Treat what will KILL the patient first. Stabilize before diagnosing. Clinical trends matter more than any single set of vitals. Glucose in every AMS.
Universal 6-Step Approach
| Step | Action | Exam Tip |
|---|---|---|
| 1 — Scene Safety + PPE | Protect yourself first; upgrade PPE for suspected infection (droplet for meningitis/pneumonia) | Always first answer on NREMT — never skip this |
| 2 — Primary Survey (ABCDE) | Airway → Breathing → Circulation → Disability (AVPU/GCS + glucose) → Expose | Disability includes neuro AND glucose — check both |
| 3 — Can't-Miss Checks | Glucose for AMS/seizure/stroke mimic; 12-lead for chest pain/SOB/syncope; SpO₂; EtCO₂ | DO NOT forget glucose in any AMS patient |
| 4 — Stabilize | O₂/ventilations; IV/IO; fluids or pressors; antidotes where appropriate | Intervene on immediate threats before full diagnosis |
| 5 — History + Exam | OPQRST, SAMPLE; medications (insulin, anticoagulants, beta-blockers, opioids) | Medication list = treasure map for diagnosis |
| 6 — Reassess | Vitals trends and mental status trends matter more than one set; document changes | Deteriorating trend = re-evaluate, upgrade level of care |
NREMT STRATEGY: Every medical scenario starts the same: scene safety → BSI → primary survey → glucose check. Never skip this sequence regardless of what the patient is doing.
Toxidrome Quick Reference — Identify the Pattern
| Toxidrome | Key Drugs | Pupils | HR | Skin | AMS |
|---|---|---|---|---|---|
| Sympathomimetic | Cocaine, meth, MDMA | Dilated (mydriasis) | Tachy, HTN | Diaphoretic, flushed | Agitated/psychotic |
| Cholinergic (SLUDGE) | Organophosphates, nerve agents | Pinpoint (miosis) | Brady | Diaphoretic, wet | AMS, seizure |
| Opioid | Heroin, fentanyl, morphine | Pinpoint (miosis) | Brady | Cool, clammy | Coma, respiratory depression |
| Anticholinergic | Diphenhydramine, TCAs, atropine | Dilated (mydriasis) | Tachy | Dry, flushed, hot | Agitated, hallucinations |
| Sedative-Hypnotic | Benzos, barbiturates, GHB, alcohol | Normal/small | Normal/brady | Normal | CNS depression, coma |
| Serotonin Syndrome | SSRIs + MAOIs, tramadol, triptans | Normal/dilated | Tachy, hyperthermic | Diaphoretic | Clonus, hyperreflexia, AMS |
Respiratory failure is a rapid, preventable progression. CPAP is first-line for CHF and COPD. Silent chest in asthma = impending arrest. O₂ titrated to 88–92% in COPD.
Distress vs. Failure vs. Arrest
| Stage | Clinical Signs | Immediate Action |
|---|---|---|
| Distress (Compensated) | Tachypnea, retractions, accessory muscle use, SpO₂ ≥94%, normal mentation | O₂ (titrate to SpO₂ 94–99%); position of comfort (upright/tripod); bronchodilators if wheeze |
| Failure (Decompensating) | SpO₂ <90% despite O₂; altered mentation; severe accessory use; bradycardia developing | Immediate BVM PPV; CPAP if appropriate and cooperative; prepare advanced airway |
| Arrest | Apnea or agonal breathing; pulseless or near-pulseless; unresponsive | CPR + advanced airway; treat reversible cause (tension PTX, obstruction) |
CPAP / NIPPV in EMS
| Condition | Starting PEEP | Notes |
|---|---|---|
| CHF/Pulmonary Edema | 10 cmH₂O | Higher PEEP forces fluid back into vasculature; reduces preload/afterload; apply EARLY |
| COPD / Asthma | 5 cmH₂O | Lower PEEP first; avoid air trapping/auto-PEEP; can nebulize albuterol inline |
| Undifferentiated distress | 5–7.5 cmH₂O | Titrate up based on response; watch BP carefully |
- Indications: Cardiogenic pulmonary edema, COPD exacerbation, severe asthma, undifferentiated moderate-to-severe distress
- Contraindications: AMS/uncooperative, active vomiting, suspected pneumothorax, SBP <90 mmHg, facial trauma, suspected epiglottitis
CPAP EXAM TRAP: CPAP is NOT a substitute for intubation. If patient deteriorates or cannot protect airway → advanced airway.
COPD Exacerbation
- Barrel chest, prolonged expiration, pursed-lip breathing, tripod position
- EtCO₂ elevated (hypercapnia); shark-fin waveform on capnography
- SpO₂ may be chronically low — baseline 88–92% in severe COPD
- Cor pulmonale signs: JVD, peripheral edema, hepatomegaly
- 1Position upright; reassure; minimize exertion
- 2O₂ TITRATED to SpO₂ 88–92% in known COPD — avoid hyperoxia (risk of hypercapnic respiratory failure in CO₂ retainers)
- 3Bronchodilators: albuterol + ipratropium neb — both reduce bronchoconstriction via different mechanisms
- 4CPAP 5 cmH₂O if moderate-to-severe distress and patient cooperative
- 5Corticosteroids per protocol (methylprednisolone or dexamethasone)
- 6If failing: BVM with prolonged exhalation (I:E 1:3 or longer) to prevent auto-PEEP; advanced airway at low rate/high tidal volume
- 7Rapid transport; early hospital notification
COPD O₂ TRAP: Give enough O₂ to maintain SpO₂ 88–92% — NOT 100%. High-flow O₂ in CO₂ retainers can blunt hypoxic drive and cause apnea.
Asthma — Severe / Status Asthmaticus
| Sign | Mild | Moderate | Severe / Near-Fatal |
|---|---|---|---|
| Speech | Full sentences | Phrases | Words only or unable to speak |
| Accessory muscles | None | Present | Severe; see-saw breathing |
| SpO₂ | >95% | 91–95% | <91% |
| EtCO₂ | Normal 35–45 | Normal | RISING (patient tiring — danger sign) |
| Wheeze | Mild | Diffuse | ABSENT = "silent chest" — impending arrest |
- 1High-flow O₂ (titrate SpO₂ 94–99%)
- 2Albuterol neb 2.5–5 mg (may give continuously for severe); add ipratropium for moderate/severe
- 3Magnesium sulfate 2 g IV over 20 min for severe refractory asthma
- 4Systemic corticosteroids per protocol — dexamethasone or methylprednisolone
- 5Epinephrine 1:1000 IM 0.3–0.5 mg for life-threatening/near-arrest asthma
- 6CPAP 5 cmH₂O if cooperative and not in arrest
- 7If intubating: low rate (8–10 bpm), high tidal volume (6–8 mL/kg), long I:E (1:3) — avoid breath stacking
SILENT CHEST = IMPENDING ARREST: A quiet asthmatic who stopped wheezing is NOT improving — they are too tired to move air. Immediate aggressive intervention.
Pulmonary Edema (Acute Cardiogenic) — LMNOP
- Severe dyspnea; orthopnea; bilateral crackles (wet rales); frothy/pink sputum
- Hypertension (often) OR hypotension (cardiogenic shock — worse prognosis)
- JVD; peripheral edema; S3 gallop rhythm; SpO₂ markedly decreased
- 1L — Lasix (furosemide) IV per protocol: vasodilator effect immediate; diuresis delayed 20–30 min
- 2M — Morphine (use cautiously; fentanyl preferred): reduces preload/anxiety; watch for hypotension
- 3N — Nitroglycerin SL/IV: powerful preload reducer; START if SBP >90; contraindicated with RV infarct, PDE-5 inhibitors
- 4O — Oxygen: titrate SpO₂ 94–99%
- 5P — Position: upright with legs dependent (reduces preload/venous return)
- 6CPAP 10 cmH₂O: dramatically improves oxygenation; reduces preload/afterload; apply EARLY
- 712-lead: rule out STEMI as cause; look for arrhythmias
- 8If hypotensive (cardiogenic shock): cautious fluid 250 mL bolus; vasopressor; AVOID large fluids and CPAP
Pulmonary Embolism (PE)
| Feature | Detail |
|---|---|
| Classic triad | Sudden dyspnea + pleuritic chest pain + tachycardia; may have hemoptysis or syncope |
| Massive PE | Obstructive shock: hypotension + JVD + CLEAR lungs (vs. cardiogenic = crackles) |
| 12-lead classic (rare) | S1Q3T3: deep S in I, Q wave + inverted T in III; right bundle branch pattern; sinus tachy most common |
| EtCO₂ clue | DECREASING EtCO₂ with normal/increasing respiratory rate = dead space ventilation = PE |
| Treatment | O₂; IV access; 12-lead; fluid bolus 500 mL NS for hypotension; avoid massive fluids (worsens RV dilation) |
| Arrest management | CPR; consider thrombolytics in pulseless arrest if PE suspected (50 mg tPA IV) |
Stroke: check glucose FIRST, document last known well, transport to stroke center. Seizures: midazolam IM/IN is preferred prehospital. Exertional syncope = cardiac emergency.
Stroke — Types & Recognition
| Type | Mechanism | Key Clues | Prehospital Impact |
|---|---|---|---|
| Ischemic (87%) | Thrombotic or embolic occlusion | Gradual onset; vascular distribution; may have A-fib hx | tPA window 3–4.5 hours from last known well — document this precisely |
| Hemorrhagic (13%) | Rupture of cerebral vessel → mass effect | Sudden "thunderclap" worst-of-life headache; rapidly progressive deficits | DO NOT give aspirin or anticoagulants — can worsen bleeding |
| TIA | Transient ischemic event; resolves <24 hrs | Symptoms resolved on arrival; still needs immediate workup — 10–15% stroke risk in 90 days | Transport urgently; treat as stroke; document deficits and timeline |
Cincinnati Prehospital Stroke Scale (CPSS)
| Assessment | Normal | Abnormal |
|---|---|---|
| Facial Droop: ask patient to smile or show teeth | Both sides move symmetrically | One side droops or does not move |
| Arm Drift: eyes closed, arms outstretched 10 sec | Both arms stay equal; no drift | One arm drifts down or pronates |
| Speech: say "you can't teach an old dog new tricks" | Normal clarity and word choice | Slurred, wrong words, or unable to speak |
BE-FAST (expanded CPSS): Balance, Eyes (visual changes), Face droop, Arm drift, Speech abnormal, Time — call stroke alert and transport
Stroke Prehospital Treatment — In Order
- 1Scene safety; call stroke alert early — prehospital notification reduces door-to-treatment time
- 2ABCs: O₂ ONLY if SpO₂ <94% (hyperoxia worsens ischemic neuronal injury)
- 3CHECK GLUCOSE FIRST — hypoglycemia is the most common stroke mimic; treat if <60 mg/dL
- 4Document CPSS; note exact time of LAST KNOWN WELL — critical data point for tPA eligibility
- 512-lead: A-fib = embolic stroke source; rule out acute MI
- 6IV access; blood glucose; do NOT aggressively reduce BP (permissive hypertension up to 220/120 in ischemic stroke)
- 7Head of bed flat (increases cerebral perfusion) unless vomiting/airway concern
- 8Rapid transport to stroke center (comprehensive > primary if LVO suspected) with pre-alert
BP IN STROKE TRAP: Do NOT aggressively lower BP in acute ischemic stroke prehospital — hypertension maintains collateral perfusion to ischemic penumbra
Stroke Mimics
| Mimic | Key Differentiator |
|---|---|
| Hypoglycemia | Always check glucose; focal deficits + low BG = treat hypoglycemia first |
| Todd's Paralysis | Post-ictal focal weakness after seizure; resolves over hours; witnessed seizure history |
| Complex migraine | Headache + aura + visual changes + prior migraine history; younger patient |
| Bell's Palsy | Forehead INVOLVED in peripheral palsy (central stroke spares forehead — UMN vs LMN) |
| Hypertensive encephalopathy | Global symptoms, severe HTN, more confusion than focal deficits |
Seizures — Recognition & Management
| Scenario | Key Focus |
|---|---|
| First seizure, new onset | Treat; find cause (glucose, hypoxia, toxin, head injury, fever) |
| Known epilepsy — breakthrough | Assess cause of breakthrough (missed meds, illness, stress, sleep deprivation) |
| Alcohol withdrawal seizures | Benzodiazepine specific treatment (GABA-A mechanism); can be severe and recurrent |
| Status epilepticus (>5 min or 2+ without recovery) | Aggressive benzo treatment; airway management; glucose; toxin screen |
| Eclampsia (pregnant) | MgSO₄ first-line; NOT benzodiazepines; protect airway; transport |
- 10–2 min: ABCs; protect from injury (NOT physical restraint); lateral position; suction; O₂; CHECK GLUCOSE
- 22–5 min: IV/IO access; treat hypoglycemia if present (D50W 25g IV)
- 35 min: Benzodiazepine FIRST LINE — midazolam 0.1–0.2 mg/kg IM/IN preferred prehospital (no IV needed); max 10 mg; OR lorazepam 2–4 mg IV
- 45–10 min: If no cessation, second benzodiazepine dose per protocol
- 5>10 min refractory: levetiracetam, fosphenytoin, or phenobarbital per ALS/medical control; prepare airway
IM MIDAZOLAM = BETTER PREHOSPITAL: IM midazolam achieves therapeutic levels faster and stops seizures more effectively than IV lorazepam in prehospital studies
Syncope — Differential Diagnosis
| Type | Clues | Action |
|---|---|---|
| Vasovagal (most common) | Prolonged standing, emotional stress, pain, heat; prodrome (nausea, diaphoresis, tunnel vision) | Monitor; IV; 12-lead; transport if unclear cause or injury |
| Orthostatic | Positional (lying → standing); dehydration, anti-HTN medications | Check orthostatic vitals (10 mmHg SBP drop = positive); IV fluids; transport |
| Cardiac (most dangerous) | Exertional syncope; no prodrome; palpitations preceding event; known cardiac hx | 12-lead immediately; monitor continuously; aggressive transport |
| Structural | Aortic stenosis (exertional + harsh systolic murmur), HCM (young athlete) | Exertional syncope = serious until proven otherwise |
| Neurologic (rare) | TIA/vertebrobasilar; focal neuro symptoms present; seizure | Treat as stroke/seizure if focal deficits present |
EXERTIONAL SYNCOPE = CARDIAC EMERGENCY: Syncope during exercise is never benign until proven otherwise — aggressive workup and transport
DKA = Type 1, rapid onset, acidosis, fruity breath. HHS = Type 2, elderly, glucose >600, profound dehydration. Hypoglycemia mimics stroke and seizure — always check.
DKA vs. HHS — Side-by-Side
| Feature | DKA | HHS (Hyperosmolar Hyperglycemic State) |
|---|---|---|
| Patient | Type 1 DM (usually); any age | Type 2 DM (usually); elderly |
| Glucose | 250–600 mg/dL (can be lower with SGLT2 inhibitors) | >600 mg/dL (often >1000); extremely high |
| Ketones | YES — fruity breath; Kussmaul respirations | Minimal to none |
| pH / Acidosis | Metabolic acidosis (pH <7.3) | Usually normal pH |
| Onset | Rapid (hours) | Gradual (days to weeks) |
| Dehydration | Moderate (3–5 L deficit) | Severe (8–10 L deficit; profound) |
| AMS | Variable (often mild) | More severe; coma common |
| Prehospital Tx | O₂ PRN; IV isotonic fluids (1 L NS bolus if shock); EtCO₂ monitoring; transport | O₂ PRN; aggressive IV fluids; treat shock; transport |
HYPOGLYCEMIA MIMICS STROKE OR SEIZURE: A patient with focal neurological deficits or seizure may simply be hypoglycemic. Check glucose before calling a stroke alert.
Thyroid & Adrenal Emergencies
| Condition | Key Presentation | Prehospital Treatment |
|---|---|---|
| Thyroid Storm | Fever (often >40°C), rapid A-fib, agitation/delirium, diarrhea, vomiting, exophthalmos | ABCs; active cooling; IV fluids; rate control for A-fib per protocol; rapid transport |
| Myxedema Coma | AMS/coma; hypothermia; bradycardia; hypoventilation; hypoglycemia possible; non-pitting edema | Airway/ventilation support early (hypoventilates); gentle passive warming; glucose check; transport |
| Addisonian Crisis | Weakness, vomiting, abdominal pain, hypotension/shock; history of steroid use or chronic adrenal insufficiency | ABCs; O₂; large-bore IV; aggressive isotonic fluids (very responsive to fluids); glucose check; transport |
Upper GI bleed: hematemesis or melena, high mortality with varices. Lower GI: hematochezia. AAA = load and go. Mesenteric ischemia = pain out of proportion to exam.
GI Bleed — Upper vs. Lower
| Feature | Upper GI Bleed | Lower GI Bleed |
|---|---|---|
| Source | Above ligament of Treitz: esophageal varices, peptic ulcer, Mallory-Weiss tear | Below ligament of Treitz: diverticulosis, colitis, AVM, colorectal cancer |
| Presentation | Hematemesis (bright red or coffee grounds); melena (black, tarry, malodorous) | Hematochezia (bright red blood per rectum) |
| Shock risk | High — varices can be rapidly exsanguinating | Usually slower; massive if aortoenteric fistula or large diverticular hemorrhage |
| Key risk factor | Cirrhosis/varices; NSAIDs/aspirin for peptic ulcer | Less relevant unless portal HTN |
| Prehospital Tx | O₂; 2 large-bore IVs; isotonic fluids titrated to perfusion; treat shock; transport | Same supportive approach; direct pressure not applicable; treat shock |
VARICEAL BLEED: Patient with cirrhosis + massive hematemesis = esophageal variceal hemorrhage — extremely high mortality. Aggressive resus, early notification, rapid transport.
Abdominal Emergency Differential
| Condition | Location | Key Clue | Danger Sign |
|---|---|---|---|
| Appendicitis | RLQ (McBurney's point); starts periumbilical | Anorexia + fever + migratory pain; Rovsing's/psoas sign | Perforation → peritonitis → sepsis |
| Diverticulitis | LLQ primarily | Age >50; fever; LLQ pain; constipation/diarrhea | Abscess, perforation, sepsis |
| Pancreatitis | Epigastric → back | Radiates to back; worse supine, better leaning forward; alcohol/gallstones hx | Hemorrhagic pancreatitis = shock; third spacing |
| Cholecystitis | RUQ + Murphy's sign | Worse after fatty meals; N/V; fever | Charcot's triad (RUQ pain + fever + jaundice) = ascending cholangitis = emergency |
| Bowel Obstruction | Diffuse crampy → constant | Distension; vomiting; no flatus; high-pitched bowel sounds | Strangulation = ischemia → necrosis → sepsis |
| AAA | Periumbilical or back; tearing pain | Pulsatile abdominal mass; elderly male smoker; may mimic renal colic | Rupture = rapid exsanguination — LOAD AND GO |
| Ectopic Pregnancy | Unilateral LLQ or diffuse | Pregnant patient + abdominal pain + vaginal bleeding + peritoneal signs | Rupture = massive intra-abdominal hemorrhage |
| Mesenteric Ischemia | Diffuse | Pain out of proportion to exam; A-fib (embolic source) | Bowel infarction = sepsis; very high mortality |
AAA EXAM TRAP: Elderly male with sudden severe back or abdominal pain + hypotension = ruptured AAA until proven otherwise. Do NOT waste time on-scene.
BVM before naloxone in opioid OD. TCA = wide QRS = sodium bicarb. CO poisoning = SpO₂ falsely normal. Organophosphates = decon FIRST. Cocaine chest pain = never give beta-blockers.
Opioid Overdose
| Feature | Detail |
|---|---|
| Classic triad | Respiratory depression + AMS/coma + miosis (pinpoint pupils) |
| Modern challenge | Illicit fentanyl/carfentanil (50–10,000× morphine potency); multiple doses of naloxone may be needed |
| BVM first | Ventilation is the priority — do not delay BVM to find/give naloxone |
| Naloxone goal | Adequate respirations, NOT full awakening — aggressive reversal precipitates acute withdrawal and combativeness |
| High-dose opioid | If no response to 2–4 mg naloxone = suspect high-potency opioid (fentanyl analog); repeat dosing |
NALOXONE EXAM TRAP: The FIRST action in opioid overdose is BVM ventilation — not naloxone. Ventilation corrects hypoxia immediately. Naloxone is second.
Stimulant / Sympathomimetic Overdose
| Drug Class | Examples | Key Treatment |
|---|---|---|
| Cocaine | Cocaine, crack | Benzos for agitation/seizure; AVOID BETA-BLOCKERS (unopposed alpha vasoconstriction); nitroglycerin for chest pain |
| Amphetamines / MDMA | Meth, Adderall, MDMA, bath salts | Benzos first-line; cooling if hyperthermic; aggressive monitoring |
| Cathinones (bath salts) | MDPV, mephedrone | Extreme agitation; may need chemical restraint; benzos; cooling |
COCAINE + CHEST PAIN: NEVER give beta-blockers — blocks beta receptors while leaving alpha receptors unopposed → severe coronary vasoconstriction and hypertension
TCA Overdose — Most Dangerous Overdose in EMS
- 3 Receptor Blockades: (1) Sodium channel blockade → wide QRS, dysrhythmias, hypotension; (2) Anticholinergic → dry/flushed/tachy/AMS; (3) Alpha-1 blockade → hypotension
- QRS >100 ms = sodium bicarb threshold; QRS >160 ms = ~50% VT risk
- Can deteriorate from awake and talking to cardiac arrest within minutes
- 1Scene safety — TCA is often a suicide attempt; ensure safety
- 2ABCs — airway at extreme risk; have advanced airway ready
- 312-lead/monitor: check QRS width and terminal R wave in aVR
- 4IV access × 2
- 5Sodium Bicarbonate 1–2 mEq/kg IV bolus for QRS >100 ms, arrhythmias, or hypotension
- 6Seizures: benzodiazepines first-line; AVOID phenytoin (also sodium channel blocker — worsens TCA toxicity)
- 7Hypotension: IV fluids; sodium bicarb; norepinephrine if refractory
- 8Rapid transport — ICU monitoring required
TCA EXAM TRAPS: (1) NEVER give phenytoin for TCA seizures. (2) NEVER give sodium bicarb as bolus in alkalotic patient. (3) Wide QRS + hypotension = sodium bicarb FIRST.
Other Critical Toxidromes & Antidotes
| Toxin | Mechanism / Clues | Specific Treatment |
|---|---|---|
| Organophosphates / Nerve Agents | Cholinergic: SLUDGE/BBB; bradycardia; bronchorrhea; can drown patient in secretions | 1. DECON FIRST. 2. Suction airway. 3. Atropine 2–4 mg IV (repeat until secretions dry). 4. Pralidoxime (2-PAM) per protocol |
| Carbon Monoxide | CO binds Hgb 250× more than O₂ → functional anemia; SpO₂ reads FALSELY NORMAL | Remove from exposure; 100% NRB O₂ immediately regardless of SpO₂; monitor for AMS/arrhythmia; hyperbaric if available |
| Beta-Blocker OD | Bradycardia + hypotension + AMS + hypoglycemia | Glucagon 3–10 mg IV (reverses effects); atropine; high-dose insulin therapy (hospital) |
| CCB Overdose | Bradycardia + hypotension + AMS; NO hypoglycemia (differentiates from BB OD) | Calcium chloride 1 g IV; high-dose insulin (hospital); vasopressors |
| Acetaminophen OD | Initially ASYMPTOMATIC; liver failure 72–96h later | N-acetylcysteine (NAC) at hospital; EMS: ABCs, transport, document time/dose ingested |
| Salicylate OD | Tinnitus, Kussmaul hyperventilation, AMS, diaphoresis; mixed acid-base | O₂; IV fluids; sodium bicarbonate (alkalinizes urine → traps salicylate) |
| Alcohol (Ethanol) | CNS depression; Wernicke-Korsakoff risk in chronic alcoholism | ABCs; airway protection; thiamine 100 mg IV BEFORE glucose to prevent Wernicke's |
| Serotonin Syndrome | SSRIs + MAOIs/tramadol/fentanyl; hallmarks: CLONUS, hyperreflexia, hyperthermia | Benzos for agitation; cyproheptadine (hospital); cooling; stop offending agents |
CO POISONING TRAP: SpO₂ reads FALSELY NORMAL — pulse ox cannot distinguish oxyhemoglobin from carboxyhemoglobin. Give 100% O₂ to all suspected CO patients regardless of SpO₂.
Sepsis: 30 mL/kg bolus + antibiotics ASAP. Meningitis: droplet precautions, petechiae = emergency. Anaphylaxis: epinephrine IM FIRST — not antihistamines.
Sepsis — qSOFA Screen & Hour-1 Bundle
| qSOFA Screen (≥2 = High Sepsis Risk) | Finding |
|---|---|
| Altered mentation (any) | New confusion, agitation, AMS |
| Respiratory rate ≥22 bpm | Tachypnea |
| Systolic BP ≤100 mmHg | Hypotension (may be late sign) |
- 1PPE: appropriate to suspected source (droplet for pneumonia/meningitis; contact for diarrheal illness)
- 2ABCs: O₂ to SpO₂ 94–99%; ventilatory support if needed; EtCO₂ monitoring
- 3IV/IO × 2; blood glucose; lactate if point-of-care available
- 430 mL/kg IV isotonic crystalloid (NS or LR) for septic shock or hypoperfusion; reassess after each bolus
- 5Persistent hypotension (SBP <90) after fluids: norepinephrine or dopamine per protocol
- 6Early antibiotic administration per protocol — every hour delay increases mortality
- 7Temperature management: cool if hyperthermic; warm if hypothermic
- 8Sepsis alert to receiving facility; rapid transport
Sepsis Sources — PPE & Recognition
| Source Clue | Suspect | Precaution |
|---|---|---|
| Productive cough + fever + crackles | Pneumonia (most common sepsis source) | Droplet precautions; respiratory isolation |
| Dysuria, flank pain, fever in elderly | Urosepsis (UTI → bacteremia) | Standard precautions |
| Abdominal pain + fever + peritoneal signs | Intra-abdominal (perforation, abscess) | Standard precautions |
| Fever + petechial/purpuric rash + neck stiffness | Meningococcemia — EMERGENCY | Droplet precautions immediately; antibiotics ASAP |
| Dialysis patient + fever/AMS | Bacteremia (catheter/access) | Standard precautions |
Meningitis — Critical Field Points
- Classic Triad: fever + headache + nuchal rigidity (stiff neck)
- Kernig's sign: inability to extend knee when hip is flexed
- Brudzinski's sign: passive neck flexion causes involuntary hip/knee flexion
- Petechial/purpuric rash = meningococcemia = septic shock + meningitis simultaneously
- Droplet precautions immediately — N95 mask, gown, gloves
- Transport rapidly; antibiotic administration should not be delayed for any procedure
Anaphylaxis vs. Allergic Reaction
| Feature | Allergic Reaction (Mild-Mod) | Anaphylaxis (Severe, Systemic) |
|---|---|---|
| Respiratory | Minimal to none; mild wheeze possible | Stridor, hoarseness, severe wheeze; airway edema; respiratory arrest possible |
| Cardiovascular | Normal BP | Hypotension; distributive shock; cardiac arrest |
| Skin | Urticaria, hives, localized angioedema | Hives may be ABSENT in severe anaphylaxis; angioedema of lips/tongue/airway |
| CNS | Anxious, normal mentation | AMS, syncope, loss of consciousness |
| Treatment | Antihistamine; consider corticosteroid; observe | EPINEPHRINE IM FIRST — always before antihistamines |
- 1EPINEPHRINE 1:1000 IM 0.3–0.5 mg (anterolateral thigh) — never delay; only treatment that addresses ALL components
- 2High-flow O₂; airway setup; prepare for surgical airway if angioedema progressing
- 3IV access × 2; 1–2 L NS bolus (massive vasodilation = distributive shock)
- 4Albuterol neb for bronchospasm component
- 5Diphenhydramine 25–50 mg IV (adjunct only — does NOT reverse anaphylaxis)
- 6Methylprednisolone or dexamethasone IV per protocol (prevents biphasic reaction)
- 7Epinephrine may be repeated every 5–15 min IM or IV infusion for refractory shock
- 8All patients need hospital observation — biphasic anaphylaxis can recur 4–8 hours later
ANAPHYLAXIS EXAM TRAP: (1) Epinephrine FIRST — always before antihistamines. (2) Hives may be absent in severe anaphylaxis. (3) All anaphylaxis patients need hospital observation for biphasic reaction.
Hyperkalemia: peaked T waves → wide QRS → sine wave → arrest. Calcium chloride FIRST stabilizes the membrane. Hyponatremia seizures: never give hypotonic fluids.
Hyperkalemia — EKG Changes & Treatment
| K+ Level | EKG Change | Treatment |
|---|---|---|
| 5.5–6.0 mEq/L (mild) | Peaked, narrow, tall T waves | Treat cause; monitor; transport |
| 6.0–6.5 mEq/L (moderate) | Flattened P waves; prolonged PR; peaked T waves | Calcium + albuterol + bicarb per protocol; urgent transport |
| 6.5–7.0 mEq/L (severe) | Widened QRS; beginning to merge with T wave | Calcium chloride 1g IV + albuterol + bicarb; pacing readiness; emergency |
| >7.0 mEq/L (critical) | Sine wave pattern; imminent PEA/VF arrest | Aggressive multi-modal treatment; immediate transport; prepare for arrest |
- 1Calcium chloride 1g IV slow push — stabilizes myocardial membrane IMMEDIATELY (does NOT lower K+; buys time)
- 2Albuterol 10–20 mg neb (shifts K+ into cells; acts in 15–30 min)
- 3Sodium bicarbonate 1 mEq/kg IV (shifts K+ intracellularly in acidemic patients)
- 4Dextrose + regular insulin per protocol (shifts K+ into cells; acts 20–30 min)
- 5All above are temporizing — definitive elimination requires hemodialysis (hospital)
- 6Treat arrhythmias per ACLS; consider transcutaneous pacing for bradycardia
Hyponatremia
| Severity | Signs | Prehospital Action |
|---|---|---|
| Mild (Na 130–135) | Nausea, headache, malaise | IV access; monitor; transport |
| Moderate (Na 125–130) | Confusion, lethargy, muscle cramps | O₂; IV access; cautious isotonic fluid only; transport |
| Severe (Na <120) | Seizures, coma, cerebral edema, herniation risk | O₂; airway support; benzos for seizures; hypertonic saline (3% NaCl) per protocol; transport |
HYPONATREMIA TRAP: NEVER give hypotonic fluids (D5W, 0.45 NS) — worsens cerebral edema and herniation. Use isotonic NS or hypertonic saline for severe cases.
Rhabdomyolysis
- Mechanism: muscle breakdown → myoglobin release → renal tubular obstruction → acute kidney injury
- Causes: crush injury, exertion, heat stroke, seizures, electrical injury, alcohol/statin toxicity, compartment syndrome
- Classic clue: "cola-colored" or "tea-colored" urine (myoglobinuria)
- CK dramatically elevated (often >10,000 U/L)
- Prehospital treatment: aggressive IV fluid resuscitation (1–2 L NS to maintain urine output); treat underlying cause; transport
Rule #1: assume organic/medical cause first. Hypoglycemia, hypoxia, overdose, head injury, sepsis, and metabolic emergencies all present as "behavioral" emergencies.
Always Rule Out Medical Causes First
| Medical Cause | Clue to Look For |
|---|---|
| Hypoglycemia | Diaphoresis, tremors; glucose check MANDATORY |
| Hypoxia | SpO₂ decreased; cyanosis; respiratory signs |
| Opioid/Sedative OD | Miosis; respiratory depression; substance use history |
| Stimulant/Amphetamine | Tachycardia, hypertension, diaphoresis, hyperthermia |
| Alcohol intoxication or withdrawal | Odor; history; CIWA symptoms (tremor, seizure, tachycardia) |
| Head trauma | Signs of trauma; history of fall/assault; focal neuro deficits |
| Sepsis / Infection | Fever; hypotension; tachycardia; source of infection |
| Stroke | Focal neuro deficits; acute onset; CPSS positive |
| Psychiatric (diagnosis of exclusion) | All above ruled out; consistent with prior psychiatric history |
Excited Delirium Syndrome (ExDS)
- Presentation: extreme agitation + unusual strength + hyperthermia + diaphoresis + insensitivity to pain + paranoia
- Common causes: stimulant drugs (cocaine, meth, bath salts), severe psychiatric illness, or combined
- Dangers: sudden respiratory/cardiac arrest during or after physical restraint; hyperthermia causing organ failure
- Treatment: chemical sedation (ketamine or benzodiazepine per protocol) EARLY; cooling measures; monitor airway continuously; avoid prone restraint
- Never leave patient prone and unmonitored after sedation — highest risk period for respiratory arrest
Alcohol Withdrawal — Severity Scale
| Stage | Timing | Signs | Risk & Treatment |
|---|---|---|---|
| Mild withdrawal | 6–24 hrs | Tremors, anxiety, diaphoresis, tachycardia, hypertension | Low — monitor; transport if concerned |
| Moderate withdrawal | 24–48 hrs | Above + hallucinations (visual/auditory/tactile); Wernicke risk | Moderate — benzos per protocol; thiamine 100 mg IV; transport |
| Delirium Tremens (DTs) | 48–72 hrs (up to 96 hrs) | Severe agitation, confusion, tachycardia, hypertension, fever, seizures | HIGH MORTALITY — aggressive benzos (lorazepam or diazepam IV); monitor continuously; ICU |
WERNICKE'S ENCEPHALOPATHY: Give thiamine 100 mg IV BEFORE glucose in chronic alcoholics/malnourished patients — glucose without thiamine can precipitate irreversible Wernicke's encephalopathy (AMS + ataxia + ophthalmoplegia)
Hypotension is a LATE sign. Tachycardia + altered mentation + delayed cap refill = shock. JVD differentiates obstructive/cardiogenic (elevated) from hypovolemic/distributive (flat).
Shock Differential — Full Comparison
| Shock Type | Mechanism | Skin | JVD | Lungs | Fluid Response | Specific Action |
|---|---|---|---|---|---|---|
| Hypovolemic | Volume loss (hemorrhage, dehydration, burns) | Cool, clammy, pale | Flat | Clear | Excellent — aggressive IVF | Stop bleeding; aggressive crystalloid/blood; permissive hypotension in trauma (SBP 80–90) |
| Distributive — Septic | Vasodilation + capillary leak from infection | Warm + flushed (early); cool + mottled (late) | Flat | Variable | Good initially; may need vasopressor | 30 mL/kg bolus; norepinephrine if refractory; antibiotics ASAP |
| Distributive — Anaphylactic | Vasodilation + airway edema + bronchospasm | Flushed; hives | Flat | Wheeze / stridor | Good with fluids + epi | EPINEPHRINE IM FIRST; fluids; bronchodilators; airway |
| Distributive — Neurogenic | Loss of sympathetic tone (spinal cord injury) | Warm, dry (no vasoconstriction) | Flat | Clear | Moderate | Bradycardia + hypotension + warm skin after trauma = neurogenic; atropine; vasopressors |
| Cardiogenic | Pump failure (MI, arrhythmia, cardiomyopathy) | Cool, clammy | ELEVATED | Crackles (wet) | POOR — can worsen | Cautious fluid 250 mL; vasopressors/inotropes; CPAP; 12-lead; treat MI |
| Obstructive — Tension PTX | IVC compression from air | Cool, clammy | ELEVATED | Absent breath sounds (affected side) | POOR — mechanical cause | Needle decompression IMMEDIATELY (2nd ICS MCL or 4th-5th ICS AAL) |
| Obstructive — Tamponade | Pericardial fluid compresses heart | Cool, clammy | ELEVATED | CLEAR | MODERATE — cautious fluids | Beck's Triad: hypotension + JVD + muffled heart sounds; electrical alternans on EKG |
| Obstructive — Massive PE | Pulmonary vascular obstruction | Cool | ELEVATED | CLEAR | MODERATE | Obstructive shock + JVD + clear lungs; thrombolytics if arrest; transport |
SHOCK EXAM TRICK: JVD is the key differentiator. Flat JVD = distributive or hypovolemic (give fluids). Elevated JVD = obstructive or cardiogenic (fluids may worsen).
Heat stroke = AMS + temp >40°C = cool immediately (ice water immersion). Hypothermic arrest = not dead until warm and dead. Drowning = fix hypoxia first.
Heat Emergencies
| Condition | Core Temp | Sweating | AMS | Treatment |
|---|---|---|---|---|
| Heat Cramps | Normal | Yes — profuse | No | Oral or IV fluids; rest; electrolyte replacement; cool environment |
| Heat Exhaustion | <40°C (104°F) | Yes | Mild (fatigue, weakness, HA, dizziness) | Cool environment; remove clothing; cool IV fluids; oral hydration if alert |
| Heat Stroke — Classic | >40°C (104°F) | ABSENT (hot, dry skin) | SEVERE — AMS, confusion, seizures, coma | EMERGENCY: immediate aggressive cooling (ice water immersion preferred); ABCs; large-bore IVs; rapid transport |
| Heat Stroke — Exertional | >40°C (104°F) | May be present (diaphoretic) | SEVERE — AMS, rhabdomyolysis risk | Same as classic; also treat rhabdomyolysis; aggressive cooling |
HEAT STROKE = BRAIN DAMAGE: Core temp >40°C + altered mentation = neurological emergency. Cooling is the treatment — antipyretics do NOT work for heat stroke (not a fever).
Hypothermia
| Stage | Core Temp | Signs | Treatment |
|---|---|---|---|
| Mild | 32–35°C (90–95°F) | Shivering, confusion, ataxia | Remove wet clothes; passive warming (blankets); protect from wind/cold |
| Moderate | 28–32°C (82–90°F) | Shivering STOPS; paradoxical undressing; AMS; bradycardia; A-fib | Active external warming (heat packs wrapped, warm IVFs, warm environment) |
| Severe | <28°C (<82°F) | Rigidity; no shivering; profound bradycardia or arrest; appears dead | Gentle handling (AVOID rough movement — triggers VF); CPR if pulseless; transport to rewarming-capable facility |
HYPOTHERMIC ARREST: "Not dead until warm and dead." Do not withhold CPR or terminate resuscitation until patient is rewarmed to near-normal core temperature.
Drowning
- Near-drowning physiology: hypoxia → cardiac arrest; not hypothermia or water in the lungs
- Fresh water: hypotonic → absorbed into circulation → electrolyte dilution + hemolysis
- Salt water: hypertonic → draws fluid into lungs → pulmonary edema
- Treatment: immediate ventilation/oxygenation is the priority; CPR if pulseless; C-spine only if trauma mechanism; rewarm if hypothermic; CPAP/BVM for respiratory failure
- Good neurological outcomes are possible even after prolonged submersion in cold water — always resuscitate
Know every number cold. The NREMT is designed to catch field shortcuts — know the right answer even when the wrong answer sounds reasonable in the field.
High-Yield Numbers — Medical Emergencies
| Value | Meaning |
|---|---|
| <60 mg/dL | Symptomatic hypoglycemia threshold — treat below this |
| >600 mg/dL glucose | HHS threshold |
| 250–600 mg/dL glucose | Typical DKA range |
| 3–4.5 hours | tPA eligibility window for ischemic stroke from last known well |
| >5 minutes | Seizure duration defining status epilepticus |
| 0.4–2 mg IV/IN | Naloxone starting dose for opioid OD (titrate to respirations) |
| >100 ms QRS | TCA overdose → treat with sodium bicarbonate |
| >160 ms QRS | TCA overdose VT risk (~50% incidence above this threshold) |
| 1–2 mEq/kg NaHCO₃ | Dose for TCA OD, hyperkalemia, salicylate OD |
| 30 mL/kg NS | Sepsis Hour-1 fluid resuscitation bolus |
| 1 g calcium chloride IV | Hyperkalemia cardiac membrane stabilization; CCB OD antidote |
| 3–10 mg glucagon IV | Beta-blocker OD antidote |
| 2 g magnesium sulfate IV | Torsades de Pointes; severe asthma |
| 0.3–0.5 mg IM epi 1:1000 | Anaphylaxis epinephrine dose (anterolateral thigh) |
| 88–92% SpO₂ | Target range for known COPD — avoid hyperoxia |
| 94–99% SpO₂ | Target for most other conditions (stroke, post-ROSC) |
| 5 cmH₂O PEEP | CPAP starting pressure for COPD/asthma |
| 10 cmH₂O PEEP | CPAP starting pressure for cardiogenic pulmonary edema |
| >40°C (104°F) + AMS | Heat stroke = emergency cooling |
| 100 mg thiamine IV | Before glucose in chronic alcoholics/malnourished — prevent Wernicke's |
Exam Traps by Category
| Category | Trap | Correct Answer |
|---|---|---|
| Respiratory | CPAP in suspected pneumothorax? | CONTRAINDICATED — increases intrathoracic pressure; worsen PTX |
| Respiratory | 100% O₂ in COPD? | Target 88–92% SpO₂ only — hyperoxia blunts hypoxic drive |
| Respiratory | Silent chest in asthma = improving? | NO — impending arrest; aggressive intervention immediately |
| Neurology | Lower BP aggressively in ischemic stroke? | NO — permissive hypertension up to 220/120; collateral perfusion |
| Neurology | First action for opioid OD? | BVM ventilation FIRST — not naloxone |
| Toxicology | Beta-blockers for cocaine chest pain? | NEVER — unopposed alpha vasoconstriction; give nitroglycerin/benzos |
| Toxicology | Phenytoin for TCA seizures? | NEVER — also a sodium channel blocker; worsens TCA toxicity |
| Toxicology | SpO₂ normal = no CO poisoning? | NEVER — pulse ox cannot detect CO; give 100% O₂ regardless |
| Sepsis | Withhold fluids in septic shock? | NO — 30 mL/kg bolus is first-line; every hour delay increases mortality |
| Electrolytes | First drug for hyperkalemia? | Calcium chloride — membrane stabilization FIRST before shifting K+ |
| Electrolytes | Hypotonic fluids for hyponatremia seizures? | NEVER — worsens cerebral edema; use isotonic or hypertonic saline |
| Shock | Elevated JVD in shock means? | Obstructive or cardiogenic — fluids may worsen; treat the cause |
| Environmental | Antipyretics for heat stroke? | DO NOT WORK — heat stroke is not a fever; cool the patient aggressively |
| Psychiatric | First assumption in behavioral emergency? | Medical/organic cause — always rule out before assuming psychiatric |
Rapid Reference — Medical Quick Action Table
| Presentation | First Action | Key DO NOT |
|---|---|---|
| AMS of unknown cause | Check glucose IMMEDIATELY | Never assume psychiatric without ruling out medical |
| Opioid OD (slow/no breathing) | BVM ventilation first | Do not delay ventilation to find/give naloxone |
| TCA OD (wide QRS) | Sodium bicarbonate IV + airway ready | Never give phenytoin; avoid quinidine-like antiarrhythmics |
| Anaphylaxis | Epinephrine IM 1:1000 anterolateral thigh | Do not give antihistamine as primary treatment |
| Septic shock | IV + 30 mL/kg NS + antibiotics ASAP | Do not withhold fluids waiting for diagnosis |
| Severe COPD | Albuterol + ipratropium; CPAP 5 cmH₂O; O₂ to 88–92% | Never give 100% O₂ unmonitored to CO₂ retainer |
| Acute pulmonary edema | Sit upright; CPAP 10 cmH₂O; nitroglycerin SL | Never give large fluids; avoid if RV infarct or hypotensive |
| Status epilepticus (>5 min) | Midazolam IM/IN (preferred prehospital) | Never delay benzo to establish IV access first |
| Ischemic stroke | Check glucose; document last known well; stroke center | Never aggressively lower BP; never give aspirin without CT |
| Cocaine chest pain | O₂; nitroglycerin; benzos for agitation | Never give beta-blockers |
| Organophosphate poisoning | Decon FIRST; suction airway; atropine IV | Never enter without PPE; never skip decon |
| CO poisoning (SpO₂ normal) | 100% NRB O₂; remove from source | Never trust pulse oximetry for CO |
| Hyperkalemia (peaked T/wide QRS) | Calcium chloride 1g IV slow push first | Never give insulin/dextrose as first drug |
| Heat stroke (AMS + high temp) | Aggressive cooling immediately; ABCs | Never rely on antipyretics |
| Hypothermic arrest | CPR; gentle handling; transport for rewarming | Never give up until patient is warm and not responding |