Transcript August 2012 CE - Reading the Scene

Reading The Scene
August 2012 CE
Condell Medical Center
EMS System
Site Code#107200E-1212
Prepared by: Sharon Hopkins, RN, BSN, EMT-P
1
Objectives
Upon successful completion of this module,
the EMS provider will be able to:
• 1. Describe components of the scene
assessment/size-up.
• 2. Describe benefits of the windshield
survey.
• 3. Define the term mechanism of injury.
• 4. Describe common mechanism of
injuries and potential injuries.
• 5. Define nature of illness.
2
Objectives cont’d
• 6. Describe the index of suspicion.
• 7. Describe the 4 main impacts that occur
in a motor vehicle collision (MVC).
• 8. Define the term general impression.
• 9. Describe the role of critical thinking or
clinical judgment
• 10.Describe the components of the
primary assessment.
3
Objectives cont’d
• 11. Given a scenario, determine a
general impression
• 12. Given a scenario, determine key
questions to ask
• 13. Given a scenario, determine the Region X
SOP to follow
• 14. Given a scenario, demonstrate the
primary survey.
• 15. Successfully complete the post quiz with a
score of 80% or better.
4
Scene Assessment
•
•
•
•
Completed for every call you go on
Opportunity to gather information
Starts with scene safety
Is an on-going process and subject to
change
• Utilize your senses
– Sight, hearing, smell
5
Scene Size-up
• First part of any patient assessment
process
• Always begins with evaluation of scene
safety
– This includes medical and trauma calls
– Evaluated in an on-going manner
• Safety can be subject to change
• After a scene size-up, you will have more
patient involvement
6
Scene Size-up
• Scene safety
• Take Standard Precautions
– Minimally gloves on all calls
• What’s the mechanism of injury or nature of the
illness?
• Determine number of patients
– Is there a clue that something more is going on?
– Is there a need to activate the multiple patient plan?
• Do you need additional help?
7
The “Windshield Survey”
• Implies the survey taken prior to exiting
the ambulance
– Is the scene safe?
– Are there any hazards you perceive?
– If trauma, what clues are there regarding the
mechanism of injury?
– Will you need police for traffic or crowd
control?
8
Mechanism of Injury - MOI
• A force that produced an injury
– A MVC at 45 mph
• Can have common/anticipated injuries to certain
situations
– i.e.: orthopedic injuries from falls
– Allows prediction of injuries and complications
• i.e.: blow to the chest could cause a collapsed lung
• Some injuries will be assumed present based on
the MOI until proven otherwise
– Cervical spine injury if the patient is complaining of
neck pain after a fall from a height
9
Common MOI
• Twisting injuries tend to affect
–
–
–
–
–
–
–
–
–
Hip
Femur
Knee
Tibia/fibula
Ankle
Shoulder
Elbow
ulna,/radius
Wrist
10
Common MOI
• Forced bending or extension tend to affect
– Elbow
– Wrist
– Fingers
– Femur
– Knee
– Foot
– Cervical spine
11
Common MOI
• Direct blows may affect
– Clavicle
– Scapula
– Shoulder girdle
– Humerus
– Knee
– Hip
– Femur
12
Common MOI
• Indirect blows may affect
–
–
–
–
–
–
–
–
–
Pelvis
Hip
Femur
Knee
Tibia/fibula
Shoulder
Humerus
Elbow
Ulna/radius
13
Nature of Illness
• Information obtained from a medical
patient to help determine the possible
problem with the patient
• Information obtained from
– The scene
– The patient
– The family members
– Bystanders
14
Index of Suspicion
•
•
•
•
Use your “sixth sense”
Keep heightened suspicion and open mind
Be cautious of jumping to a diagnosis
Don’t be swayed by the patient’s opinion
– “I’m not really hurt”
– “It’s just a chest cold”
• Anticipate the worse and hope for the best
15
MVC
• With every one incident 3 collisions
actually occur
– A vehicle collision when the vehicle strikes an
object
– The body collision when the body strikes the
interior of the vehicle
– Organ collisions when the organs strike the
interior surfaces of the body
16
Reading the Scene
• The type of collision helps to predict the type of
injuries most likely received by your patient
• Knowing your anatomy, you can predict what
body parts have been injured
• You can then predict what signs and symptoms
the patient is most likely to present
• You are already formulating your treatment plan
based on your anticipation of the injuries
17
Traumatic Mechanism of Injuries
•
•
•
•
•
•
•
•
Head-on collision
Rear-end collision
Side impact collision
Rollover collision
Rotational impact collision
Falls
Blunt trauma
Penetrating trauma
18
Reading the Scene
• Your patient may not be aware of how they
were injured
• Gather clues as you approach the scene
• What kind of damage to the environment
do you note?
• What marks on the body are giving clues?
19
General Impression
• Your impression of the patient’s condition
– Based on your scene size-up with
mechanism of injury or nature of the
illness (i.e.: the patient's chief complaint)
– Based on the patient’s appearance
– Meant to evolve as you gather additional
data
– Drives your decision on how to treat the
patient
20
Practice Forming
Your General Impression
• Read the following 4 presentations
• Determine what you consider the patient’s
general impression to be
• Determine which SOP(s) would be
followed?
21
General Impression
Presentation #1
A 60 y/o patient complains of burning chest
pain for 2 hours with SOB
• They are pale, diaphoretic and anxious
• Your general impression?
– Cardiac patient until proven otherwise
• SOP to follow?
– Routine Medical Care; Acute Coronary
Syndrome
22
General Impression
Presentation #2
• You respond to a school for a 6 y/o who
fell off the jungle gym and is not acting
right
• The patient has vomited several times
• Your general impression?
– Head injury
• SOP to follow?
– Routine Trauma Care, Pediatric; Nausea
Management
23
General Impression
Presentation #3
• Your patient was stung by a bee while
drinking from a can of soda
• The patient has hives and is anxious
• Your general impression?
– Allergic reaction
• SOP to follow?
– Allergic Reaction
• Will be able to determine specific level of
reaction after further patient assessment
24
General Impression
Presentation #4
• You are called to the scene for a mother in
labor
• Upon arrival the patient states they want to
push
• Your general impression?
– OB delivery
• SOP to follow?
– Emergency Childbirth
25
Critical Thinking or Clinical
Judgment
• This is based on experience
• The more experience you have the better
your critical thinking skills are and the
better your clinical judgment
– These are difficult skills to teach
– These are honed with experience
– These can be improved by learning lessons
from other calls
• This is the development of your “sixth
sense”
26
Primary Assessment
• First step in any patient assessment
process
• Purpose – to determine any life threats
• Typical progression is A-B-C
– Perform C-A-B is the patient is apneic and
pulseless following the AHA guidelines
• Complete the primary assessment without
interruption EXCEPT for airway problem or
uncontrolled hemorrhage
27
Primary Assessment
• Form a general impression
• Assess the mental status
– Include cervical spinal immobilization
simultaneously if indicated
•
•
•
•
Assess the airway
Assess the breathing
Assess the circulation
Determine the transport priority
28
General Impression
• What is the patient’s chief complaint
– “Read the scene” for a traumatic event to get
clues
– Ask the patient what is wrong
– Don’t rely only on the initial information from
dispatch
29
Control of the Cervical Spine
• Apply manual control/immobilization of the
cervical spine if there is ANY suspicion of
neck or spinal injury
• A more detailed assessment will follow
• Maintain manual motion restriction until
the cervical spine has been cleared or until
full motion restriction has been applied
– Cervical collar, back board, head blocks
• Can be used in medical situations also
30
Determine the Mental Status
• Use the AVPU scale to determine the general
mental status
– A – the patient is awake
• They may be alert and oriented or confused
– V – the patient responds to verbal stimulation
• Any slight movement is considered a response
– P – the patient responds to some tactile stimulation
with some kind of response
• Watch for any small muscle movement including a twitch or
moaning & groaning
– U – the patient is totally unresponsive without any
response at all
31
Assess Airway
• Is the airway open?
– Can the patient speak?
– Do you hear any unusual noises?
• Is suction required?
–Limit to <10 seconds if suction must be
used
– Is there a need for any adjunct tools to be
used?
32
Assess Breathing
• Is the patient breathing?
• Is there any evidence of distress?
– If yes, do you consider it mild, moderate, or
severe?
• Does the patient meet criteria for
supplemental oxygen?
– Signs of respiratory distress?
– When the pulse oximeter is applied, is it >94%?
• Is there evidence that the patient needs
ventilation support (i.e.: BVM)?
33
Assess Circulation
• Were there any signs of major
hemorrhage as you approached the
scene?
• Does the patient have a pulse?
– What is the general rate & quality?
• Do not spend time now yourself to actually count
the heart rate!!!
• Is there any hemorrhage that needs to be
controlled?
34
Determine Transport Priority
• How quickly do you need to initiate
transport?
– A stable patient allows for more
treatment/interventions at the scene
– A potentially unstable patient indicates more
rapid transport with most interventions
performed enroute
– An unstable patient requires most
interventions to be started while enroute
• Perform only life-saving interventions at the scene
35
Practice “Reading the Scene”
and Doing Your Job
Read the following scenarios
Determine your general impression
Determine if there is any life threat
– Is it actual or highly likely?
What more information may be needed
during assessment?
Determine which SOP(s) you will need to
follow
36
Scenario #1
• Your “windshield survey” as you are
approaching the scene:
37
Scenario #1
• You are called to the scene for a 25 y/o
female with a seizure
• Upon arrival, the patient appears
unresponsive
– Lying on the ground
– Audible gurgling, visible oral secretions
– Responds to painful stimuli with moaning
• Your general impression?
– Adult with seizure activity who is now post
ictal
38
Scenario #1- Critical Thinking
• What could cause seizures?
– Epilepsy?
– Diabetic – most likely hypoglycemia?
– History of head injury?
• What is your priority of care?
– Clear the airway
• Positioning – side-lying
• Suction
– Consider need for cervical spine
immobilization
39
Scenario #1 – Questions to Ask
• Does anyone know the history?
• Can witnesses describe the seizure?
• Was the patient helped to the ground or
did they fall?
40
Scenario #1 - Interventions
•
•
•
•
Protect the airway
Consider c-spine control if needed
Obtain a blood glucose level
Perform a head to toe assessment looking
for evidence of trauma
– Prior trauma that could cause seizures
– Trauma from the seizure event
41
Scenario #1 - Critical Thinking
• Which benzodiazepine is used to terminate
active seizure activity per the Region X SOP’s?
– Versed
• Which route is preferred initially and why?
– IN – to avoid inadvertent needle sticks
• What is the dosage schedule for adults?
– 2 mg IN/IVP/IO every 2 minutes titrated to 10mg
– For peds: 0.1 mg/kg
– For continued or recurring seizure, contact Medical
Control (to repeat same orders to additional 10 mg)
42
Scenario #1 – Critical Thinking
• If your patient is having a long term active
seizure, how would you control/support the
airway?
– Positioning
• Side lying to drain oral secretions
– Suctioning
• Limited to <10 seconds
– BVM support
• Diaphragm in spasm so patient's
ventilations ineffective and too hard to
evaluate quality of respirations
43
Scenario #2 – Windshield Survey
• Your patient is in the car on the left
44
Scenario #2
• You respond to the scene of a MVC
• Your windshield survey shows major front
end damage with airbag deployment
• The patient was unrestrained driver who is
still in the car
45
Scenario #2 – Critical Thinking
• What injuries are most likely with an
unrestrained driver in a front end collision?
– Great potential for injuries to all parts of the
body
– “Up and over” the steering wheel
• Head and neck from windshield impact
• Chest and abdominal organs from impact with
steering wheel
– “Down and under” the steering wheel
• Knee, leg, hip injuries from striking the dash
46
Scenario #2 – Questions to Ask
• What are the steps in the scene size-up?
Take Standard Precautions
Is the scene safe?
Number of patients?
What is the MOI?
Do I need help or specialized equipment?
• When do you identify potential life threats?
– By the time you get to the end of the primary
assessment
47
Scenario #2 - Interventions
• Immediate control of the c-spine
• Provide airway & breathing assistance if
needed
• Consider need for supplemental oxygen
• Determine transport priority
– Guides decisions for interventions performed
on scene versus enroute
• Determine transport destination
– Level I or Level II trauma center?
48
Scenario #2 – Critical Thinking
• What are the evaluations performed for
spinal clearance in the field?
Evaluate the mechanism of injury
Evaluate the signs and symptoms
Evaluate the reliability of the patient
49
Scenario #3
• You are called to the scene for an
unconscious person
• Upon arrival, you recognize the patient
– You are frequently called for hypoglycemia
• The patient is agitated, clammy, unable to
follow commands
• The family is unable to get the patient to
eat or drink anything
50
Scenario #3 – Critical Thinking
• What could be causing the signs and
symptoms (be careful of tunnel vision)
– Hypoglycemia (again on this patient!!!)
– Head injury
– Illicit drug use
– Stroke
– Heat stroke
51
Scenario #3 – Questions to Ask
• Is there anyone that can provide the
history of events for today?
• Can we get a blood sugar level?
– Blood sugar is 32
• Is there evidence of something other than
hypoglycemia causing the altered level of
consciousness?
– What would be evidence of other reasons for
a change in mental status?
52
Scenario #3 - Interventions
• Establish IV access
• Administer 50% Dextrose 50 ml slow IVP
• Repeat blood sugar level at least once
more and more as needed
• Watch for infiltration during administration
of Dextrose
53
Scenario #3 – Critical Thinking
• What happens if Dextrose infiltrates?
– It is very irritating to the vein and tissues and
may cause damage
• If you are unable to establish IV access,
would you place an IO in this patient?
– This patient most likely should be given
Glucagon IM and transported in the absence
of IV access
• IO would be indicated if the glucose level was
critical for this patient and causing seizure activity
54
Scenario #3 – Critical Thinking
•
•
•
•
You establish IV access
You administer Dextrose
Can this patient sign a release?
Yes, if the blood sugar level is assessed
and documented to be over 60
– Document instructions provided to the patient
– Document who will be staying with the patient
– Document the IV was discontinued and that
the catheter was intact
55
Scenario #4
• As you are approaching, this is what you
see:
56
Scenario #4
• You are called to the scene for an older
patient who fell and can’t get up
• You notice a fresh abrasion on their chin
• The patient just requests help getting up
and does not want to be evaluated or
transported
– They say they are sorry to “bother you”
– They don’t want to take up any more of your
time
57
Scenario #4 – Critical Thinking
• Why did the patient fall?
– Consider a cardiac issue or stroke for any
patient with dizziness or syncope type
complaints until proven otherwise
• What injuries could this patient have?
– With a chin abrasion, consider hyperextension
of the neck
• This patient very likely could have a
cervical spine injury even without
neurological symptoms
58
Scenario #4 – Questions to Ask
•
•
•
•
“What made you fall?” (VERY important to ask!!!)
What is the patient’s history?
Has the patient had other recent falls?
What medications is the patient taking?
– Anticoagulants increases the risk of internal
bleeding
– Sleep aids may make the patient less alert
– Beta blockers, calcium channel blockers, and
ACE inhibitors (used to control High B/P) could
cause a drop in pulse rates resulting in
dizziness
59
Scenario #4 - Interventions
• Try to convince the patient to allow for a
physical assessment
• Try to talk the patient out of signing a
release
– Many elderly have frail bone structures and
are prone to fractures that may not be evident
at the time of injury
– It is not unusual for the patient to selftransport to the ED a few days later and find
they have a fracture or dislocation somewhere
60
Scenario #5
• As you approach the scene, you notice
another adult is with the patient
61
Scenario #5
• You are called to the scene for an elderly
patient who fell
• The patient has a GCS of 14
– They are “pleasantly confused”
– Answer most questions appropriately
– Is cooperative
• Your evaluation finds a probable hip
fracture
62
Scenario #5 – Critical Thinking
• Why would this patient be confused?
– Dementia with advanced age
– Influence of their prescribed medications
– Taking non-prescribed medications
– Head injury from the fall
• Epidural – usually see more rapid decline after a
lucid period
• Subdural – usually develops signs and symptoms
gradually over a period of time
– Elderly have shrunken brain tissue and more
room to bleed before vital tissue is compromised
63
Scenario #5 – Questions to Ask
• Perform routine assessment of the patient
– Patient fell so should receive a head-to-toe
assessment
– Evaluate the level of consciousness and try to
compare to their norm
– Perform a neurological exam
64
Scenario #5 – Critical Thinking
• What are the components of a field neurological
exam?
–
–
–
–
–
–
Level of consciousness (i.e.: AVPU)
Speech
GCS
Pupillary response
Motor response
Sensory test
• Most important is to evaluate the responses over
time watching for a change
65
Scenario #5
• What are the components of the Cincinnati
Stroke Scale?
Facial droop
Arm drift
Speech pattern
• How are they performed?
Ask the pt to smile big to show all their teeth
Ask the pt to hold out their arms for 10 seconds
Ask the pt to repeat a phrase
66
Scenario #5 - Interventions
• Provide care for the probable hip fracture
– Immobilization provided by long back board
• Evaluate distal CMS before and after moving
• Evaluate for additional injuries due to the
fall
• Obtain a blood glucose level
• Bring all medication containers to the
hospital
67
Scenario #6
• As you approach, this is what you observe
68
Scenario #6
• EMS called to the scene for a patient with
difficulty breathing
• Patient is extremely obese
• Patient is anxious, pale, diaphoretic with obvious
labored breathing
• Patient is partially reclined (ambulation is difficult
due to the obesity)
• Patient is “less alert” than 1 hour ago per family
• Monitor shows sinus tachycardia
• SpO2 80%
69
Scenario #6 – Critical Thinking
• What would cause dyspnea in this patient?
A respiratory issue?
A cardiac issue?
Their weight?
• What would cause a low O2 saturation?
Poor oximetry probe site choice
Pulmonary hypoperfusion
• Pulmonary embolism
Poor ventilation capacity due to size
70
Scenario #6 – Critical Thinking
• Pulmonary embolism - PE
– A blood clot that lodges in a pulmonary artery
– Blocks blood flow thru the vessel
– Is life threatening – decreased pulmonary
blood flow could cause hypoxemia
–  risk in sedentary people or immobility (i.e.:
recent surgery, long distance travel, longbone fractures with casting, bedridden
–  risk in certain populations (i.e.: pregnancy
due to venous pooling, atrial fib, sickle cell
anemia, oral birth control pills especially if a
71
smoker
Scenario #6 - PE
• Sources of PE
– Blood clots – most common
– Air embolism (i.e.: during external jugular stick)
– Fat embolism (i.e.: from a long bone fracture)
– Amniotic fluid embolism (i.e.: during OB
delivery)
– Foreign body (i.e.: sheared IV catheter tip)
• Clots tend to form with stagnation of blood
(i.e.: immobility)
• Clot blocks pulmonary blood flow
72
Scenario #6 – PE Signs &
Symptoms
•
•
•
•
•
•
•
•
•
•
Depends on size & location of obstruction
Usually have sudden onset severe unexplained dyspnea
Sometimes pleuritic chest pain
Unproductive cough (or hemoptysis if cough is
productive)
Labored breathing, tachypnea
Tachycardia; occasionally dropping B/P
Often clear breath sounds
Confusion/agitation with hypoxia
May find warm, swollen, painful lower extremity (a clot)
Key: low oxygen saturation!!!
– Does not improve even with supplemental oxygen
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Scenario #6 – PE Management
• Establish and maintain airway
• Assist ventilations if necessary
• Supplemental oxygen at highest flow rate
possible
• Carefully monitor vital signs and EKG rhythm
– Watch for cardiac arrest
• Rapid transport
• Avoid lifting legs or knees to avoid dislodging
thrombi in lower extremities
74
Scenario #6 – Questions to Ask
• Patient’s history
• Medications
• Description of the dyspnea
– OPQRST evaluation
• Recent travel, surgeries, periods of
immobilization
• Have high index of suspicion for pulmonary
embolism especially if the SpO2 is low
– High mortality rates
75
Scenario #6 - Interventions
• High flow oxygen
• If IV established, minimal fluid for now
(i.e.: TKO)
• Cardiac monitor
• Frequent reassessment of vital signs
• Rapid transport
76
Scenario #6 – Critical Thinking
• How would you position an obese patient
for intubation?
– Use towels to elevate the shoulders – notice
ear to sternal notch line-up on the right
77
Scenario #6 – Critical Thinking
• Discussion point: What transport
modifications need to be made to move
and then transport an extremely obese
person?
78
Scenario #6
• Did you know?
• Where are you???
• BMI rough calculation = weight (lbs) x 703
height (inches)2 79
Scenario #7
• This is what you see as you approach:
80
Scenario #7
• A 58 y/o male calls for abdominal pain,
belching, nauseated, and weak
• Sudden onset while bowling
• Is pale, diaphoretic, anxious
• VS: 132/98; P 86; R 20; SpO2 98%
81
Scenario #7 – Critical Thinking
• What is your impression?
– Abdominal pain?
– Cardiac?
– Indigestion?
– The flu?
• Think: what’s the worst case scenario for a
patient with “abdominal” pain?
– An actual cardiac event until proven otherwise
82
Scenario #7 – Questions to Ask
• Assess the patient following the OPQRST
format
– Covers important assessment components
• The answers to questions may prompt
further questioning
– i.e.: “P” – What makes the pain worse?
- What makes the pain better?
– What have you taken for the pain?
83
Scenario #7 - Interventions
• Routine Medical Care SOP
• Would you put the patient on a cardiac
monitor?
– Defend why not or why you would
• EKG rhythm:
Normal sinus rhythm
84
Scenario #7 – Critical Thinking
• The patient’s rhythm is NSR
• What more could a 12 lead tell you?
– Evidence of ST elevation and location
– Location influences decisions of care by you:
• i.e.: NTG administration or not
•
Potential need for carefully monitored
fluid administration
Potential for heart blocks
85
Scenario #7 - Interventions
• Acute Coronary Syndrome SOP
• Critical thinking:
– The patient states they took an antacid and
Tylenol
– Would you still administer ASA?
• Yes, ASA has different actions than Tylenol
– Why is ASA important to give so early?
• ASA blocks platelets from aggregating or
congregating at the site of the plaque rupture
which would further block blood flow
86
Scenario #7
• Is there ST elevation?
ST elevation I, aVL, V2 – V5
87
Scenario #7 – Critical Thinking
• Now what are your interventions?
– Have IV access
– Administer NTG after checking B/P and
screening for Viagra use
– What is the dose of NTG?
• 0.4 mg SL; may be repeated every 5 minutes to
max of 3
• Watch the blood pressure before & after
administration
– Consider use of Morphine for pain
– What is the dose of Morphine?
• 2 mg slow IVP every 2 minutes to max of 10 mg
88
Scenario #8
• As you approach, this is what you see:
89
Scenario #8
• You respond to the scene of a 4 y/o patient
who has a peanut allergy and took a bite
of dip with peanuts by mistake
• They are pale, clammy, anxious, itching,
visible hives, increased respirations, and
audible wheezing
• As you approaching, the parent is
preparing the patient’s Epipen
90
Scenario #8 – Critical Thinking
• VS: B/P 88/50; P – 100; R - 26
• What is your impression?
– Allergic reaction or anaphylaxis?
– What is the difference?
• The blood pressure would be dropping in
anaphylaxis due to the wide spread
vasodilation response of the body
– Did you know?
• The faster the reaction appears, usually the
more severe the reaction
91
Scenario #8 – Questions to Ask
• Determine the status of the airway
– Laryngeal edema can occur so protecting the
airway is the first concern
• If the patient's Epipen is ready to be
administered, would you allow that to be
used or prepare your Epi dose?
– It seems most prudent to use the quickest
available source of epinephrine
92
Scenario #8 - Interventions
• Which path of the Allergic reaction is
followed on the Region X SOP’s?
– Allergic reaction with airway involvement
• Why?
– The patient is wheezing; B/P is adequate for a
4 y/o
• What drugs are indicated?
– Epinephrine 1:1000 SQ, Benadryl, DuoNeb
(Albuterol mixed with Atrovent)
93
Scenario #8 – Critical Thinking
• What is the dose of the medications for
this 4 year old who weighs 40 pounds?
• Epinephrine 1:1000 – 0.01 mg/kg SQ
0.18 ml (0.18 mg) SQ
• Benadryl 1 mg/kg slow IVP or IM
0.36 ml (18 mg)
• Albuterol 2.5 mg/3 ml mixed with Atrovent
0.5 mg/2.5 ml
94
Scenario #8 – Critical Thinking
• What benefit do these medications provide?
– Epinephrine
• Bronchodilator to open the airways
• Vasoconstrictor to prevent the blood vessels from
dilating causing a drop in cardiac output
• Relatively short acting by often 1 dose is sufficient
– Benadryl
• Antihistamine to stop the release of histamine that
is causing the reactions seen; last 4-6 hours
– DuoNeb – Albuterol mixed with Atrovent
• Promotes bronchodilation
95
Bibliography
• Bledsoe, B., Porter, R., Cherry, R.
Essentials of Paramedic Care 2nd edition
Update. Brady. 2011.
• Limmer, D., O’Keefe, M. Emergency Care
12th Edition. Brady. 2012.
• Region X SOP’s IDPH Approved
January 6, 2012
• Walraven, G., Basic Arrhythmias 7th
Edition. Brady. 2011.
96