Primary Assessment Study Guide for the EMT Test

Chief Complaint and Life Threats: Part 1

While many emergencies involve more than one health concern, one of your first jobs as an EMT is to determine which patient condition is the most threatening and should be treated first. You’ll also need to decide if any of them pose a threat to life. Here is some information about many of the types of emergencies you may see to help you during your first examination of the patient.

Common Respiratory Emergencies and Conditions

Emergencies may require you to assess and treat patients with malfunction of, or damage to, the respiratory system. Respiratory system conditions can also affect your treatment plan during other types of emergencies. Here is a brief description of the most common respiratory emergencies and conditions you may encounter. Make sure you know how to identify and treat all of them. Refer to other sources, such as your textbook, for complete information.

Carbon Dioxide Retention and Hypoxic Drive

Carbon dioxide retention can occur due to various types of lung diseases, most commonly COPD, which can alter the patient’s drive to breathe. Normally, when carbon dioxide levels increase, it triggers a person to breathe deeper and faster. In people who have chronically high levels of carbon dioxide, the body gets used to the high levels and instead begins to base the drive to breathe on low oxygen levels. This is referred to as hypoxic drive.

Dyspnea

Dyspnea is shortness of breath or difficulty breathing that can occur for a variety of reasons. Respiratory illnesses, such as asthma and COPD, can lead to dyspnea. Additional causes of dyspnea include pulmonary edema, airway obstruction, and anxiety. Symptoms include shallow, rapid breathing, and anxiety. Treatment is often aimed at the underlying cause.

Airway Infection (Upper and Lower)

Airway infections can occur due to a variety of conditions such as croup, respiratory syncytial virus (RSV), and pneumonia. An infection can affect the lower or upper airways. Symptoms may include wheezing, shortness of breath, and coughing. Treatment will depend on the cause, but may include bronchodilators, steroids, and oxygen.

Acute Pulmonary Edema

Pulmonary edema is excess fluid in the lungs. It can occur suddenly due to congestive heart failure. Symptoms include shortness of breath, pink and frothy sputum, and a cough. The patient may also have crackles. Oxygen and the medication Lasix® (furosemide) are typical treatments.

COPD

COPD, or chronic obstructive pulmonary disease, is caused by damage to the alveoli and is often due to smoking. Symptoms may include wheezing, shortness of breath, and coughing. Treatment can include bronchodilators, steroids, and oxygen.

Asthma and Hay Fever

Asthma is a chronic condition that can cause increased mucus production, inflammation of the airways, and airway constriction. Symptoms may include wheezing, coughing, and dyspnea. Hay fever is an allergic reaction to an allergen. Symptoms may include sneezing, coughing, and a runny nose. Asthma may be treated with bronchodilators and steroids. Hay fever may be treated with antihistamines and decongestants.

Anaphylaxis

Anaphylaxis is a severe allergic reaction to an allergen. The condition can be life-threatening since it can lead to airway swelling and a drop in blood pressure. Symptoms can include trouble breathing, stridor, and hives. Treatment includes epinephrine and airway management.

Spontaneous Pneumothorax

A pneumothorax involves air in the pleural space. It can occur spontaneously due to a lung infection, trauma, or for unknown reasons. Symptoms include chest pain, dyspnea, and decreased breath sounds over the affected area. Treatment includes inserting a chest tube to remove the air. Spontaneous pneumothorax is more likely to occur in patients with weakened areas of the lung, including those with chronic lung disease such as emphysema or asthma. It is also more common in tall, thin young males, especially during strenuous activity or severe coughing.

Pleural Effusion

A pleural effusion involves an accumulation of fluid outside the lungs in the pleural space. It can occur due to an infection, a congestive heart failure, and cancer. Symptoms include shortness of breath and decreased breath sounds over the affected area. Treatment involves removal of the fluid in a procedure that must be performed at the hospital. Prehospital management involves keeping the patient comfortable and administering supplemental oxygen if the patient is hypoxic.

Pulmonary Embolism

A pulmonary embolism is a blood clot in the pulmonary artery. The clot usually travels from another part of the body, such as the legs or pelvis. It can restrict blood flow to the lungs, decrease oxygen levels in the body, and be life-threatening. Symptoms can include dyspnea, tachycardia, and hypoxia. Administration of blood thinners at the hospital is the usual treatment.

Hyperventilation

Hyperventilation is an abnormally high respiratory rate. Causes may include pain, anxiety, and fever. Treatment involves addressing the underlying cause.

Environmental/Industrial Contaminants

Environmental and industrial contaminants can involve the inhalation of various chemicals, substances, and gases that irritate the airway, such as carbon monoxide. Symptoms can include coughing, dyspnea, and an altered level of consciousness. Treatment includes administration of supplemental oxygen and airway management.

Foreign Body Aspiration

Foreign body aspiration is the inhalation of something, such as food or an object, into a person’s airway. Symptoms include shortness of breath and stridor. Treatment may involve removing the foreign body at the hospital. Prehospital treatment includes airway management and supportive care.

Tracheostomy Dysfunction

Patients who have a tracheostomy tube can experience various complications, such as mucus plugs blocking the airway, bleeding, and dislodgment of the tube. Symptoms can include a blocked airway, cyanosis, and hypoxia. Treatment depends on the complication. For example, an airway obstruction due to a mucus plug can be treated by suctioning the tube and changing the inner cannula of the trach.

Cystic Fibrosis

Cystic fibrosis is a genetic disorder that affects the digestive system and the** lungs**. Symptoms include excessive mucus production, wheezing, and dyspnea. Treatment by the prehospital provider includes medication to loosen mucus, suctioning, and oxygen.

Here are some terms to know:

status asthmaticus—severe asthma attack that does not respond to standard treatments (inhalers)
bronchodilators—medications that relax the muscles around the airways, making it easier to breathe (albuterol)
croup—viral infection of the upper airway, most common in young children; causes swelling around the larynx, trachea, and bronchi
epiglottitis—a serious, potentially life-threatening infection that causes swelling of the epiglottis; has the potential to block the airway and make breathing difficult
emphysema—A chronic lung disease where the alveoli are damaged, which causes shortness of breath and reduced oxygen exchange.
allergen—substance that causes an allergic reaction in certain people (pollen, food, insect bites)
RSV—Respiratory Syncytial Virus; a common virus that infects the lungs and airways; especially common in young children
bronchiolitis—lung infection that causes inflammation and mucus buildup in the bronchioles, making breathing difficult

Common Cardiac and Circulatory Emergencies

Diseases or dysfunctions of the heart and/or the vessels are common. The Center for Disease Control and Prevention (CDC) states that one in four Americans suffer from heart disease. Here are some common cardiac conditions to look for:

Atherosclerosis

Atherosclerosis is a cardiovascular disease where a buildup of plaque forms inside the walls of the blood vessels. This buildup obstructs blood flow and interferes with their ability to dilate or contract.

Arteriosclerosis

Arteriosclerosis is a general hardening and loss of flexibility of the arteries which can restrict blood flow and decrease perfusion to body tissues.

Here are some terms to know:

occlusion—blockage or closing of a blood vessel preventing normal blood flow
lumen—opening of a blood vessel through which fluid or air can flow
ischemia—lack of blood flow, potentially causing tissue damage
thromboembolism—blood clot that forms in one place and then comes loose and travels through the bloodstream to block another vessel
acute myocardial infarction—heart attack; occurs when blood flow to part of the heart is blocked, causing tissue damage or death
cardiac arrest—cessation of the heart’s pumping action

Acute Coronary Syndrome

Acute coronary syndrome is a description of a conglomeration of symptoms brought on by myocardial ischemia. There are two categories into which these symptoms are classified.

Angina Pectoris

This disease process can be painful, although not life-threatening. The pain is caused by decreased oxygen flow due to a blockage or narrowing in the blood vessels that supply the heart, or arterial spasm, and it may be present during stress or physical exertion. The pain is typically located in the mid-chest area and is described by patients as a squeezing, pressure sensation, much like reflux or GERD symptoms. There may also be jaw and/or arm pain and nausea. Angina does not cause heart cell death; however, it can cause arrhythmias and serve as a precursor or warning to initiate preventive measures.

Acute Myocardial Infarction (AMI)

The key identifiers of AMI symptoms include acute onset of nausea, sweating, chest pressure or squeezing, arm, jaw, lower back, and/or abdominal pain. Some patients experience other diverse symptoms and some patients have no symptoms prior to onset. The pain is derived from arterial blockage, which can cause irreversible cell death. Sudden death can occur as a result of an AMI. Additionally, STEMI, which stands for ST-segment elevation myocardial infarction, is a type of heart attack associated with specific ECG changes and possible blockage of blood flow to part of the heart muscle.

Here are some terms and concepts to understand:

syncope—fainting, temporary loss of consciousness, caused by sudden lack of blood flow to the brain
signs and symptoms of ACS—chest discomfort, radiation of pain (jaw, arm, back), shortness of breath, nausea, vomiting, sweating, dizziness, palpitations
coronary artery bypass graft (CABG)—a surgical procedure in which a blood vessel from the chest or leg is used to create a new pathway for blood flow around a blocked coronary artery
difference between angina pectoris and acute myocardial infarction (AMI)—The key difference between these two disease processes is that angina can be relieved with rest and or nitroglycerin administration. The pain from AMI will persist despite treatment until the underlying cause is treated.
symptom differential between gender and age population—Cardiac symptoms can vary depending on contributing factors like age and gender. Men experiencing a cardiac emergency often present with central or left-sided chest discomfort, pain radiating to their arm, jaw, neck, back, shortness of breath, and diaphoresis. Women experiencing AMI more often experience less obvious symptoms, including fatigue, dizziness, nausea/vomiting, and abdominal pain. In terms of age discrepancies, younger patients (<50) are more likely to present with clear, typical symptoms such as chest pain or pressure. Older patients (<70) often present more atypically, experiencing symptoms like altered mental status, weakness, or GI symptoms, sometimes with no chest discomfort at all.

Cardiogenic Shock

Low cardiac output creates decreased oxygenation to the body. This low output keeps the heart from performing at full pressure/force to send adequate amounts of oxygenated blood throughout the body, resulting in pump failure. Over time, this condition can impair organ functions.

Here are some concepts to understand:

signs and symptoms of cardiogenic shock—These are hypotension (BP <90 systolic), rapid and weak pulse, diaphoresis, pale skin, shortness of breath, and chest pain.
time frame for cardiogenic shock to occur after AMI—Patients are at highest risk for cardiogenic shock during the first few hours post AMI; however, it most commonly develops within 24 hours.

Congestive Heart Failure

In congestive heart failure, the heart’s pumping mechanism is weaker, resulting in slower blood flow throughout the heart and, in turn, the entire body. This lack of pumping action creates fluid stasis around the heart and congestion in the lungs.

Here are some concepts to understand:

function of the left ventricle and atria—The left ventricle is responsible for pumping oxygen-rich blood received from the left atrium into the aorta. The aorta takes the oxygen-rich blood from the left ventricle and carries it to the rest of the body through branching arteries.
pulmonary and dependent edema—Pulmonary edema is a buildup of fluid in the lungs, usually caused by left-sided heart failure. Dependent edema is swelling in the lower parts of the body (legs, feet, ankles) caused by fluid buildup, often secondary to right-sided heart failure.
digoxin—a cardiac medication that helps the heart pump more forcefully and may also slow the heart rate; patients may take it for certain heart rhythm problems or heart failure

Hypertensive Emergencies

Hypertension is defined as acute or chronic high blood pressure outside of the normal range. Identification of classic signs and symptoms that create hypertensive emergencies is key to accurate and timely treatment. The ideal blood pressure, according to the American Heart Association, is 120/80. High blood pressure is defined as 140/90 or higher. An EMT should be familiar with three common hypertensive emergencies: AMI, aortic aneurysm, and dissecting aortic aneurysm.

Here are some concepts to understand:

cardiac process for systolic and diastolic readings—Systolic blood pressure (the top number) measures the pressure in the arteries when the heart contracts. Diastolic blood pressure (the bottom number) measures the pressure in the arteries when the heart relaxes between beats.
normal blood pressure ranges for adults—While blood pressure readings can vary by patient, a normal/ideal blood pressure is typically 120/80. Normal readings for systolic pressure range from 90 to 120 mmHg, and normal diastolic pressure ranges from 60 to 80 mmHg. A systolic below 90 is considered to be hypotension; a systolic above 140 or a diastolic above 90 is considered hypertension.
possible signs and symptoms of hypertensive emergency—symptoms of hypertension can include headache, dizziness/lightheadedness, nosebleeds, blurred vision, chest pain, shortness of breath, and fatigue
aortic aneurysm—a bulge or weakening in the wall of the aorta with the potential for rupture; can result in severe internal bleeding; life-threatening. Uncontrolled hypertension is a major risk factor for aortic dissection. Patients with a suspected aortic dissection may have unequal blood pressure readings between the arms or diminished pulses in the lower extremities. These findings can occur when the dissection disrupts blood flow through the aorta or its branches.
differences between symptoms of AMI and dissecting aortic aneurysm—AMI often presents with chest discomfort, arm/jaw pain, shortness of breath, sweating, etc. In contrast, an aortic aneurysm typically presents with severe, sudden, tearing pain in the chest, back, or abdomen.