Patient Treatment and Transport Study Guide for the EMT Test

Interventions for Special Populations

While every emergency situation is unique, there are certain tendencies among particular groups of patients. Knowing them will give you a broad basis for interpreting the emergency and planning for care. First, it is important to understand the typical characteristics of the majority of people within a specific age span.

Life Span Development

Life span development refers to changes that occur from birth to death. A thorough understanding of life span development helps EMTs and paramedics appropriately treat patients of all ages.

Neonates and Infants

A baby is considered a neonate from birth to 1 month. From 1 month to 1 year, a baby is considered an infant. There are many differences between treating an infant and an adult. One significant difference to keep in mind is that, typically, the younger the baby, the faster the respiratory rate and heart rate. Babies tend to be nose breathers and have smaller airways than an older child or adult, which can make them especially vulnerable to airway obstruction.

Here is a term to know:

fontanelles—soft spots on an infant’s skull where the bones have not yet fully fused together

Neonatal Resuscitation Sequence

After delivery, assess the newborn’s breathing, color, tone, and heart rate while keeping the baby warm. If the newborn is not breathing well after drying, warming, airway positioning, suctioning when needed, and stimulation, begin positive-pressure ventilation with a newborn-sized bag-mask device. If there is no pulse, or if the heart rate stays below 60 beats/min after effective ventilations, begin chest compressions and continue ventilations according to local protocol.

Toddlers and Preschoolers

A child is considered a toddler from 1 to 3 years. A preschooler is a child from 3 to 6 years old. The heart and respiratory rates of a child of this age are slower than those in an infant, but faster than those in an adult. Separation anxiety may be common for toddlers, and language development may vary. Accidents are a top cause of death in children of this age.

Here is a term to know:

preconventional reasoning—This is the earliest level of moral development in which a child’s decisions about right and wrong are based on personal consequences, not rules or principles. Knowing this can be helpful to EMTs when assessing pediatric behavior.

School-Age Children

Children from age 6 to 12 are considered school-aged. Their vital signs are just slightly faster than an adult’s. Peer acceptance is becoming increasingly important to school-age children. When treating school-age children, it is important to explain procedures so children understand what is happening. This may reduce the child’s fear and anxiety and expedite treatment.

Adolescents

Children from age 13 to 18 are considered adolescents. Medically, adolescents are often treated similarly to adults, though in some cases, medication is administered based on weight instead of age. Since adolescent development can vary greatly, it’s important to consider the child’s size and not just age. Accidents are the leading cause of death in adolescents.

Early Adults

Early adulthood is considered to be from age 19 to 40. During this time, adults tend to be in their peak physical shape. Vital signs tend to be similar in both early and middle adulthood. Toward the end of early adulthood, changes in the body may take place, including loss of muscle mass, increased body fat, and slowed reflexes. Unintentional injury is the leading cause of death for young adults.

Middle Adults

Middle adulthood is considered to be from age 41 to 60. Although it can vary, middle adulthood may be the start of medical problems for some people. Diabetes, cardiovascular disease, and vision and hearing problems commonly start in middle adulthood. For adults aged 41 to 44, unintentional injuries are still the top cause of death, while cancer is the leading cause of death in middle-aged adults 45 to 60.

Older Adults

Older adults are classified as being age 61 and older. During this stage of adulthood, chronic medical problems, such as COPD and heart disease, are more likely to develop than in the younger adult years. The leading cause of death in older adults up to age 65 is cancer. After age 65, heart disease is the top cause of death.

Here is a term to know:

life expectancy—average number of years a person is expected to live based on factors such as age, sex, lifestyle, and overall health

Pediatric Emergencies

Pediatric patients can have many of the same emergencies as adult patients, but treating children requires special consideration. You need to understand the physical and emotional differences between adult and pediatric patients.

Developmental Stages

Each child is unique, but they may have some similarities in development based on age. When treating children, it is helpful to have an idea of the developmental stage. Infants easily cry as you examine them and may not remain still. Toddlers may also become anxious, so keep their parents near to avoid separation anxiety. Preschool children may have a limited vocabulary but may be able to answer simple questions, such as “Where does it hurt?” School-age children and teens can usually respond to questions and provide information about their symptoms. If possible, allow children in this age group to make appropriate choices, such as which arm they want their BP measured in.

Pediatric Anatomy and Physiology

Children have smaller airways and a large tongue in proportion to mouth size, which may mean it is more difficult to intubate them. Also, children have higher heart rates than adults. A child’s abdominal muscles are less developed than an adult’s, which means they have less protection from trauma to the abdomen. A child’s bones are not as hard as an adult’s, which means they may suffer a fracture more easily.

Pediatric Patient Assessment

During a scene size-up with a pediatric patient, make sure you have the proper equipment to treat a child. It is also helpful to do a quick assessment of the environment to determine if the conditions may have contributed to the child’s injuries or ailment. During the primary assessment, focus on the ABCs as you would with an adult. The pediatric assessment triangle (PAT) can be a useful tool. The PAT involves a quick, 30-second assessment to determine work of breathing, muscle tone, and level of consciousness. Since an infant or young child will not be able to tell you what’s wrong or give a medical history, you’ll need to rely on signs and information from parents and caregivers. Children can take a turn for the worse quickly, so careful reassessment is vital to determine if there is a change in status.

Pediatric Respiratory Emergencies

Respiratory emergencies in children can involve chronic conditions (such as asthma), infections (such as RSV and pneumonia), or acute conditions (such as an airway obstruction from choking). Children have smaller airways and can develop breathing problems more quickly than adults. When assessing a child’s work of breathing and level of distress, look for retractions, grunting, wheezing, and nasal flaring. A child in respiratory distress requires oxygen to avoid hypoxia.

Pediatric Airway Obstruction

For a pediatric airway obstruction, treatment depends on the child’s age and level of responsiveness. A conscious infant with a severe airway obstruction should receive cycles of five back slaps followed by five chest thrusts until the object is cleared or the infant becomes unresponsive. Abdominal thrusts are not used for infants because they can cause injury. If the infant becomes unresponsive, begin CPR and check the airway before giving breaths.

BRUE

BRUE stands for a brief resolved unexplained event. It describes a sudden, short episode in an infant that may involve changes in breathing, color, tone, or responsiveness and then resolves before evaluation. Even if the infant appears normal when EMS arrives, the event should still be taken seriously, and the EMT should assess the infant, gather a detailed history, monitor for changes, and follow local protocols.

Pediatric Circulatory Emergencies

Circulatory emergencies in children, such as cardiac arrest, most commonly occur due to respiratory arrest. When a child goes into respiratory failure and oxygen levels drop, it can lead to bradycardia and cardiac arrest. If cardiac arrest does occur in a child, it is treated the same way as it is in an adult. Medication doses are lower, but ACLS protocols are similar.

Pediatric Neurologic Emergencies

Neurological emergencies in children are most commonly caused by hypoglycemia, seizures, and hypoxia. It’s important to determine if the child has an altered level of consciousness (ALOC), which may cause the child to present as sleepy, irritable, or combative.

Pediatric Gastrointestinal Emergencies

Stomach pain is common in children and is not usually serious. But, in some cases, abdominal pain can indicate a medical problem, infection, or injury. Appendicitis is the most common gastrointestinal emergency you will encounter in pediatric patients. Symptoms of appendicitis include vomiting, abdominal pain, and fever. Children will also likely have abdominal tenderness.

Pediatric Poisoning and Fluid Loss Emergencies

Children may ingest various substances, which can lead to poisoning. Signs of poisoning can vary based on the substance, but may include sleepiness, vomiting, and ALOC. Common sources of poisoning in children include vitamins, cleaning products, and alcohol. It is important to determine how much of the substance was ingested, when it occurred, and whether there was any choking after ingestion. Treatment may start with a call to the poison control hotline for information regarding a specific poison. In some cases, treatment may also include administration of activated charcoal.

Fever Emergencies

Children, especially infants, can develop high fevers when they have an infection. Common causes of fever in children include infections, such as pneumonia and gastroenteritis. Febrile seizures (seizures due to a high fever) can also occur in children, especially infants and toddlers. If you’re called for a child who had a febrile seizure, provide monitoring of the airway during transport.

Pediatric Drowning Emergencies

Drowning is the second leading cause of accidental death in children from ages 1 to 4. Young children can even drown in bathtubs and toilets. The severity of symptoms will likely depend on how long the child was submerged in the water. Signs may include coughing, choking, or, in the most serious cases, apnea and cardiac arrest. Treatment involves BLS and ALS support and management of the ABCs, as well as rapid transport.

Pediatric Trauma

Pediatric trauma can occur in a variety of incidents, including motor vehicle accidents, falls, and sports injuries. In some cases, a child may be too young to tell you where it hurts, so you’ll have to determine injuries from an exam and witness reports. The treatment for pediatric trauma patients varies greatly depending on the injury. Keep in mind that children have less blood volume than adults and may develop shock more easily due to internal bleeding.

Disasters

When treating children who are victims of a disaster, it can be helpful to use the JumpSTART triage system. The system is intended for children less than 8 years of age. Children are triaged according to their ability to walk, breathe, and respond appropriately to painful stimuli. Children are assigned a tag color: green for minor problems, yellow for second-priority patients, and red for the most serious. This system allows children with the highest priority to be transported first.

Child Abuse and Neglect

As an EMT, you may encounter a child who is a victim of abuse. Signs of child abuse include multiple injuries at different stages of healing, unusual marks that could be caused by cigarettes, and unexplained decreased levels of consciousness. Signs of neglect may include a child who appears malnourished or dirty and uncared for. EMTs are required to report incidents of suspected child abuse and neglect. Keep in mind, you do not have to prove that there is abuse. Your job is just to report suspected abuse.

SIDS and ALTE

Sudden Infant Death Syndrome (SIDS) is the unexplained death of an infant. Risk factors for SIDS include having a mother who smoked during pregnancy and having a low birth weight. Since the campaign to put babies to sleep on their back started, the incidence of SIDS has decreased, but about 3,500 babies still die every year in the USA from SIDS. Infants may also suffer from an apparent life-threatening event (ALTE), which involves a period of apnea and unresponsiveness, but the child resumes breathing. When treating a child with SIDS or ALTE, it’s helpful to note the environment and look for signs of abuse and objects in the child’s crib.

Here are some terms to know:

croup—respiratory condition most commonly seen in young children, usually caused by a viral infection; leads to swelling of the upper airway, which can cause a barking cough and stridor
epiglottitis—serious, potentially life-threatening infection that causes inflammation and swelling of the epiglottis; can block the airway and present with drooling, stridor, and difficulty swallowing
pertussis—also known as whooping cough, is a highly contagious bacterial respiratory infection that primarily affects children; characterized by severe coughing fits followed by a whooping sound
grunting—noisy exhalation often heard in infants and young children who are having difficulty breathing; the body’s attempt to keep the small airways and alveoli in the lungs open to improve oxygen exchange
shaken baby syndrome—serious form of child abuse that occurs when an infant or young child is violently shaken since the forceful shaking can cause brain injury, bleeding, and damage to the spinal cord or neck

Geriatric Emergencies

Geriatric emergencies involve caring for adults age 65 or older. Geriatric patients may present with a wide variety of medical conditions that are similar to younger adults. But it is important to understand the unique aspects of caring for older adults.

Generational Considerations

It is essential to understand that not all geriatric patients are the same. It is helpful to approach each patient with an open mind and to not rely on stereotypes. There are factors to keep in mind, however. For example, geriatric patients may be more likely to be living on fixed incomes, which may lead to skipping medications to save money.

Common Illnesses and Causes of Death

Geriatric patients are more likely to suffer complications from common illnesses than younger adults. For example, conditions such as pneumonia may lead to respiratory failure and even death. In addition, the leading causes of death in the geriatric population include heart disease, stroke, and cancer.

Body Changes

The process of aging is gradual and varies from person to person. Several changes may occur as a person ages. Some changes may depend on how well people take care of themselves and their lifestyle choices, but, in general, various body systems (lungs, heart, and bones) are likely to have age-related changes.

Respiratory Changes and Common Problems

Changes to the respiratory system may include a loss of elasticity in the lung tissue. The muscles that support breathing may also become weaker, which affects how deeply a person breathes. The changes in the lungs and respiratory system may make geriatric patients more likely to develop certain conditions, such as pneumonia. Some older adults may become less active, which may also put them at risk for a pulmonary embolism.

Cardiovascular Changes and Problems

Cardiovascular changes that may occur in older adults include a thickening of the arteries, which contributes to high blood pressure and heart disease. Due to the changes in the arteries, geriatric patients may experience emergencies such as a heart attack, stroke, or heart failure.

Nervous System Changes and Problems

Nervous system changes that may occur in geriatric patients include a decrease in sense functioning, such as hearing, vision, and smell. Some adults may also develop cognitive issues, such as memory problems. Problems with balance may also occur. Dementia is one issue that many older adults face.

Gastrointestinal Changes and Problems

Changes to the gastrointestinal system in older adults include decreased gastric juices and saliva, which can contribute to other problems, such as a higher risk of aspiration. Some geriatric patients may also develop ulcers, diverticulitis, and constipation.

Renal System Changes and Problems

The kidneys may not function as well as they do in younger adults. Some geriatric patients also develop urinary incontinence. In other cases, urinary retention may develop. Men may develop an enlarged prostate, which can lead to urinary problems. Bladder infections also increase in the geriatric population.

Endocrine System Changes and Problems

The endocrine system controls several body functions, including metabolism and body temperature. As a person ages, hormone production may change, which can affect the endocrine system and, in turn, body functions. Certain conditions, such as diabetes, are common in older adults.

Immune System Changes and Problems

Geriatric patients generally are more susceptible to infection and disease. They may also have a decline in immune system function, which makes it harder to fight an infection when it develops. Weight loss, falls, fever, and an altered mental status are common signs and symptoms of infection in geriatric patients.

Toxicology and Older Patients

Older adults metabolize medication differently than younger adults. Changes in an older adult’s kidney function and gastrointestinal system may alter the way medication is excreted from the body. In addition, they are at risk of medication errors, including taking too much medication or from interactions among multiple medications.

Behavioral Emergencies

Although many older adults lead fulfilling lives, some may develop emotional problems that lead to behavioral emergencies. Depression is common in geriatric patients for a variety of reasons, from poor health to a loss of purpose. As with any depressed patient, suicide is a risk and needs to be taken seriously.

The GEMS Diamond

The GEMS diamond is intended to be a reminder of things to keep in mind when assessing a geriatric patient. It is not meant to replace the basics or the ABCs of care. Instead, it involves important factors to consider. “G” stands for geriatric patients. “E” stands for the environment, which involves assessing the patient’s environment for clues about their condition. “M” stands for medical conditions, which reminds you to assess for medical conditions and medications. Lastly, “S” stands for social assessment, which involves determining if the patient can care for themselves and perform daily living skills.

Patient Assessment

As always, assess for scene safety. Geriatric patients may live alone, and it is essential to make sure nothing is hampering you from entering the home, such as clutter. If conditions appear unsafe for the patient to live in, additional assistance is needed. Complete the primary assessment as you would with any patient, paying special attention to level of consciousness. Older adults may be more likely to have an ALOC due to infection and illness. Taking a medical history is critical with geriatric patients, since they may have a history of conditions that could help you evaluate the current problem. Continue with a secondary assessment, including taking vital signs. Keep in mind, vital signs may be different in geriatric patients due to changes that occur with aging. Lastly, continue to reassess during transport and watch for signs of instability that will require immediate treatment.

Trauma and Geriatric Assessment

In general, older adults may experience fractures and serious injuries more frequently than younger adults. Changes in an older adult’s systems, including skeletal, put them at higher risk for complications if they sustain a trauma. Pelvic and hip fractures are common in older adults, and suspected injuries should be thoroughly assessed.

Falls and Geriatric Assessment

Falls are the leading cause of trauma in older adults. Changes to the bones and muscles put geriatric patients at a higher risk of fracture when they fall. Issues with balance are more common in older adults as well, which puts them at a higher risk of trauma. When an older patient falls, it’s also important to determine why he/she fell. Determine if the fall was due to a medical condition or to environmental factors so future falls can be prevented.

Geriatric Care Facilities

Geriatric care facilities vary and include assisted living facilities as well as nursing homes. The level of care also ranges from medication and daily living skills assistance to skilled nursing care. You may be called to either facility to treat and transport a patient to the hospital. Staff at geriatric care facilities can be a great source of information on the patient’s condition and medical history.

Dying Patients

At some point, you will have to deal with a geriatric patient who is dying. Some patients may choose to go to hospice and may have a Do Not Resuscitate (DNR) in place. Before limiting resuscitation efforts, it is critical to verify a DNR. When dealing with a patient who is dying, it’s essential to show respect and compassion for both the patient and family members.

Elder Abuse and Neglect

Elder abuse and neglect are serious problems that should be reported, per your agency’s policy. Signs of abuse or neglect in the elderly include chronic pain without an underlying cause, overly defensive answers about injuries, repeated soft tissue injuries, and self-destructive behavior. Physical signs of abuse may include pressure bruising, burns, and multiple injuries in varied states of healing.

Here are some terms to know:

elder abuse—intentional or neglectful harm of an older adult, typically over the age of 65, by a caregiver, family member, or other trusted person; can be physical, emotional, sexual, or through neglect or financial exploitation
advanced directives—legal documents in which a person states their wishes for medical care in the event they become unable to make decisions for themselves due to illness or incapacity
VRE—vancomycin-resistant enterococcus, a type of bacteria that has become resistant to the antibiotic vancomycin
MRSA—methicillin-resistant Staphylococcus aureus, a type of bacterial infection caused by Staphylococcus aureus that is resistant to many common antibiotics, including methicillin
polypharmacy—the use of multiple medications by a patient, often defined as taking five or more medications simultaneously
decubitus ulcer—pressure ulcer; a skin and underlying tissue injury caused by prolonged pressure
osteoporosis—progressive condition in which bones become weak, brittle, and more likely to fracture due to loss of density
syncope—temporary, sudden loss of consciousness caused by a brief decrease in blood flow to the brain
delirium—sudden, temporary change in mental status characterized by confusion, disorientation, difficulty focusing, and fluctuating levels of alertness
dementia—chronic, progressive decline in cognitive function that affects memory, judgement, communication, and the ability to perform daily activities