Clinical Cases in Paramedicine

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Clinical Cases in Paramedicine  Throughout the text, cases of varying levels of complexity are designed to meet the needs of Case-Based Learning (CBL) and Problem-Based Learning (PBL) curricula used in paramedic training programmes worldwide. Each chapter contains six case studies—introductory, intermediate, and advanced—and features interactive learning activities, discussion questions, practical tips, and authoritative guidance aligned to national and international best-practice standards. Case studies illustrate scenarios related to trauma, medical emergencies, obstetrics, respiratory and cardiac events, minor injuries, drug overdoses, and many others. This comprehensive resource: 
Features case studies of varying lengths and degrees of complexity to suit different readers, from student to professional Suitable for use in many international programmes Offers chapter introductions and summaries, practice questions, and additional online resources Contains clinical, legal, ethical, cultural, remote and rural case studies Includes a cumulative and comprehensive “Test Your Knowledge” concluding chapter Those studying or working in paramedicine must keep pace with changes in the field using the latest evidence and expert opinion.
is an essential volume for paramedic students and early-career professionals, as well as educators, lecturers, and trainers.

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Circulation to the skin

Flushed cheeks.

Work of breathing

Breathing appears rapid and shallow. An audible wheeze is noted.

SYSTEMATIC APPROACH

Danger

None at this time.

Response

Alert on the AVPU scale.

Airway

Clear.

Breathing

RR: 28. Regular and shallow. No accessory muscle use. Expiratory wheeze on auscultation.

Circulation

HR: 100. Regular and strong. Capillary refill time <2 seconds. Flushed cheeks and peripherally warm.

Disability

Moving all four limbs.

Pupils equal and reactive to light (PEARL).

Exposure

Bystanders have left. Next of kin are now on scene.

Temperature: warm summer evening – approx. 20 °C.

Vital signs

RR: 28 bpm

HR: 100 bpm

BP: 125/74 mmHg

SpO 2: 93%

Blood glucose: 5.2 mmol/L

Temperature: 36.9 °C

PEF: 300 L/min

GCS: 15/15

4 Lead ECG: sinus tachycardia

TASK

Look through the information provided in this case study and highlight all of the information that might concern you as a paramedic.

Aside from auscultation, which you have already done, what examination techniques should you incorporate into this patient assessment? Inspection – observe the chest for an abnormalities such as wounds, scars, bruising, asymmetry and recession.Palpation – feel for any asymmetry, vocal fremitus and tenderness.Percussion – hyper‐ or hypo‐resonance.

What adventitious (added) sounds might indicate asthma and why? Expiratory wheeze. This sound is made when air has a restricted path through the bronchi, due to inflammation and muscle spasm in the airways.

What medicine (pharmacology) is likely to relieve the patient’s symptoms and why? Nebulised salbutamol – it is a Beta2, adrenergic agonist that relaxes smooth muscle in the bronchi.

Case Progression

You treat the patient with 5 mg of nebulised salbutamol and 6 L of oxygen. The nebuliser finishes and you remove the mask.

Patient assessment triangle

General appearance

The patient is now speaking in full sentences.

Circulation to the skin

Flushed.

Work of breathing

Normal effort of breathing.

SYSTEMATIC APPROACH

Danger

None at this time.

Response

Alert.

Airway

Clear.

Breathing

RR:16. Regular. Normal depth. No accessory muscle use. No wheeze or adventitious sounds.

Circulation

HR: 105. Regular and strong. Capillary refill time <2 seconds. Flushed cheeks and peripherally warm.

Disability

No change.

Exposure

No change.

Vital signs

RR: 16 bpm

HR: 105 bpm

BP: 128/78 mmHg

SpO 2: 97%

Blood glucose: not repeated

Temperature: not repeated

PEF: 380 L/min

GCS: 15/15

4 lead ECG: sinus tachycardia

1 What kinds of questions would you ask this patient specifically related to asthma as part of the history‐taking process? See Table 1.1.

Table 1.1 History‐taking questions

Asthma historyDoes this feel like your normal asthma? Is this the worst it’s ever been? What time did this episode start today? Do you take your asthma medication regularly? What were you doing when it started today? What usually triggers your symptoms? When was the last time your visited your GP and/or went to hospital with these symptoms? Have you ever been intubated or been in ICU with these symptoms? Medication historyWhat asthma medications do you take? How frequently do you have to take your medication? Do you usually have to take your inhaler while exercising? When was the last time you had a medication review with your GP? Have you had any recent changes in medication? Do you take any other medications? Have you had any coaching on the best way to take your inhaler? F/SH (family and social history)Does anyone else in your family experience asthma? Do you smoke? If so, how frequently? Do you drink or take any drugs recreationally? Who do you live with? What do you do for work? Do you exercise regularly? Are you under any particular stress at the moment? Past medical history (PMH)Do you have any other medical problems? Do you have any allergies? Have you had a cough or cold recently?

1 The patient is 160 cm tall, what should her predicted peak expiratory flow reading (PEFR) be? Her first reading was 300 – what percentage is that from predicted? (Hint: you will be required to look this up using the Australian National Asthma Council chart found here: http://www.peakflow.com/pefr_normal_values.pdfor by doing an internet search.)400 L/min.75%.

LEVEL 1 CASE STUDY

Chronic obstructive pulmonary disease (COPD)

Information type Data
Time of origin 07:09
Time of dispatch 07:12
On‐scene time 07:30
Day of the week Wednesday
Nearest hospital 15 minutes
Nearest backup 40 minutes
Patient details Name: Dave Beater DOB: 21/09/1954

CASE

You have been called to a residential address for a 66‐year‐old male with difficulty in breathing. The caller states he has been breathless all night and has had a cough recently. He has seen his GP who prescribed antibiotics and steroids but he feels his breathing has got worse overnight.

Pre‐arrival information

The patient is conscious and breathing and is in a first‐floor flat/unit.

Windscreen report

The location appears safe. Greeted at the main door by the patient’s wife.

Entering the location

Wife escorts you up in the lift to the patient’s flat.

On arrival with the patient

Patient is sat in the tripod position and appears distressed. He makes eye contact when you arrive, but does not speak as is so short of breath. He has a productive cough that results in a string of green‐looking sputum that he manages to capture in his handkerchief to show you.

Patient assessment triangle

General appearance

Alert, and makes eye contact, but is acutely distressed. Can only speak in single words and is reluctant to talk. In tripod position, coughing.

Circulation to the skin

Pink face, breathing through pursed lips.

Work of breathing

Increased work of breathing – rapid and shallow breaths with accessory muscle use.

SYSTEMATIC APPROACH

Danger

None at this time.

Response

Alert.

Airway

Clear.

Breathing

RR: 36. Rapid and shallow, with accessory muscle use. Widespread bilateral wheeze noted on auscultation.

Circulation

HR: 110. Radial palpable – irregular. Capillary refill time 2 seconds.

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