06 Medical Emergencies

The EMT priority framework

Medical emergencies are managed by priority rather than by naming the disease first. The EMT should repeatedly move from immediate danger to life threats, focused assessment, treatment, reassessment, and transport.

1. Ensure scene safety and use appropriate PPE. Consider violence, traffic, hazardous substances, infectious exposure, and environmental danger.

2. Form a general impression by noting apparent age, position, work of breathing, skin signs, severity of illness, and responsiveness.

3. Perform the Primary assessment. Evaluate responsiveness, airway, breathing, circulation, and major bleeding, correcting life threats immediately.

4. Obtain vital signs and a focused history, including onset, provoking factors, quality, radiation, severity, time, allergies, medications, past history, last oral intake, and events leading to the illness or injury.

5. Check blood glucose when altered mental status, seizure, weakness, or unusual behavior is present, unless a more immediate threat requires attention first.

6. Treat within scope and local protocol, then reassess after every intervention.

7. Recognize time-sensitive conditions and notify receiving resources early when appropriate.

The most useful decision rule is: choose the action that addresses the most immediate life threat and is appropriate for the EMT’s scope. A detailed history should not delay airway support, ventilation, hemorrhage control, rapid cooling, epinephrine for anaphylaxis, or transport for a time-sensitive illness.

Takeaway: Protect yourself, identify life threats, support airway and breathing, assess circulation and glucose, treat within scope, reassess, and transport.

Neurologic emergencies

Neurologic emergencies often require rapid recognition and transport because symptoms may be time-sensitive.

Stroke and transient ischemic attack

Stroke may result from interrupted or ruptured cerebral blood flow. Suspect it when there is sudden facial droop, one-sided weakness or numbness, speech difficulty, vision change, severe unexplained headache, dizziness, loss of balance, or altered coordination. Use a validated stroke screen according to local protocol and determine the Last known well time. Check glucose, assess airway and breathing, and transport rapidly to an appropriate stroke-capable facility. Symptoms that resolve may represent a transient ischemic attack and still require emergency evaluation.

Do not delay transport for a lengthy secondary assessment. Keep the patient NPO unless medical direction says otherwise, reassess neurologic status and airway frequently, and consider hypoglycemia, seizure, intoxication, and hypoxia as possible alternate or contributing causes.

Seizures

During an active seizure, clear nearby hazards, protect the patient’s head, place padding under the head when possible, and time the seizure. Do not restrain the patient and do not place anything in the mouth. After convulsions stop, assess airway, breathing, oxygenation, glucose, injuries, and the postictal state.

Emergency intervention and transport are especially important for a seizure lasting more than five minutes, repeated seizures without recovery, persistent respiratory difficulty, pregnancy, diabetes with loss of consciousness, injury, or a first-time seizure.

Altered mental status

Altered mental status is a symptom, not a diagnosis. Consider the reversible causes represented by AEIOU-TIPS:

• Alcohol or acidosis

• Epilepsy or electrolytes

• Insulin problems

• Overdose or oxygen deficiency

• Uremia

• Trauma, temperature, or tumor

• Infection

• Psychiatric or poisoning causes

• Stroke, shock, or seizure

Evaluate glucose, oxygenation, temperature, medication or substance exposure, trauma, and focal neurologic findings. Do not label a patient as “just psychiatric” until medical causes have been considered.

Takeaway: For neurologic presentations, establish the last known normal time, protect the patient during seizures, check reversible causes such as glucose and hypoxia, and transport promptly when a serious condition is possible.

Diabetic emergencies

Diabetic emergencies can produce overlapping symptoms, so assessment and glucose testing are more reliable than appearance alone.

Hypoglycemia

Hypoglycemia may cause sweating, tremors, pallor, hunger, weakness, confusion, bizarre behavior, seizure, or unconsciousness. A conscious patient who can follow commands and swallow safely may receive oral glucose according to local protocol. Never place glucose, food, or liquid in the mouth of a patient with impaired consciousness or an ineffective swallow because aspiration may result.

If the patient cannot protect the airway, support airway and breathing, check glucose, request advanced care when indicated, and transport. Blood glucose below approximately $70\ \mathrm{mg/dL}$ is considered low in the supplied material, but treatment decisions must also account for symptoms, airway protection, protocol, and the overall presentation.

Hyperglycemia and diabetic ketoacidosis

Hyperglycemia may develop gradually and may cause thirst, frequent urination, dehydration, weakness, nausea, vomiting, abdominal pain, and altered mental status. Diabetic ketoacidosis may produce deep, rapid respirations and a fruity odor. EMT care generally consists of airway and breathing support, oxygen when indicated, assessment for shock and dehydration, prevention of aspiration, and prompt transport.

Do not assume that a high glucose reading explains all altered mental status. Stroke, sepsis, intoxication, and trauma may coexist.

A confused, sweaty, shaky patient is more suggestive of hypoglycemia, whereas a dehydrated patient with vomiting and deep, rapid respirations may have a hyperglycemic crisis. Confirm with glucose testing rather than relying on appearance alone.

Takeaway: Give oral glucose only when the patient can follow commands and swallow safely; otherwise prioritize airway and breathing support and transport.

Allergic reactions and anaphylaxis

Allergic reactions range from localized symptoms to rapidly progressive airway and circulatory compromise.

A mild reaction may cause localized itching, hives, or redness. Anaphylaxis is a severe systemic reaction that may include respiratory distress, wheezing, stridor, swelling of the lips or tongue, hypotension, vomiting, or altered mental status. Skin findings may be absent even in a severe reaction.

Epinephrine is the first-line treatment for anaphylaxis. Assist with or administer an epinephrine auto-injector only as permitted by state law, medical direction, and local protocol. Provide airway and breathing support, high-concentration oxygen when indicated, rapid transport, and repeated reassessment.

An antihistamine is not the first intervention for a patient with wheezing, stridor, or shock after an exposure. Those findings indicate an immediate threat to the airway or circulation, and epinephrine should not be replaced by an antihistamine or delayed for one.

Takeaway: Rapidly progressive allergic symptoms plus respiratory distress, airway swelling, hypotension, or altered mental status should be treated as anaphylaxis and managed with prompt epinephrine according to protocol.

Toxicologic emergencies

Toxicologic emergencies require protection of the crew, rapid support of life threats, and ongoing reassessment because patients may deteriorate suddenly.

General poisoning care

Protect yourself and the crew first. Identify the substance, route, amount, time of exposure, and whether other people are affected. Remove the patient from danger only when safe, avoid contaminating the ambulance, preserve containers or medication lists when possible, and contact medical control or a poison center according to local procedure. Do not induce vomiting unless specifically directed by an appropriate authority.

Manage the patient rather than focusing only on the suspected substance. Assess airway, breathing, circulation, mental status, temperature, glucose, and cardiac rhythm when available. Be prepared for vomiting, seizures, respiratory depression, and sudden deterioration.

Opioid overdose

Typical findings include decreased responsiveness, slow or absent breathing, pinpoint pupils, and cyanosis or gray skin. Ventilations and airway management take priority over naloxone. Provide rescue breathing or positive-pressure ventilation as needed, administer Naloxone according to protocol, and continue reassessment because its effects may not last as long as the opioid’s effects.

Carbon monoxide exposure

Carbon monoxide poisoning should be suspected when patients have headache, dizziness, weakness, nausea, vomiting, chest pain, confusion, or when multiple people become ill in the same environment. Carbon monoxide is odorless and colorless. Do not enter or remain in a contaminated area without appropriate protection. Remove patients to fresh air only when safe, provide oxygen according to protocol, and transport. A normal standard pulse oximeter reading does not reliably exclude carbon monoxide poisoning.

Takeaway: Scene safety comes first. Support ventilation before waiting for an antidote to work, and never allow an apparently improved toxicologic patient to bypass reassessment and emergency care.

Environmental emergencies

Environmental emergencies require removing the patient from the hazard while addressing airway, breathing, circulation, temperature, and associated trauma.

Heat illness

Heat exhaustion may cause heavy sweating, weakness, dizziness, headache, nausea, and dehydration. Heat stroke is more serious and may include altered mental status, seizure, collapse, very high body temperature, and hot skin that may be dry or sweaty. Rapid cooling and emergency transport are priorities, and cooling should not be delayed while waiting for transport.

Move the patient to a cool area, remove excess clothing, apply cool water or wet coverings, circulate air, and use cold packs or cold-water immersion when available and safe.

Hypothermia and frostbite

Hypothermia may cause shivering, fatigue, poor coordination, confusion, slurred speech, drowsiness, and later decreased responsiveness. Handle the patient gently, remove wet clothing, insulate the patient, and warm the body’s core gradually. Do not give alcohol or liquids to a patient who cannot swallow safely.

Frostbitten tissue may appear pale, waxy, numb, or firm. Do not rub or massage it, and do not thaw it if refreezing is possible.

Drowning and water-related illness

Ensure rescuer safety before entering the water. Once the patient is removed, address airway, breathing, and circulation immediately. Respiratory impairment is the primary threat. Also consider hypothermia and trauma, especially spinal injury from diving. Continue monitoring even if the patient initially appears stable because respiratory deterioration can occur.

Takeaway: Remove the hazard safely, correct the temperature emergency without harmful shortcuts, and continue monitoring for delayed respiratory or neurologic deterioration.

Infectious emergencies and infection control

Infection control protects the patient, EMTs, other patients, and receiving personnel. Use Standard Precautions for every patient based on anticipated exposure: perform hand hygiene, wear gloves and other PPE as indicated, use respiratory hygiene and cough etiquette, handle sharps safely, and clean and disinfect reusable equipment and contaminated surfaces.

Consider an infectious emergency when a patient has fever, altered mental status, respiratory distress, shock, a petechial or purpuric rash, severe weakness, or a relevant exposure history. Fever with a nonblanching petechial rash may suggest meningococcal disease; use appropriate droplet precautions and notify receiving personnel. For suspected airborne or highly contagious disease, follow agency and public-health guidance rather than improvising PPE.

Sepsis may present with infection plus abnormal mental status, rapid breathing, abnormal pulse, poor perfusion, fever or unusually low temperature, and weakness. EMT priorities are early recognition, airway and breathing support, treatment of shock, frequent reassessment, and rapid transport with prearrival notification when appropriate.

Takeaway: Apply routine precautions consistently, add precautions when the suspected hazard requires them, and treat possible sepsis as a time-sensitive emergency.

Behavioral emergencies and suicide risk

A behavioral emergency may result from psychiatric illness, intoxication, hypoglycemia, hypoxia, head injury, stroke, infection, or another medical condition. Begin with safety and a calm, organized approach.

• Maintain an exit route and request law-enforcement assistance when necessary.

• Use a calm voice, simple questions, and nonthreatening body language.

• Reduce noise, stimulation, and the number of people speaking.

• Ask directly about suicidal thoughts, a plan, access to means, and recent attempts.

• Search for medical causes, including glucose abnormality, overdose, trauma, and hypoxia.

• Do not promise secrecy; communicate safety concerns to appropriate resources.

Warning signs of suicide include talking about wanting to die, hopelessness, feeling like a burden, making a plan, giving away possessions, saying goodbye, dangerous risk-taking, increased substance use, and extreme mood changes. A patient with imminent risk should not be left alone. Use the least restrictive safe intervention and follow local procedures for medical and behavioral-health support.

A specific plan combined with available means indicates an immediate safety concern. The EMT should maintain observation, request appropriate assistance, use respectful communication, and arrange care and transport according to local procedure.

Takeaway: Treat behavior as a possible medical presentation until medical causes are considered, and prioritize immediate safety for patients at risk of harming themselves or others.

Priority-based decision practice

NREMT-style decisions usually depend on identifying the immediate threat rather than selecting the most detailed diagnosis. Apply this sequence to common presentations:

1. Sudden facial droop, speech difficulty, or one-sided weakness: check glucose and determine the Last known well time, then initiate rapid stroke transport.

2. Active generalized seizure: clear nearby objects, protect the patient’s head, and time the seizure. Do not restrain the patient or place anything in the mouth.

3. Confused, pale, sweaty diabetic patient who can follow commands and swallow safely: administer oral glucose according to protocol.

4. Wheezing, facial swelling, and dizziness after an exposure: treat possible Anaphylaxis with epinephrine according to protocol while supporting airway and breathing.

5. Unresponsive patient with slow, shallow respirations and pinpoint pupils: provide ventilatory support and manage the airway; administer Naloxone according to protocol without delaying ventilation.

6. Multiple people with headache, nausea, and dizziness in a building with a fuel-burning appliance: suspect Carbon monoxide poisoning and avoid unsafe entry.

7. A confused, hot, collapsing patient after exertion in high temperatures: begin rapid cooling while arranging emergency transport.

8. A confused, shivering patient rescued from cold water: remove wet clothing, insulate the patient, and handle the patient gently.

9. Fever, altered mental status, and a petechial rash: use appropriate PPE and consider droplet precautions.

10. A patient with a suicide plan and access to pills: ensure immediate safety, request appropriate assistance, and do not leave the patient alone.

For each case, the best answer is the intervention that addresses the most immediate life threat, stays within scope and protocol, and does not delay definitive care.

Takeaway: On priority questions, choose immediate life-saving support and timely transport over a lengthy history, a less urgent medication, or an unsupported assumption about the diagnosis.