Module III: Medical

NREMT PRACTICE ANALYSIS TASK ITEMS
•	Assess a patient experiencing an allergic reaction 
•	Provide care to the patient experiencing an allergic reaction 
•	Assess a near drowning patient 
•	Provide care to a near drowning patient 
•	Assess a patient with a possible overdose 

COGNITIVE OBJECTIVES
At the completion of this unit, the paramedic will be able to:
3.1	Describe physical manifestations in anaphylaxis. (C-1) / 5-5.13	
3.2	Differentiate manifestations of an allergic reaction from anaphylaxis. (C-3) / 5-5.14	
3.3	Recognize the signs and symptoms related to anaphylaxis. (C-1) / 5-5.15	
3.4	Differentiate among the various treatment and pharmacological interventions used in the management of anaphylaxis. (C-3) / 5-5.16	
3.5	Correlate abnormal findings in assessment with the clinical significance in the patient with anaphylaxis. (C-3) / 5-5.18	
3.6	Develop a treatment plan based on field impression in the patient with allergic reaction and anaphylaxis. (C-3) / 5-5.19	
3.7	List signs and symptoms of near-drowning. (C-1) 5-10.54	
3.8	Describe the lack of significance of fresh versus saltwater immersion, as it relates to near-drowning. (C-3) / 5-10.55	
3.9	Discuss the incidence of "wet" versus "dry" drownings and the differences in their management. (C-3) 5-10.56	
3.10	Discuss the complications and protective role of hypothermia in the context of near-drowning. (C-1) / 5-10.57	
3.11	Correlate the abnormal findings in assessment with the clinical significance in the patient with near-drowning. (C-3) / 5-10.58	
3.12	Differentiate among the various treatments and interventions in the management of near-drowning. (C-3) 5-10.59	
3.13	Integrate pathophysiological principles and assessment findings to formulate a field impression and implement a treatment plan for the near-drowning patient. (C-3) / 5-10.60	
3.14	Differentiate toxic substance emergencies based on assessment findings. (C-3) / 5-8.60	
3.15	Correlate abnormal findings in the assessment with the clinical significance in the patient exposed to a toxic substance. (C-3) / 5-8.61	
3.16	Correlate the abnormal findings in assessment with the clinical significance in patients with the most common poisonings by overdose. (C-3) / 5-8.44 	
3.17	Correlate the abnormal findings in assessment with the clinical significance in patients using the most commonly abused drugs. (C-3) / 5-8.53	
3.18	List the clinical uses, street names, pharmacology, assessment finding and management for patient who have taken the following drugs or been exposed to the following substances: (C-1) / 5-8.56 
•	Cocaine 
•	Marijuana and cannabis compounds 
•	Amphetamines and amphetamine-like drugs 
•	Barbiturates 
•	Sedative-hypnotics 
•	Cyanide 
•	Narcotics/ opiates 
•	Cardiac medications 
•	Caustics 
•	Common household substances 
•	Drugs abused for sexual purposes/ sexual gratification 
•	Carbon monoxide 
•	Alcohols 
•	Hydrocarbons 
•	Psychiatric medications 
•	Newer anti-depressants and serotonin syndromes 
•	Lithium 
•	MAO inhibitors 
•	Non-prescription pain medications 
•	Nonsteroidal antiinflammatory agents 
•	Salicylates 
•	Acetaminophen 
•	Metals 
•	Plants and mushrooms 

DECLARATIVE

I.	Anaphylaxis 
A.	Epidemiology 
B.	Pathophysiology 
C.	Assessment findings 
1.	Not all signs and symptoms are present in every case 
2.	History 
a.	Previous exposure 
b.	Previous experience to exposure 
c.	Onset of symptoms 
d.	Dyspnea 
3.	Level of consciousness 
a.	Unable to speak 
b.	Restless 
c.	Decreased level of consciousness 
d.	Unresponsive 
1.	Upper airway 
a.	Hoarseness 
b.	Stridor 
c.	Pharyngeal edema/ spasm 
2.	Lower airway 
a.	Tachypnea 
b.	Hypoventilation 
c.	Labored - accessory muscle use 
d.	Abnormal retractions 
e.	Prolonged expirations 
f.	Wheezes 
g.	Diminished lung sounds 
3.	Skin 
a.	Redness 
b.	Rashes 
c.	Edema 
d.	Moisture 
e.	Itching 
f.	Urticaria 
g.	Pallor 
h.	Cyanotic 
4.	Vital signs 
a.	Tachycardia 
b.	Hypotension 

5.	Gastrointestinal 
a.	Abnormal cramping 
b.	Nausea/ vomiting 
c.	Diarrhea 
6.	Assessment tools 
a.	Cardiac monitor 
b.	Pulse oximetry low 
c.	End tidal CO2 high 
A.	Management of anaphylaxis 
1.	Remove offending agent (i.e. remove stinger) 
2.	Airway and ventilation 
a.	Positioning 
b.	Oxygen 
c.	Assist ventilation 
d.	Advanced airway 
3.	Circulation 
a.	Venous access 
b.	Fluid resuscitation 
4.	Pharmacological 
a.	Oxygen 
b.	Epinephrine - main stay of treatment 
i.	Bronchodilator 
ii.	Decrease vascular permeability 
c.	Antihistamine 
d.	Antiinflammatory/ immunosuppressant 
e.	Vasopressor 
5.	Psychological support 
6.	Transport considerations 
B.	Management of allergic reaction 
1.	Without dyspnea 
a.	Antihistamine 
2.	With dyspnea 
a.	Oxygen 
b.	Subcutaneous epinephrine 
c.	Antihistamine 
II.	Near-Drowning 
A.	Definition 
1.	Submersion episode with at least transient recovery 
B.	Pathophysiology 
1.	Wet versus dry drownings 
a.	Fluid in posterior oropharynx stimulates laryngospasm 
b.	Aspiration occurs after muscular relaxation 
c.	Suffocation occurs with or without aspiration 
d.	Aspiration presents as airway obstruction 
2.	Fresh versus saltwater considerations 
a.	Despite mechanistic differences, there is no difference in metabolic result 
b.	No difference in out-of-hospital treatment 
3.	Hypothermic considerations in near-drownings 
a.	Common concomitant syndrome 
b.	May be organ protective in cold-water near-drownings 
c.	Always treat hypoxia first 
d.	Treat all near-drowning patients for hypothermia 
C.	Treatment 
1.	Establish airway 
a.	Conflicting recommendations regarding prophylactic abdominal thrusts 
b.	Questionable scientific data to support prophylactic abdominal thrusts 
c.	Ventilation 
d.	Oxygen 
2.	Trauma considerations 
a.	Immersion episode of unknown etiology warrants trauma management 
3.	Post-resuscitation complications 
a.	Adult respiratory distress syndrome (ARDS) or renal failure often occur post-resuscitation 
b.	Symptoms may not appear for 24 hours or more, post-resuscitation 
c.	All near-drowning patients should be transported for evaluation 
III.	General toxicology, assessment and management 
A.	Types of toxicological emergencies 
1.	Unintentional poisoning 
a.	Dosage errors 
b.	Idiosyncratic reactions 
c.	Childhood poisoning 
d.	Environmental exposure 
e.	Occupational exposures 
f.	Neglect and Abuse 
2.	Drug/ alcohol abuse 
3.	Intentional poisoning/ overdose 
a.	Chemical warfare 
b.	Assault/ homicide 
c.	Suicide attempts 
B.	Use of poison control centers 
C.	Routes of absorption 
1.	Ingestion 
2.	Inhalation 
3.	Injection 
4.	Absorption 
D.	Poisoning by ingestion 
1.	Examples 
2.	Assessment findings 
3.	General management considerations 
E.	Poisoning by inhalation 
1.	Examples 
2.	Assessment findings 
3.	General management considerations 
F.	Poisoning by injection 
1.	Examples 
2.	Assessment findings 
3.	General management considerations 
G.	Poisoning by absorption 
1.	Examples 
2.	Assessment findings 
3.	General management considerations 
H.	Alcoholism 
1.	Epidemiology 
2.	Psychological issues 
3.	Psycho-social issues 
4.	Pathophysiology of long term alcohol abuse 
a.	End organ damage 
b.	Malnutrition 
c.	Withdrawal syndrome 
5.	Assessment findings 

I.	Toxic syndromes 
1.	Cholinergics 
a.	Common causative agents 
i.	Pesticides (organophosphates / carbamates) 
ii.	Nerve agents (sarin / Soman) 
b.	Assessment findings 
i.	Headache 
ii.	Dizziness 
iii.	Weakness 
iv.	Nausea 
v.	SLUDGE (salivation, lacrimation, urination, defecation, GI upset, emesis) 
vi.	Bradycardia, wheezing, bronchoconstriction, myosis, coma, convulsions 
vii.	Diaphoresis, seizures 
c.	Management 
2.	Anticholinergic 
a.	Common causative agents 
b.	Assessment findings 
c.	Management 
3.	Hallucinogens 
a.	Common causative agents 
i.	lysergic acid diethylamide (LSD) 
ii.	phenyclicidine (PCP) 
iii.	Peyote 
iv.	mushrooms 
b.	Assessment findings 
i.	Chest pain 
c.	Management 
4.	Narcotics/ opiates 
a.	Common causative agents - 
i.	heroin 
ii.	morphine 
iii.	codeine 
iv.	meperidine 
v.	propoxyphene 
b.	Assessment findings 
i.	Euphoria 
ii.	Hypotension 
iii.	Respiratory depression/ arrest 
iv.	Nausea 
v.	Pinpoint pupils 
vi.	Seizures 
vii.	Coma 
c.	Management 
5.	Sympathomimetics 
a.	Common causative agents 
b.	Assessment findings 
c.	Management 
IV.	Specific toxicology, assessment and management 
A.	Cocaine 
1.	Clinical uses 
2.	Common causative agents 
3.	Common street names 
4.	Assessment findings 
5.	Management 
B.	Marijuana and cannabis compounds 
1.	Clinical uses 
2.	Common causative agents 
3.	Common street names 
4.	Assessment findings 
5.	Management 
C.	Amphetamines and amphetamine-like drugs 
1.	Clinical uses 
2.	Common causative agents 
3.	Common street names 
4.	Assessment findings 
5.	Management 
D.	Barbiturates 
1.	Clinical uses 
2.	Common causative agents 
3.	Common street names 
4.	Assessment findings 
5.	Management 
E.	Sedative-hypnotics 
1.	Clinical uses 
2.	Common causative agents 
3.	Common street names 
4.	Assessment findings 
5.	Management 
F.	Cyanide 
1.	Clinical uses 
2.	Common causative agents 
3.	Common street names 
4.	Assessment findings 
5.	Management 
G.	Narcotics/ opiates 
1.	Clinical uses 
2.	Common causative agents 
3.	Common street names 
4.	Assessment findings 
5.	Management 
H.	Cardiac medications 
1.	Clinical uses 
2.	Common causative agents 
3.	Common street names 
4.	Assessment findings 
5.	Management 
I.	Caustics 
1.	Clinical uses 
2.	Common causative agents 
3.	Common street names 
4.	Assessment findings 
5.	Management 
J.	Common household poisonings 
1.	Clinical uses 
2.	Common causative agents 
3.	Common street names 
4.	Assessment findings 
5.	Management 

K.	Drugs abused for sexual purposes/ sexual gratification 
1.	Clinical uses 
2.	Common causative agents 
3.	Common street names 
4.	Assessment findings 
5.	Management 
L.	Carbon monoxide 
1.	Clinical uses 
2.	Common causative agents 
3.	Common street names 
4.	Assessment findings 
5.	Management 
M.	Alcohols 
1.	Clinical uses 
2.	Common causative agents 
3.	Common street names 
4.	Assessment findings 
5.	Management 
N.	Hydrocarbons 
1.	Clinical uses 
2.	Common causative agents 
3.	Common street names 
4.	Assessment findings 
5.	Management 
O.	Tricyclic antidepressants 
1.	Clinical uses 
2.	Common causative agents 
3.	Common street names 
4.	Assessment findings 
5.	Management 
P.	Newer anti-depressants and serotonin syndromes 
1.	Clinical uses 
2.	Common causative agents 
3.	Common street names 
4.	Assessment findings 
5.	Management 
Q.	Lithium 
1.	Clinical uses 
2.	Common causative agents 
3.	Common street names 
4.	Assessment findings 
5.	Management 
R.	Non-prescription pain medications 
1.	Clinical uses 
2.	Common causative agents 
3.	Common street names 
4.	Assessment findings 
5.	Management 
S.	Nonsteroidal anti-inflammatory agents 
1.	Salicylates 
2.	Clinical uses 
3.	Common causative agents 
4.	Common street names 
5.	Assessment findings 
6.	Management 

T.	Acetaminophen 
1.	Clinical uses 
2.	Common causative agents 
3.	Common street names 
4.	Assessment findings 
5.	Management 
U.	Metals 
1.	Clinical uses 
2.	Common causative agents 
3.	Common street names 
4.	Assessment findings 
5.	Management 
V.	Plants and mushrooms 
1.	Clinical uses 
2.	Common causative agents 
3.	Common street names 
4.	Assessment findings 
5.	Management