Medical Emergencies

This section of our NREMT study guide provides a direct and comprehensive overview of common medical emergencies.

It covers patient assessment, specific abdominal and gastrointestinal conditions, toxicology, allergic reactions, and endocrine emergencies.

Patient Assessment Fundamentals

Core Principles

• Sign vs. Symptom: A sign is an objective finding that an EMT can see, hear, feel, or measure. It is a piece of clinical evidence. Examples include a rash, bleeding, a blood pressure reading of 120/80 mmHg, or wheezing heard on auscultation. A symptom is a subjective finding that the patient feels and tells you about. It is part of their personal experience. Examples include nausea, chest pain, dizziness, or a headache.
• Vital Signs Monitoring: The frequency of vital sign assessment depends on the patient’s stability. For an unstable patient (e.g., altered mental status, signs of shock, severe pain), you must assess vitals at least every 5 minutes. For a stable patient, you should assess vitals at least every 15 minutes.
• Sphygmomanometer (BP Cuff) Sizing: Proper cuff size is critical for an accurate reading. The bladder of the cuff should encircle 80% of the arm’s circumference. The width of the cuff should be approximately two thirds the length of the upper arm, from the armpit to the elbow crease. A cuff that is too small will give a falsely high reading; a cuff that is too large will give a falsely low reading.
• Assessing Response to Painful Stimuli: To determine the level of consciousness in a non responsive patient, apply a central painful stimulus. This tests the integrity of the central nervous system. Common methods include:
  • Pinching the earlobe.
  • Pressing firmly on the bone above the eye (supraorbital foramen).
  • Pinching the trapezius muscles in the neck/shoulder area.
  • Performing a sternal rub (use with caution as it can cause bruising).

Abdominal Emergencies

Anatomy of the Abdomen

• Right Upper Quadrant (RUQ): Contains the liver, gallbladder, duodenum, and a portion of the pancreas. Pain here often points to gallbladder or liver issues.
• Left Upper Quadrant (LUQ): Contains the stomach, spleen, and a portion of the pancreas. Pain here can be related to the spleen or pancreatitis.
• Right Lower Quadrant (RLQ): Contains the large and small intestines, including the appendix. This is the classic location for appendicitis pain.
• Left Lower Quadrant (LLQ): Contains the large and small intestines, including the descending and sigmoid colon. Pain here is often related to diverticulitis.

Signs of Internal Abdominal Bleeding

• Cullen’s Sign: A bluish discoloration or bruising around the umbilicus (belly button). It is a late sign of intraperitoneal hemorrhage (bleeding within the abdominal cavity).
• Grey Turner’s Sign: Bruising along the flanks (the area between the last rib and the top of the hip). It is a late sign of retroperitoneal hemorrhage (bleeding behind the abdominal lining).
• Kehr’s Sign: Referred pain felt in the tip of the left shoulder when the patient is lying down. This is caused by blood from an injured spleen irritating the diaphragm. It is a classic sign of a ruptured spleen.
• Murphy’s Sign: Sharp pain and a sudden stop in inspiration when an examiner presses on the RUQ during deep inspiration. This is a key sign of acute cholecystitis (gallbladder inflammation).

Gastrointestinal (GI) Bleeding

• Signs of GI Bleeding: Dark, tarry, foul smelling stools (melena), vomit with a “coffee grounds” appearance (partially digested blood), and bright red bloody vomit (hematemesis).
• Upper GI Bleeding Causes:
  • Mallory Weiss Syndrome: A tear in the mucous membrane lining the lower esophagus, often caused by violent coughing or vomiting.
  • Boerhaave Syndrome: A full thickness rupture of the esophagus, a true surgical emergency.
• Lower GI Bleeding Causes: Can be caused by conditions like ulcerative colitis (inflammation of the colon) or diverticulosis.

Specific Abdominal Conditions

• Appendicitis: Inflammation of the appendix. Typically presents with pain that starts around the umbilicus and migrates to the RLQ, accompanied by nausea, vomiting, low grade fever, and rebound tenderness.
• Cholecystitis/Gallstones: Inflammation of the gallbladder, often due to gallstones. Presents with sharp RUQ pain that may radiate to the right shoulder, nausea, vomiting, and fever. Pain often worsens after a fatty meal.
• Pancreatitis: Inflammation of the pancreas. Presents with severe LUQ and RUQ pain that often radiates straight through to the back. Pain is constant and worsens after eating.
• Hepatitis: Inflammation of the liver. Presents with RUQ pain, jaundice (yellowing of the skin and eyes), and fatigue.

Toxicology and Overdoses

• Opiates/Narcotics (e.g., heroin, fentanyl): Classic triad of signs includes pinpoint pupils, respiratory depression, and sedation/coma. Treat with naloxone.
• Sympathomimetics (e.g., cocaine, meth): Stimulants that cause hypertension, tachycardia, dilated pupils, agitation, and hyperthermia.
• Anticholinergics (e.g., Benadryl): Cause tachycardia, hyperthermia, dilated pupils, and dry skin/mucous membranes. The mnemonic is: “hot as a hare, blind as a bat, dry as a bone, red as a beet, and mad as a hatter.”
• Cholinergics (e.g., organophosphates): Cause excessive fluid secretions. The mnemonic is SLUDGEM: Salivation, Lacrimation (tears), Urination, Defecation, Gastric upset, Emesis (vomiting), Miosis (pinpoint pupils).
• Sedative Hypnotics (e.g., Xanax, Valium): Cause hypoventilation, hypotension, slurred speech, and sedation. They generally do not affect pupil size.
• Beta Blockers: Overdose causes bradycardia, hypotension, and potentially hypoglycemia, especially in children.
• Activated Charcoal: Dose is 1 to 2 grams per kg. It is not effective for ingestions of acids, alkalis, heavy metals, or petroleum products.

Allergic Reactions and Anaphylaxis

• Localized Reaction: Involves local heat, hives (urticaria), and redness at the site of contact. This is caused by the release of histamine.
• Anaphylaxis: A severe, systemic reaction involving two or more body systems. Signs include widespread hives, bronchospasm (wheezing), hypotension (vasodilation), tachycardia, and anxiety.
• Bee Stings: Scrape the stinger away with a firm object. Do not use tweezers.
• Medications:
  • Epinephrine: The primary treatment for anaphylaxis. It is a sympathomimetic that causes vasoconstriction (to raise blood pressure) and bronchodilation (to open the airways).
  • Diphenhydramine (Benadryl): An antihistamine that blocks the effects of histamine. Main side effect is drowsiness.
  • Albuterol: A bronchodilator that relaxes the smooth muscles of the airways.

Endocrine Emergencies: Diabetes

• Normal Blood Glucose: 80–120 mg/dL.
• Hypoglycemia (Low Blood Sugar): Has a rapid onset. Signs are often neurological: altered mental status, slurred speech, seizures. The skin will be cool, pale, and clammy due to a sympathetic nervous system response. Treat a conscious patient with oral glucose.
• Hyperglycemia (High Blood Sugar): Has a gradual onset over hours or days. Signs are related to dehydration: intense thirst (polydipsia), frequent urination (polyuria), and hunger (polyphagia). The skin is often warm and dry.
• Diabetic Ketoacidosis (DKA): More common in Type 1 diabetes. Characterized by severe hyperglycemia, dehydration, and ketoacidosis. Presents with a fruity (acetone) breath odor and Kussmaul respirations (rapid and deep breaths) as the body tries to blow off acid.
• Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS): More common in Type 2 diabetes. Characterized by extremely high blood glucose levels and profound dehydration, but without significant ketoacidosis. Altered mental status can be severe.
• Type 1 vs. Type 2 Diabetes: Type 1 is an autoimmune disease where the body does not produce insulin. Type 2 is a condition of insulin resistance, often linked to lifestyle and obesity.

Other Medical Emergencies

• Seizures: The period after a seizure is the postictal state, characterized by lethargy, confusion, and headache.
• Febrile Seizures: Occur in children under 6 due to a rapid spike in temperature. Management is focused on passive cooling.
• Hypertensive Emergency: Systolic BP > 180 mmHg. Presents with severe headache, ringing in ears, bounding pulse, and nosebleed.
• Neurological Deficits:
  • Aphasia: Inability to understand or express speech.
  • Agnosia: Inability to recognize or name common objects.
  • Dysarthria: Slurred, difficult speech due to muscle weakness.