal to the
patient has an airway or injury.
breathing problem, or significant ● Communication and documentation
bleeding. ○ Include a description of the
○ A patient who has a significant problems found during your
MOI but whose condition assessment.
appears otherwise stable should ○ Report problems with the ABCs,
also be transported promptly. open fractures, and
○ Patients with a simple MOI may compromised circulation.
be further assessed. ○ Document complete description
History Taking of injuries and the MOIs
● Investigate t(e chief complAint. associated with them.
● Obtain a medical h)story and be aleru
for injury-speaafic rigns and symptoms Emergency Medical Care
and ● Perform a primary assessment.
● Stabilize the patient’s ABCs.
● Perform a rapid scan or focus on a
specific injury.
 46

● Follow standard precautions. ○ Goals of in-line traction:

● Suspect internal bleeding. ■ To stabilize the fracture
● Follow the steps in Skill Drill 29-2. fragments
■ To align the limb
Splinting sufficiently
● A splint is a flexible or rigid device that is ■ To avoid potential
used to protect and maintain the neurovascular
position of an injured extremity. compromise
○ Splint all fractures, dislocations, ● In-line traction splinting (cont’d)
and sprains before moving the ○ Imagine where the uninjured
patient, unless he or she is in limb would lie, and pull gently
immediate danger. along the line of that imaginary
○ Splinting reduces pain and limb until the injured limb is in
makes it easier to transfer and approximately that position.
transport the patient.
● Splinting will help to prevent:
○ Further damage to muscles, the
spinal cord, peripheral nerves,
and blood vessels
○ Laceration of the skin
○ Restriction of distal blood flow
○ Excessive bleeding of the
tissues
○ Increased pain ●
○ Paralysis of extremities
● General principles of splinting RIGID SPLINTS
○ Remove clothing from the area. ● Made from firm material
○ Note and record the patient’s ● Applied to the sides, front, and/or back
neurovascular status. of an injured extremity
○ Cover all wounds with a dry, ● Prevent motion at the injury site
sterile dressing. ● Takes two EMTs to apply
○ Do not move the patient before
splinting an extremity, unless ● Two situations in which you must splint
there is danger. the limb in the position of deformity:
● General principles of splinting (cont’d) - When the deformity is severe
○ Pad all rigid splints. - When you encounter resistance
○ Maintain manual stabilization. or extreme pain when applying
○ If you encounter resistance, gentle traction to the fracture of
splint the limb in its deformed a shaft of a long bone
position.
○ Stabilize all suspected spinal Formable Splints
injuries in a neutral, in-line Most commonly used formable splint is the
position. precontoured, inflatable, clear plastic air splint
○ When in doubt, splint. ● Comfortable
● General principles of in-line traction ● Provides uniform contact
splinting ● Applies firm pressure to a bleeding
○ Act of pulling on a body wound
structure in the direction of its ● Used to stabilize injuries below the
normal alignment elbow or knee
 47

Drawbacks: Hazards of Improper Splinting

● The zipper can stick, clog with dirt, or ● Compressions of nerves, tissues, and
freeze. blood vessels
● Significant changes in the weather affect ● Delay in transport of a patient with a
the pressure of the air in the splint. life-threatening injury
● Reduction of distal circulation
Traction Splints ● Aggravation of the injury
Used primarily to secure fractures of the shaft of ● Injury to tissue, nerves, blood vessels,
the femur or muscles
Several different types:
● Hare splint Sager splint Reel splint Transportation
Kendrick splint Very few, if any, musculoskeletal injuries justify
Do not use for any of these conditions: the use of excessive speed during transport.
● Injuries of the upper extremity - A patient with a pulseless limb must be
● Injuries close to or involving the knee given a higher priority.
● Injuries of the hip Injuries of the pelvis - If the treatment facility is an hour or
● Partial amputations or avulsions with more away, transport by helicopter or
bone separation immediate ground transportation.
● Lower leg, foot, or ankle injury
● Proper application requires two Injuries of the Clavicle and Scapula
well-trained EMTs. The clavicle is one of the most commonly
fractured bones in the body.
- Occur most often in children
Pelvic Binder - A patient will report pain in the shoulder
Used to splint the bony pelvis to reduce and will hold the arm across the front of
hemorrhage from bone ends, venous disruption, the body
and pain
Fractures of the scapula occur much less
Meant to provide temporary stabilization frequently because the bone is well protected by
- Should be light, made of soft material, many large muscles.
easily applied by one person, and - Almost always the result of a forceful,
should allow access to the abdomen, direct blow to the back
perineum, anus, and groin - The associated chest injuries pose the
greatest threat of long-term disability.
Pneumatic Antishock Garments Injuries of the
Use as a splinting device if a patient has injuries - These fractures can be splinted
to the lower extremities/pelvis. effectively with a sling and swathe.

Do not use the PASG if any of the following Dislocations of the Shoulder
conditions exist: The humeral head is most commonly dislocates
● Pregnancy anteriorly. Shoulder dislocations are very painful.
● Pulmonary edema - Stabilization is difficult because any
● Acute heart failure attempt to bring the arm in toward the
Do not use the PASG if (cont’d): chest wall produces pain.
● Penetrating chest injuries - Splint the joint in whatever position is
● Groin injuries more comfortable for the patient.
● Major head injuries
● A transport time of less than 30 minutes Fractures of the Humerus
Occur either proximally, in the midshaft, or
 48

distally at the elbow. Consider applying traction ● Common in people of all age groups
to realign the fracture fragments before splinting ● Seen most often in children and elderly
them.
- Splint the arm with a sling and swathe. Usually, both the radius and the ulna break at
the same time.
Elbow Injuries ● Fractures of the distal radius are known
Different types of injuries are difficult to as Colles fractures.
distinguish without x-ray examinations. ● To stabilize fractures, you can use a
padded board, air, vacuum, or pillow
Fracture of the distal humerus splint.
- Common in children
- Fracture fragments rotate significantly, Injuries of the Wrist and Hand
producing deformity and causing injuries - Must be confirmed by x-ray exams
to nearby vessels and nerves. - Dislocations are usually associated with
a fracture.
Dislocation of the elbow - Any questionable wrist injury should be
● Typically occurs in athletes splinted and evaluated in the ED.
● The ulna and radius are most often
displaced posteriorly. Fractures of the Pelvis
Often results from direct compression in the
Elbow joint sprain form of a heavy blow
● This diagnosis is often mistakenly - Can be caused by indirect forces
applied to an occult, nondisplaced - Not all pelvis fractures result from
fracture. trauma.

Fracture of olecranon process of ulna ● May be accompanied by life-threatening

● Can result from direct or indirect forces loss of blood
● Often associated with lacerations and ● Open fractures are quite uncommon.
abrasions ● Suspect a fracture of the pelvis in any
● Patient will be unable to extend the patient who has sustained a
elbow. high-velocity injury and complains of
discomfort in the lower back or
Fractures of the radial head abdomen.
● Often missed during diagnosis ● Assess for tenderness.
● Generally occurs as a result of a fall on
an outstretched arm or a direct blow to
the lateral aspect of the elbow
● Attempts to rotate the elbow or wrist
cause discomfort.

Care of elbow injuries

● All elbow injuries are potentially serious
and require careful management.
● Always assess distal neurovascular Dislocation of the Hip
functions periodically. - Dislocates only after significant injury
● Provide prompt transport for all patients - Most dislocations are posterior.
with impaired distal circulation. - Suspect a dislocation in any patient who
has been in an automobile crash and
Fractures of the Forearm has a contusion, laceration, or obvious
 49

fracture in the knee region.

● Cover any wound with a dry, sterile
Posterior dislocation is frequently complicated dressing.
by injury to the sciatic nerve. ● These fractures are best stabilized with
Distinctive signs a traction splint.
● Severe pain in the hip
● Strong resistance to movement of the Injuries of Knee Ligaments
joint Many different types of injuries occur in this
● Tenderness on palpation region.
- Ligament injuries
Make no attempt to reduce the dislocated hip in - Patella can dislocate.
the field. - Bony elements can fracture.
● Splint the dislocation.
● Place the patient supine on a When you examine the patient, you will
backboard. generally find:
● Support the affected limb with pillows. - Swelling
● Secure the entire limb to the backboard - Occasional ecchymosis
with long straps. - Point tenderness at the injury site
● Provide prompt transport. - A joint effusion
Splint all suspected knee ligament injuries.
Fractures of the Proximal Femur
● Common fractures, especially in elderly Dislocation of the Knee
● Break goes through the neck of the These are true emergencies that may threaten
femur, the interochanteric region, or the limb.
across the proximal shaft of the femur ● Ligaments may be damaged or torn.
Direction of dislocation is the position of the tibia
Patients display a certain deformity. with respect to the femur.
- They lie with the leg externally rotated, - Anterior dislocations
and the injured limb is usually shorter - Posterior dislocations
than the opposite, uninjured limb. - Medial dislocations
Complications may include:
● Assess the pelvis for any soft-tissue - Limb-threatening popliteal artery
injury and bandage appropriately. disruption
● Assess pulses and motor and sensory - Injuries to the nerves
functions. - Joint instability
● Splint the lower extremity and transport If adequate distal pulses are present, splint the
to the emergency department. knee and transport promptly.
● Can occur in any part of the shaft, from
the hip region to the femoral condyles Fractures Above the Knee
just above the knee joint May occur at the distal end of the femur, at the
● Large muscles of the thigh spasm in an proximal end of the tibia, or in the patella
attempt to “splint” the unstable limb.
● Fractures may be open. Management
● There is often significant blood loss. ● If there is an adequate distal pulse and
no significant deformity, spliît the limb
Bone fragments may penetrate or press on with the knee sprains.
important nerves and vessels. ● If there is an adequate pulse and
- Carefully and periodically assess the significant deformity, splint the joint in
distal neurovascular function. the position of deformity.
 50

● If the pulse is absent below the level of Injuries of the foot are associated with significant
injury, contact medical control. swelling but rarely with gross deformity.
● Never use a traction splint.
To splint the foot, apply a rigid padded board
Dislocation of the Patella splint, an air splint, or a pillow splint.
● Most commonly occurs in teenagers and - Leave the toes exposed.
young adults in athletic activities
● Usually, the dislocated patella displaced Compartment Syndrome
to the lateral side and exhibits a If you have a pediatric patient with a fracture
significant deformity. below the elbow or knee, be on the lookout for
● Splint the knee in the position in which these signs/symptoms:
you find it. - Extreme pain
- Decreased pain sensation
Injuries of the Tibia and Fibula - Pain on stretching of affected muscles
Tibia (shinbone) is the larger of the two leg - Decreased power
bones, and the fibula is the smaller.
If you suspect the patient has compartment
Fracture may occur at any place between the syndrome, splint the affected limb and transport
knee joint and the ankle joint. immediately.
- Usually, both fracture at the same time. - Reassess neurovascular status
Stabilize with a padded, rigid long leg splint or frequently during transport.
an air splint. Compartment syndrome must be managed
surgically.
Ankle Injuries
The ankle is a very commonly injured joint. Amputations
- Range from a simple sprain to severe Surgeons can occasionally reattach amputated
fracture-dislocations parts.
Any ankle injury that produces pain, swelling,
localized tenderness, or the inability to bear Make sure to immobilize the part with bulky
weight must be evaluated by a physician. compression dressings.
- Do not sever any partial amputations.
Management - Control any bleeding to the stump.
● Dress all open wounds. - If bleeding cannot be controlled, apply a
● Assess distal neurovascular function. tourniquet.
● Correct any gross deformity by applying
traction. With a complete amputation, wrap the clean part
● Before releasing traction, apply a splint. in a sterile dressing and place it in a plastic bag.
- Put the bag in a cool container filled with
Foot Injuries ice.
Can result in the dislocation or fracture of one or - The goal is to keep the part cool without
more of the tarsals, metatarsals, or phalanges of allowing it to freeze or develop frostbite.
the toes
Strains and Sprains
Frequently, the force of injury is transmitted up Strains
the legs to the spine. - Often no deformity is present and only
minor swelling is noted.
If you suspect a foot dislocation, assess for - Patients may complain of:
pulses and motor and sensory functions. ● Increased sharp pain with
passive movement
 51

● Severe weakness of the muscle diagnose without an x-ray examination.

● Extreme point tenderness
Strains and Sprains (2 of 4) Signs of fractures and dislocations include pain,
Strains (cont’d) deformity, point tenderness, false movement,
General treatment is similar to that of fractures crepitus, swelling, and bruising.
and includes the following:
● Rest; immobilize or splint injured area Signs of sprain include bruising, swelling, and an
● Ice or cold pack over the injury unstable joint.
● Compression with an elastic bandage
● Elevation Compare the unaffected extremity with the
● Reduced or protected weight bearing injured extremity for differences whenever
● Pain management as soon as practical possible.

Sprains There are three main types of splints used by

- Usually resulting from a sudden twisting EMTs: rigid splints, traction splints, and formable
of a joint beyond its normal range of splints.
motion
- Majority involve the ankle or the knee A sling and swathe is used commonly to treat
- Err on the side of caution and treat shoulder dislocations and to secure injured
every sprain as if it is a fracture. upper extremities to the body. Lower extremities
can be secured to the unaffected limb or to a
Sprains are typically characterized by: long backboard.
● Pain
● Swelling at the joint The most common life-threatening
● Discoloration over the injured joint musculoskeletal injuries are multiple fractures,
● Unwillingness to use the limb open fractures with arterial bleeding, pelvic
● Point tenderness fractures, bilateral femur fractures, and limb
General treatment is the same for strains. amputations.

Summary LIFTING & MOVING PATIENTS

Skeletal or voluntary muscle attaches to bone Introduction
and forms the major muscle mass of the body. ● In the course of a call, EMTs move
This muscle contains veins, arteries, and patients.
nerves. ● To move patients without injury, you
need to learn proper techniques.
There are 206 bones in the human body. ● Correct body mechanics, grips, and
devices are important.
A joint is a junction where two bones come into
contact. Moving and Positioning the
Patient
A fracture is a broken bone, a dislocation is a ● When you move a patient, take care that
disruption of a joint, a sprain is a stretching injury does not occur:
injury to the ligaments around a joint, and a - To you
strain is a stretching of the muscle. - To your team
- To the patient
Fractures of the bones are classified as open or ● Many EMTs are injured lifting and
closed. moving patients.
● Training and practice are required.
Fractures and dislocations are often difficult to ● Special lifting and moving techniques
 52

are necessary for:

- Patients with head injury, shock, ● You may injure your back:
spinal injury - If you lift with your back curved
- Pregnant patients - If you lift with your back straight but bent
- Obese patients significantly forward at the hips

Body Mechanics ● This is an incorrect method of lifting.

● In lifting:
- Shoulder girdle should be aligned over
pelvis.
- Hands should be held close to legs.
- Force then goes essentially straight
down spinal column.
- Very little strain occurs.

● Power lift
- Legs should be spread about 15″ apart
(shoulder width).
- Place feet so center of gravity is
balanced.
- With your back held upright, bring your
upper body down by bending the legs.
- Grasp the patient/stretcher.
- Lift patient by raising your upper body
and arms and straightening your legs
until standing.
- Keep the weight close to your body.
- See Skill Drill 35-1.
● Power grip gets maximum force from
hands.
- Palms up
- Hands about 10″ apart
● This is the correct way to lift. - All fingers at same angle
- Fully support handle on curved palm

● To lift a patient by a sheet or blanket:

- Center the patient.
- Tightly roll up excess fabric on the sides.
- Use the cylindrical handle to grasp
 53

fabric and lift patient.

Weight and Distribution

● Whenever possible, use a device that
can be rolled.
● When a wheeled device is not available, ● If you must use a backboard or wheeled
a backboard must be used. stretcher on stairs, see Skill Drill 35-4.
● More of the patient’s weight rests on the ● A stair chair can be used to bring a
head half of the device than on the foot conscious patient down to stretcher
half. (see Skill Drill 35-5).
● Diamond carry and the one-handed
carry use one EMT at head and foot,
and one on each side of patient’s torso.
- See Skill Drill 35-2 and Skill Drill 35-3.

● Always secure patient to backboard or

stretcher.
- So patient cannot slide significantly
when stretcher is at an angle
● Backboard should be used instead for
patient:
● Wheeled ambulance stretcher weighs
- In cardiac arrest
40–145 lb.
- Who must be moved in supine position
- Generally too heavy for use on stairs
- Who must be immobilized

Directions and Commands

● Team actions must be coordinated.
 54

● Team leader - Never push with arms fully extended.

- Indicates where each team
member should be
- Rapidly describes sequence of
steps to perform before lifting
● Preparatory commands are used.
● Example:
- Team leader says, “All ready to
stop,” to get team’s attention.
General Considerations
- Then team leader says, “Stop!”
● Move a patient in orderly, planned,
in louder voice.
unhurried manner.
● Countdowns are also used.
● Carefully plan ahead.
● Select methods that will involve least
● Estimate patient’s weight before lifting
amount of lifting and carrying.
- Adults often weigh 120–220 lb.
- Two EMTs should be able to
Emergency Moves
safely lift this weight.
● Use when there is potential for danger
● If patient weighs over 250 lb, use four
before assessment and management.
rescuers.
- Examples: fire, explosives,
- Place strongest EMT at head
hazardous materials
end.
● Use when you cannot properly assess
patient or provide immediate care
Principles of Safe Reaching and
because of patient’s location or position.
Pulling
● If you are alone, use a drag to pull
● Body drag
patient along long axis of body.
- When you use a body drag, same
● Use techniques to help prevent
principles apply as when lifting and
aggravation of patient spinal injury.
carrying.
- Clothes drag
- Keep back locked and straight.
- Blanket drag
- Kneel.
- Arm drag
- Extend arms no more than 15–20″ in
- Arm-to-arm drag
front of you.
● Log rolling
● Log roll the patient onto his or her side
to place a patient on a backboard.

- Kneel as close to the patient’s side as

possible.
- Keep your back straight.
- Roll the patient without stopping.
● Rolling the stretcher
- Stretcher should be fully elevated.
- Push the stretcher from the head end.
 55

consciousnessInadequate ventilation
- Shock
● Rapid extrication technique requires
team of knowledgeable EMTs.
- See Skill Drill 35-6.
● Rapid extrication technique is an urgent
move and should only be used if
urgency exists.
● Patient can be moved within 1 minute.
● Technique increases damage if patient
has spinal injury.
● Look at all options before using
technique.

Nonurgent Moves
● Used when both scene and patient are
stable
● To remove unconscious patient from
● Carefully plan how to move the patient.
vehicle alone:
● Team leader should plan the move.
- First move legs clear of pedals.
- Personnel
- Rotate patient so back is toward open
- Obstacles identified
car door.
- Equipment
- Place arms through armpits and support
- Path
head against your body.
● Choose between:
- Drag patient from seat to a safe
- Direct ground lift (Skill Drill 35-7)
location.
● For those with no suspected
spinal injury who are supine.
● Patient will need to be carried
distance.
● EMTs stand side by side to
lift/carry
- Extremity lift (Skill Drill 35-8)
● For those with no suspected
spinal injury who are supine or
sitting
● Helpful when patient is in small
space
● One EMT at patient’s head and
the other at patient’s feet
● Coordinate moves verbally.

● To transfer a patient from bed to

stretcher, use:
- Direct carry (see Skill Drill 35-9)
● Move supine patient from the
Urgent Moves bed to stretcher using a direct
● Necessary to move patient with: carry method.
- Altered level of - Draw sheet method
● Move patient from bed to
 56

stretcher using a sheet or produced with higher capacities.

blanket. - Does not address danger to
- Scoop stretcher (see Skill Drill 35-10) EMTs of carrying ever-heavier
weights
- Mechanical ambulance lifts are
Geriatrics uncommon in United States.
● Most patients transported by EMS are
geriatric patients. Patient-Moving Equipment
● Skeletal changes cause brittle bones, ● Stretcher is available in many models
and spinal curvatures present special with various features.
challenges. ● General features
● Allay patient’s fears with sympathetic - Head and foot end
and compassionate approach. - Strong metal frame (to push,
pull, lift)
Kyphosis - Hinges at center allow for
elevation of head/back.
- Guardrail prevents patient from
rolling out.
- Undercarriage frame allows
adjustment to any height.
- Stretcher has locking
mechanism when controls are
not activated.
- Controls are located at the foot
end and at one or both sides of
most stretchers.
Spondylosis
Types of Stretchers
● Wheeled ambulance stretcher
- Also called a stretcher or gurney
- Most commonly used device

Bariatrics
● Refers to management of obese people
● 100 million adults in the US are
overweight or obese. - Patient may be secured directly to
- Approximately 20% to 25% of stretcher
children are overweight or - Or, patient may be secured to
obese. backboard first if:
● Back injuries account for the largest ● Suspected spinal injury or
number of missed days of work. multisystem trauma
● Stretchers and equipment are being ● Patient is in need of CPR
 57

● Bariatric stretcher
- Specialized for overweight or obese
patients
- Wider wheel base for increased stability
- Some have tow package with winch.
- Rated to hold 850–900 lb
● Regular stretcher rated for 650
lb max.

● Portable/folding stretcher
- Strong, rectangular tubular metal frame
with fabric stretched across it
- Some models have two wheels.
- Some can be folded in half.
● Pneumatic and electronic-powered
- Used in areas difficult to reach
wheeled stretcher
- Weigh less then wheeled stretchers
- Battery operated electronic controls to
raise/lower undercarriage
○ This increases the weight of
stretcher.
○ Hazardous for uneven terrain or
stairs

● Flexible stretcher
- Can be rolled into a tubular package
- Excellent for storage and carrying
- Conform around a patient’s sides
- Useful for confined spaces
- Uncomfortable, but provides support
● Loading a wheeled stretcher into an
and immobilization
ambulance
- Ensure the frame is held firmly between
two hands so it does not tip.
- Newer models are self-loading, allowing
you to push the stretcher into
ambulance.
- Other models need to be lowered and
lifted to the height of the floor of
ambulance.
- Clamps in ambulance hold stretcher in ● Backboard
place. - Long, flat, and made of rigid rectangular
- See Skill Drill 35-11. material (mostly plastic)
- Used to carry and immobilize patients
 58

with suspected spinal injury or other - Also called orthopaedic stretcher

trauma - Splits into two or four pieces
- Commonly used for patients found lying ● Pieces fit around patient who is
down lying on flat surface and
- 6′ to 7′ long reconnect
- Holes serve as handles and a place to - Both sides of patient must be
secure straps. accessible.
- Short backboards or half-boards are - Patient must be stabilized and secured
used to immobilize seated patients on scoop stretcher.
● Example: the KED vest-type
device

● Stair chair
- Folding aluminum frame chairs with
fabric stretched across to form a seat
and back
- Most have rubber wheels in the back

● Basket stretcher
- Rigid stretcher also called a Stokes litter
- Used for remote locations inaccessible
by a vehicle, including water rescues
and technical rope rescues ● Neonatal isolette
- If spinal injury, secure patient to - Also called an incubator
backboard and place inside basket - Neonates cannot be transported on a
stretcher to carry patient out of location. wheeled stretcher.
- When you return to ambulance, lift the - Isolette keeps neonate warm, protects
backboard out of basket stretcher and from noise, draft, infection, excess
place on wheeled stretcher. handling.
- Isolette may be secured to wheeled
ambulance stretcher or freestanding.

Decontamination
● Decontaminate equipment after use.
- For your safety
- For the safety of the crew
- For the safety of the patient
- To prevent the spread of disease

● Scoop stretcher Medical Restraints

 59

● Evaluate for correctible causes of sliding.

combativeness. ● Carry the backboard or stretcher foot
- Head injury, hypoxia, hypoglycemia end first, so that the patient’s head is
● Follow local protocols. elevated higher than the feet.
● Restraint requires five personnel. ● Directions and commands are an
● Restrain patient supine. important part of safe lifting and
- Positional asphyxia may develop in carrying.
prone position. ● You and your team must anticipate and
● Apply restraint to each extremity. understand every move and execute it
● Assess circulation after restraints are in a coordinated manner.
applied. ● The team leader is responsible for
● Document all information. coordinating the moves.
● You should try to use four rescuers
Personnel Considerations whenever resources allow.
● Questions to ask before moving patient: ● You should know how much you can
- Am I physically strong enough to comfortably and safely lift and not
lift/move this patient? attempt to lift more than this amount.
- Is there adequate room to get the proper ● Rapidly summon additional help to lift
stance to lift the patient? and carry a weight that is greater than
- Do I need additional personnel for lifting you are able to lift.
assistance? ● The same basic body mechanics apply
● Remember, an injured rescuer cannot for safe reaching and pulling as for lifting
help anyone. and carrying.
● Keep you back locked and straight, and
SUMMARY avoid twisting.
● The first key rule of lifting is to always ● Do not hyperextend your back when
keep your back in an upright position reaching overhead.
and lift without twisting. ● For a nonurgent move, move the patient
● The power lift is the safest and most in an orderly, planned, and unhurried
powerful way to lift. manner, selecting methods that involve
● Pushing is better than pulling. the least amount of lifting and carrying.
● If you do not have a proper hold, you will ● At times, you may have to use an
not be able to bear your share of the emergency move to maneuver a patient
weight, or you may lose your grasp and before providing assessment and care.
possibly cause a lower back injury to ● You should perform an urgent move if a
one or more EMTs. patient has an altered level of
● It is always best to move a patient on a consciousness, inadequate ventilation,
device that can be rolled. or shock, or in extreme weather
● You must constantly coordinate your conditions.
movements with those of the other team ● The wheeled ambulance stretcher is the
members and make sure that you most commonly used device to move
communicate with them. and transport patients.
● Ideally, members of the lifting team ● Other devices include portable
should also be of similar height and stretchers, flexible stretchers,
strength. backboards, basket stretchers, scoop
● If you must carry a loaded backboard or stretchers, and stair chairs.
stretcher up or down stairs or other ● Whenever you are moving a patient, you
inclines, be sure that the patient is must take special care so that neither
tightly secured to the device to prevent you, your team, nor the patient is
 60

injured. – Patient compartment big

● You will learn the technical skills of enough for two EMTs and
patient packaging and handling through two supine patients
practice and training. – Equipment and supplies
● Training and practice are required to use – Two-way radio
all the equipment that is available to communication
you. – Design for maximum safety
Transport Operations and comfort

Introduction (1 of 2)
• Horse-drawn ambulances were • Ambulance licensing or certification
used in major US cities in the late standards are established by state.
1700s. • The Star of Life® emblem is affixed
• US hospitals started their own to the sides, rear, and roof of the
ambulance services in the 1860s. ambulance.
– Traveled with limited
medical supplies Preparation Phase
• Today’s ambulances are stocked • Ensure equipment and supplies are
with standard medical supplies. in their proper places and ready for
– Many have technology that use.
transmit data directly to the – Only store new equipment
emergency department after proper instruction on
• Today’s emphasis on rapid its use and consulting with
response the medical director.
• places the EMT in greater danger. – Should be durable and
standardized
Emergency Vehicle Design – Store equipment and
supplies according to how
• An ambulance is a vehicle that is urgently and how often they
used for treating and transporting are used.
patients who need emergency – Items for life-threatening
medical care to a hospital. conditions at the head of the
– The first motor-powered primary stretcher
ambulance was introduced – Items for cardiac care,
in 1906. external bleeding, and blood
– The hearse was the vehicle pressure at the side of the
most often used as an stretcher
ambulance for decades. – Cabinets and drawer fronts
• Today’s ambulances: should be transparent or
– Designed according to labeled.
government regulations – Should open easily and
– Have enlarged patient close securely
– Compartments • Medical equipment
• First-responder vehicles have – See Table 36-3.
personnel and equipment to treat – Basic supplies are common
patients until an ambulance can supplies carried on
arrive. ambulances.
• The modern ambulance contains: – Airway and ventilation
– Driver’s compartment equipment
 61

– CPR equipment – Name, present location,

– Basic wound care supplies call-back number
– Splinting supplies – Location of patient
– Childbirth supplies – Number of patients and
– Automated external severity of their conditions
defibrillator – Other pertinent information
– Patient transfer equipment
– Medications En Route to the Scene
– The jump kit
• Safety and operations equipment • Most dangerous phase for EMTs
– Personal safety equipment • Collisions cause many serious
– Equipment for work areas injuries.
• Safety and operations equipment – Fasten seatbelts and
(cont’d) shoulder harnesses before
– Preplanning and navigation moving the ambulance.
equipment • Review dispatch information.
– Extrication equipment • Prepare to assess and care for the
• Personnel patient.
– At least one EMT in the
patient compartment during Arrival at the Scene
transport • Perform a scene size-up and report
– Two EMTs are strongly your findings to dispatch.
recommended. – Look for safety hazards.
– Some services have a – Evaluate the need for
non-EMT driver and a single additional units.
EMT in the patient – Determine the mechanism
compartment. of injury or nature of illness.
• Perform daily inspections. – Evaluate the need for
– Ambulance inspection spinal stabilization.
– Inspect cleanliness, – Follow standard
quantity, and function of precautions.
medical equipment and • Mass-casualty incidents
supplies. – Estimate and communicate
• Review safety precautions. the number of patients to
– Traffic safety rules and the incident commander.
regulations – Request additional units
– Proper working order of through dispatch.
safety devices – The incident command
– Properly secure oxygen system will be established.
tanks. • Safe parking
– Properly secure all – Allow efficient traffic flow
equipment in cab, rear, and and control around an
compartments. emergency scene.
– Park 100′ before or past
Dispatch Phase the crash scene.
– Do not park alongside a
• Dispatcher should gather and crash scene.
record: • Safe parking (cont’d)
– Nature of the call – Park uphill and/or upwind
 62

of smoke or hazardous – Beginning mileage of

materials. ambulance
– Leave warning lights or • Monitor the patient’s condition en
devices on. route.
– Keep distance between the – Recheck a stable patient
emergency vehicle and every 15 minutes.
operations. – Recheck an unstable
• Safe parking (cont’d) patient every 5 minutes.
– Stay away from fires, • Contact the receiving hospital.
explosive hazards, downed • Do not abandon the patient
wires, and unstable emotionally.
structures.
– Set the parking brake. Delivery Phase
– Facilitate emergency • Notify dispatch of your arrival at the
medical care and rapid hospital.
transport from the scene. • Report your arrival to the triage
– If it is necessary to block nurse.
traffic, work quickly and • Physically transfer the patient.
safely. • Present a complete verbal report.
• Traffic control • Complete a detailed written report.
– Provide care and ensure • Restock items, if possible.
scene safety first.
– The purpose of traffic En Route to the Station
control is to ensure orderly • Inform dispatch whether you are in
traffic flow, warn other service and where you are going.
drivers, and prevent another • Back at the station:
crash. – Clean and disinfect the
– Place warning devices on ambulance and equipment.
both sides of the crash.
– Restock supplies.
Transfer Phase
• The patient must be packaged for
transport.
– Secure the patient to a Postrun Phase
backboard, scoop stretcher,
or wheeled ambulance • Complete and file additional written
stretcher. reports.
– Lift the patient into the
• Inform dispatch again of status,
compartment.
location, and availability.
– Secure the patient with at
least 3 straps.
• Perform routine inspections.

Transport Phase • Refuel the vehicle.

• Excessive speed is unnecessary
and dangerous. • Important to know the meaning of
• When you are ready to leave with the following terms:
the patient, inform dispatch of:
– Number of patients • Cleaning: The process of
– Name of receiving hospital
 63

removing dirt, dust, blood, germicidal/virucidal solution

or other visible or 1:100 bleach dilution.
contaminants from a • Clean spillage or other
surface or equipment contamination with one of
those same solutions
• Disinfection: The killing of
pathogenic agents by Air Medical Operations
directly applying a chemical • Air ambulances are used to
made for that purpose to a evacuate medical and trauma
surface or equipment patients.
– Fixed-wing units
• High-level disinfection: The – Rotary-wing units
killing of pathogenic agents (helicopters)
by the use of potent means • Specially trained crews accompany
of disinfection air ambulance flights.
– EMTs provide ground
• Sterilization: A process, support.
such as the use of heat, that • Medical evacuation (medivac) is
removes all microbial performed by helicopters.
contamination – Capabilities, protocols, and
procedures vary.
• After each call: • Why call for a medivac?
– Transport time by ground is
• Strip linens from the
too long.
stretcher and place them in
– Road, traffic, or
a plastic bag or designated
environmental conditions
receptacle.
prohibit the use of ground
transport.
• Discard medical waste.
– Patient requires advanced
• Wash contaminated areas care.
with soap and water. – Multiple patients will
overwhelm resources at the
• Disinfect all nondisposable hospital reachable by
equipment used for patient ground transport.
care. • Who receives a medivac?
– Patients with
• Clean the stretcher with time-dependent injuries or
germicidal/virucidal solution illnesses
or 1:100 bleach dilution. – Stroke, heart attack, or
spinal cord injury
• Clean spillage or other – Scuba diving accidents,
contamination with one of near-drownings, or skiing
those same solutions and wilderness accidents
– Trauma patients
• Disinfect all nondisposable – Candidates for limb
equipment used for patient replantation, burn center,
care. hyperbaric chamber, or bite
center
• Clean the stretcher with • Whom do you call?
 64

– Generally, the dispatcher • Night landings

should be notified first. – Do not shine spotlights,
– In some regions, EMS may flashlights, or any other
be able to communicate lights in the air to help the
with the flight crew after pilot.
initiating the medivac – Direct low-intensity
request. headlights or lanterns
• Establish a landing zone. toward the ground.
– Hard or grassy level – Illuminate overhead
surface between 60¢ × 60¢ hazards or obstructions, if
and 100¢ × 100¢ possible.
(recommended) • Landing on uneven ground
– Cleared of loose debris – The main rotor blade will be
– Alert the flight crew of closer to the ground on the
overhead or tall hazards. uphill side.
– Mark the landing site using – Approach from the downhill
cones or vehicles. side only.
• Establish a landing zone (cont’d). • Medivacs at hazardous materials
– Move nonessential persons incidents
and vehicles. – Notify the flight crew.
– Communicate the direction – Consult about the best
of strong wind to the flight approach and distance from
crew. the scene.
• Landing zone safety and patient – Landing zone should be
transfer uphill and upwind.
– Keep a safe distance from – Decontaminate patients
the aircraft whenever it is on before loading them into the
the ground and “hot.” helicopter.
– Stay away from the tail
rotor.
– Never approach the Medivac Issues
helicopter from the rear.
• Keep the following guidelines in • Assess the severity of the weather
mind: or environment/terrain.
– Become familiar with hand
signals. • Most helicopters are limited to flying
– Do not approach the at 10,000′ above sea level.
helicopter unless instructed
and accompanied by flight • Medivac helicopters fly between
crew. 130 and 150 mph.
– Make certain that all
• Because of the cabin’s confined
equipment and the patient
space, assess the number and size
are secured to the stretcher.
of the patients that can be safely
– Side- vs. rear-loading doors
transported in a medivac helicopter.
– Smoking, open lights or
flames, and flares are
• Typical medivac flights cost
prohibited within 50′.
between $8,000 and $10,00.

Special Considerations
 65

• Ambulance transport costs • Speed does not save lives; good

$400 to $1,000. care does. The driver and all
passengers must wear seat belts
and shoulder restraints at all times.

Summary • Air ambulances are used to

evacuate medical and trauma
• Nine phases of an ambulance call: patients. Both fixed-wing and
rotary-wing aircraft (helicopters) are
– Preparation for the call used.

– Dispatch • A medical evacuation is commonly

known as a medivac and is
– En route generally performed by helicopters.

– Arrival at scene

– Transfer of the patient to

the ambulance

• Nine phases of an ambulance call

(cont’d):

– En route to the receiving

facility (transport)

– At the receiving facility

(delivery)

– En route to the station

– Postrun

• Every ambulance must be staffed

with at least one EMT in the patient
compartment whenever a patient is
being transported. Two EMTs are
strongly recommended.

• Check all medical equipment and

supplies at least daily, including all
the oxygen supplies, the jump kit,
splints, dressings and bandages,
backboards and other stabilization
equipment, and the emergency
obstetric kit.

• Learn how to properly operate your

emergency vehicle.