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Administration of Symantec Data Loss(R) Prevention 11.5 exam

Wheezing in the Pediatric patient | 250-512 true Questions and VCE practice Test

This CE activity is accepted by artery of EMS World journal, a hard accredited by the carrying on with training Coordinating Board for Emergency clinical services (CECBEMS) for 1 CEU. To hold the CE descry at various that accompanies this article, Go to www.rapidce.com to hold the check and automatically acquire your CE credit. Questions? email editor@EMSWorld.com.?

pursuits

  • Describe the pathophysiology of bronchiolitis and list signs and indicators
  • Describe the treatment of a affected person with bronchiolitis
  • Describe the pathophysiology of asthma and listing indications and signs
  • Describe the treatment of a affected person with asthma
  • Describe the similarities and transformations between the pathophysiology of bronchiolitis and bronchial asthma
  • focus on the epidemiological qualities of bronchiolitis and asthma
  •    A wheeze is a excessive-pitched, musical, continuous sound that originates from oscillations in narrowed airways. Wheezing is most regularly the outcome of bronchiolitis in toddlers and bronchial asthma in older infants. this article will dispute the similarities and changes between these two childhood illnesses, along with management of the baby or child with wheezing.

    Bronchiolitis

    Epidemiology

       In children beneath 1 year of age, the respiratory syncytial virus (RSV) is estimated to be chargeable for up to 70% of cases in up to now suitable toddlers.1 RSV is an endemic of the family unit Paramyxoviridae, which comprises many typical respiratory viruses, reminiscent of folks that trigger measles and mumps. The identify RSV derives from the proven fact that it A) is a deadly disease that motives respiratory tract infections, and B) combines with neighborhood viruses to profile a syncytia, or virus mass. The virus is so ubiquitous that practically vulgar tiny ones will indulge in had an RSV an infection by their 2d birthday. After first-time exposure to RSV, 25%-40% of toddlers and kids will demonstrate signals or signs of bronchiolitis, and 0.5%-2% will require hospitalization. Most infants hospitalized for RSV infection are under 6 months of age.2 Bronchiolitis because of RSV become the main intuition behind hospitalization among the ordinary inhabitants of tiny ones within the united states between 1997-2000, accounting for an estimated 96,000 hospitalizations vulgar the artery through that point.3

       Mortality linked to bronchiolitis has lowered in previous a long time, despite the fact puerile tiny ones can nonetheless die from bronchiolitis. those are usually the in needy health ones who then extend bronchiolitis.3,four The mortality cost is lower than 1%, with fewer than 500 deaths a year attributed to RSV in the u.s.. extended morbidity and mortality occurs in high-possibility patients,3,5,6 together with these younger than 6 weeks ancient, and people with a tradition of untimely birth, hypoxia, congenital heart disease, ceaseless lung disease or immune deficiency.7,eight,9 Bronchiolitis is extra regular in adult males, toddlers residing in crowded situations, and infants who indulge in not been breast-fed.10,11,12

    Pathophysiology

       Bronchiolitis is predominantly a viral disease, with out a facts helping bacterial etiologies. besides RSV, other infectious brokers encompass parainfluenza, adenovirus, rhinovirus, mycoplasma and metapneumovirus. Viruses are spread from grownup to grownup by means of direct contact with nasal and oral secretions, airborne droplets produced with sneezing and coughing, and fomites. A fomite is any inanimate object, equivalent to a bedsheet or apparel, able to carrying and transferring an infectious agent.

       After inoculation, viral replication starts within the epithelial cells of the higher airway, then spreads to the mucosal surfaces of the lessen respiratory tract, together with the bronchioles. an infection of the epithelial cells outcomes in their destruction by artery of average mobilephone lysis, courtesy of the immune system, or by means of apoptosis, genetically preprogrammed cellphone dying. Necrotic cells slough off and unlock inflammatory mediators, leading to airway irritation and edema. furthermore, mucus production is extended. This combination of mobile debris, edema and extended mucus production effects in narrowing and obstruction of the bronchioles, multiplied resistance to air circulation, reduced ventilation and air trapping.

       apart from toddlers, there is additionally a risk of transmission to adults, exceptionally the immunocompromised or elderly. As such, vulgar clinical practitioners should profile expend of adequate personal protective tackle to give protection to themselves and others.

    clinical exam

       typically, the patient with bronchiolitis is more youthful than three hundred and sixty five days and items vulgar over the wintry weather months. The folks of a toddler with bronchiolitis will characterize a 1-5-day history of malaise, fever, irritability or needy feeding. A cough is normal, and loudly respiratory, grunting, dyspnea and extended travail of breathing may well be apparent; folks may additionally even characterize an audible wheeze. A guardian or caregiver could be capable of bethink publicity to someone with a respiratory an infection within the previous week. it's captious to determine if the affected person has a historical past of premature start, hypoxia, congenital coronary heart disease, persistent lung disease or immune deficiency, vulgar of which can complicate the direction of disease. A caregiver may furthermore additionally characterize periods of apnea, specially in babies younger than 6 weeks. it's essential to collect counsel about the patient's hydration repute, together with the presence of vomiting and/or diarrhea, urine output as decided by artery of the variety of diapers in a 24-hour duration, and the quantity and frequency of fluid consumption and feedings. toddlers with tachypnea may furthermore indulge in problem breast-feeding or taking a bottle.

       physical examination findings associated with bronchiolitis consist of fever, wheezing, tachycardia and tachypnea. indications of increased respiratory misery, together with accessory muscle use, nasal flaring, retractions, cyanosis and developing hypoxia, suggest severe ailment and airflow obstruction and require aggressive management. Pulse oximetry may noiseless be performed on vulgar patients with suspected bronchiolitis. it's inexpensive and gives quick and purpose facts regarding the diploma of hypoxia existing in a affected person.

       The aggregate of needy feeding and elevated insensible fluid loss secondary to tachypnea may terminate up in dehydration and hypovolemic shock, additional complicating the respiratory compromise. As such, a cautious assessment of the fontanel, epidermis turgor and mucous membranes could be appropriate.

    bronchial asthma

    Epidemiology

       bronchial asthma is likely one of the few ceaseless childhood ailments for which there had been increases in prevalence, morbidity and mortality in fresh decades. A CDC examine confirmed 34 million americans (eleven.5%), or one in 9 american citizens, indulge in been clinically determined with asthma vulgar the artery through their lifetime. present asthma prevalence is bigger amongst ladies (8.9%) than males (6.5%), and is bigger amongst toddlers a long time 17 years and younger (9.1%) than adults (7.three%).13 during the past 25 years, childhood bronchial asthma costs indulge in more than doubled.

       an ordinary annual 1.8 million emergency department visits for asthma indulge in been calculated for the three-yr length from 2001 unless 2003; 1.1 million visits were for adults and 696,900 visits were for infants. more visits were made via virile babies (423,800) than female toddlers (273,one hundred). vulgar over the same three-year period, a regular annual four,210 deaths from asthma came about, with 200 of these deaths taking space in people less than 18 years of age.14 There are separate racial disparities amongst tiny ones with this disorder. compared with white tiny ones, black children indulge in a 60% bigger prevalence expense, a 260% greater ED visit expense, a 250% greater hospitalization expense and a 500% higher death expense as a result of bronchial asthma.15 in the united states, childhood asthma is probably the most typical explanation for childhood emergency department visits, hospitalizations and ignored faculty days (10.1 million faculty days lost a yr).

    Pathophysiology

       asthma is a confirmed inflammatory ailment of the airways characterized by using variable and habitual indicators arising from episodic and reversible airflow obstruction. This airflow obstruction is the result of a lot of pathological procedures, including bronchoconstriction, airway hyperresponsiveness, irritation and edema, and increased pulmonary secretions. bronchial asthma can be labeled as atopic (extrinsic) or non-atopic (intrinsic) in accordance with the factors of indicators. The term atopy refers to a genetic predisposition in opposition t the structure of immediate hypersensitivity reactions to generic environmental allergens. Atopic asthma is brought about via allergens dote pollen or animal dander. Non-atopic bronchial asthma, in distinction, isn't caused by an publicity to an allergen, but is always a response to an endemic or upper respiratory infection.

       An exacerbation of bronchial asthma happens in two phases: early and late. during the early part, inhalation of an allergen or other irritant consequences in immediate bronchoconstriction. throughout the late phase, airway irritation, edema and hyperresponsiveness additional profile a contribution to airflow obstruction. it is charge taking a closer anatomize these accessories of asthma.

    Bronchoconstriction

       In atopic asthma, allergen-brought on bronchoconstriction effects from the IgE-elegant unencumber of bronchoconstrictor mediators, akin to histamine from mast cells. This occurs when IgE antibodies establish an allergen and connect to them, forming an allergen-antibody complicated. This allergen-antibody complicated is then diagnosed by using and bound to a mast phone. The mast mobile degranulates and releases histamine, leading to immediate bronchoconstriction. additionally, other stimuli similar to pastime, cold air, inhalation of irritants and even stress may terminate up in acute bronchoconstriction. Bronchoconstriction is essentially the most instant, preponderant physiological adventure early in an bronchial asthma attack, and airflow obstruction can be reversed at this time with the administration of bronchodilators.

    Airway inflammation and Edema

       Cells of the immune device that unlock inflammatory mediators involve lymphocytes, mast cells, eosinophils, and neutrophils to a lesser degree. unencumber of those mediators, similar to histamine and cytokines, results in multiplied capillary permeability and edema. The airflow obstruction caused via airway edema can be worsened by artery of mucus hypersecretion and the formation of mucus plugs. Airway inflammation and edema ensue later in an bronchial asthma exacerbation than does bronchoconstriction.

    Airway Hyperresponsiveness

       The time period airway hyperresponsiveness is used to interpret the exaggerated bronchoconstrictor response that happens in asthma and is linked to inflammation. The more inflammation it's latest, the better the hyperresponsiveness. a higher diploma of hyperresponsiveness correlates with an extend within the scientific severity of bronchial asthma. treatment that aims irritation can in the reduction of airway hyperresponsiveness and aid in bronchial asthma control.

    medical examination

       When evaluating the infant with bronchial asthma, the prehospital care company should noiseless inquire as to the age of the affected person, the duration and severity of the adventure, concurrent medicine use, and if there's a probability of a choking episode and foreign constitution aspiration. If there had been other attacks, the parents may noiseless attempt to compare the latest ones with previous attacks. establish vulgar treatment forms and doses. Any tradition of hardship napping or ingesting prerogative through the bombard suggests a reasonable to extreme exacerbation.

    general medical examination findings linked to asthma encompass tachypnea, tachycardia, wheezing and dry cough. in addition to wheezing, crackles or rhonchi may well be auscultated over areas the space mucus and inflammatory exudate indulge in accumulated within the airways. A taciturn chest will furthermore be an ominous register bronchial asthma, as it can furthermore testify that ventilation is extremely diminished or nonexistent. another ominous note is head-bobbing or lethargy, indicating that the patient is fitting drained, hypoxic, or approaching respiratory failure. An oxygen saturation should be determined, as it can aid in identifying the diploma of affliction.sixteen prerogative through the early levels of an exacerbation of bronchial asthma, hyperventilation effects in hypocapnia and a reduced conclusion-tidal carbon dioxide (ETCO2) studying. As bronchoconstriction and edema worsen airflow, alveolar air stream decreases and hypercapnia develops, resulting in a mount in ETCO2. No single bronchial asthma scoring desk has been universally adopted to determine the diploma of ailment or aid in determination-making concerning administration, however desk 1 can be used as a e-book.

       Measuring peak expiratory circulate cost (PEFR) is a straightforward and objective components of picking the severity of asthma in an adult, however arguably has constrained utility within the baby and child with asthma, who could be unable to commemorate commands integral for this trying out. in a single descry at, simply two-thirds of tiny ones above age 5 were capable of complete PEFR trying out throughout an bronchial asthma exacerbation.17

    management of Wheezing

       After initial comparison of airway, respiratory and circulation, and the immediate remedy of lifestyles-threats identified prerogative through the fundamental exam, the treatment of wheezing within the pediatric patient revolves round increasing air stream and oxygenation throughout the reversal of bronchoconstriction and airway edema.

    Oxygen

       All patients with wheezing may noiseless be administered oxygen by the expend of an acceptable start tackle to hold a SpO2 above 90%. patients with adequate breathing (price and tidal extent generic for age) can utilize a nasal cannula or nonrebreather masks, while patients with insufficient respiration (price and/or tidal quantity outdoor of norms for age) require BVM ventilation. care must be taken when offering BVM or mechanical ventilation, as air trapping can result in multiplied intrathoracic pressures and the possibility of lowered venous return. This could lead to decreased cardiac output and barotrauma, leading to pneumothorax. As such, enough (prolonged) expiratory time must be allowed for air to exit from the lungs. Permissive hypercapnia is a term used to interpret the extend in ETCO2 that happens when a methodology of minimizing tidal volumes and respiratory cost to be able to minimize top airway and intrathoracic pressures is utilized.

       Some EMS and demanding care transport features expend heliox within the treatment of extreme asthma. Heliox is a low-density blend (an eighty:20 ratio is usual) of helium and oxygen that results in much less-turbulent circulation through airways narrowed through bronchoconstriction and edema. In thought, the reduce in turbulent airflow should influence in decreased travail of respiration, less respiratory muscle fatigue, and a lessen probability of respiratory failure. besides the fact that children, an analysis of clinical trials assessing the expend of heliox suggests that there is insufficient facts to befriend common use, and it is continually regarded best for tiny ones with extreme exacerbation of bronchial asthma no longer responding to close remedy.18

       a relatively new profile of oxygen therapy used in cases of light wheezing in neonates and toddlers is heated, humidified, excessive-circulate nasal cannula (HFNC) remedy. HFNC allows for for the delivery of elevated gas flows (1-8 L/min in infants), with or with out an expanded oxygen concentration.19 HFNC provides some degree of continuous positive airway power (CPAP), although accurate rates are challenging to predict. Neonatal reviews demonstrate that the quantity of CPAP generated is conditional upon the prance delivered relative to the size of the affected person and on the leak across the nasal cannula.20,21,22

       continuous fine airway power, or extra particularly, nasal continuous positive airway pressure (NCPAP), has been shown to help scientific scores, lessen respiratory expense and help air stream in toddlers with bronchiolitis or asthma.23,24 dote PEFP, besides the fact that children, NCPAP is not typically well tolerated by artery of infants and youngsters.25 toddlers and youngsters with more huge respiratory distress or with apnea require endotracheal intubation and mechanical ventilation to befriend oxygenation and ventilation. a trademark of respiratory failure and impending respiratory arrest is the stressed, agitated baby in respiratory distress who vulgar at once turns into compliant. This may additionally point out that the affected person is drained and/or severely hypercapnic.

    Beta-2 Agonists

       short-performing beta-2 agonists (SABAs), similar to albuterol and levalbuterol, delivered with the aid of small-volume nebulizer, are the treatment of choice for babies with acute exacerbation of asthma. The proof aiding their expend in infants with wheezing secondary to bronchiolitis is less conclusive; despite the fact, there's adequate medical overlap between bronchial asthma and bronchiolitis that both can not be unusual on physical examination findings by myself. therefore, for the paramedic working in the prehospital environment, management of the child or infant providing with wheezing of unknown etiology may noiseless involve the expend of SABAs.

    Beta-agonists set off beta-2 receptors in the lungs, leading to leisure of bronchial light muscle, bronchodilation and better airflow.

       Epinephrine 1:a thousand and terbutaline, administered subcutaneously, can furthermore be utilized in average to severe exacerbations of asthma. due to its profound cardiovascular effects, epinephrine is frequently reserved for those newborn and infant sufferers in reasonable to extreme asthma; it isn't advised in those pediatric patients with comorbidities (e.g., congenital heart sickness) that may well be advanced with the aid of the extreme cardiac stimulation that accompanies its use.

    Anticholinergics

       Anticholinergics inhibit muscarinic cholinergic receptors in the airway, decreasing the intrinsic vagal tone latest and leading to bronchodilation. Ipratropium bromide (IB) is an anticholinergic close in the prehospital environment. The onset of motion of IB is long, and clinical advantages will furthermore be delayed for as much as 60 minutes. regardless of the delayed onset of motion, studies indulge in shown that the expend of SABAs with IB is more advantageous in reversing bronchoconstriction than using SABAs by myself.26,27 It isn't individual to indulge in prehospital protocols that permit for administration of each medicinal drugs, which are placed prerogative into a small-extent nebulizer and administered at the same time as.

    Corticosteroids

       while corticosteroids are prevalent within the treatment of qualify to extreme bronchial asthma, their expend in bronchiolitis is limited. They don't look to be considered a typical of care for the management of bronchiolitis (however they are used), and aren't advised to be used in up to now suitable children with RSV.28 Corticosteroids are used to reduce the inflammation and edema linked to both acute exacerbation and ceaseless bronchial asthma, and are most generally administered by the expend of IV within the prehospital atmosphere. dote anticholinergics, there's a delayed onset of motion (as much as a number of hours), so the advantages may additionally now not be clinically lucid within the prehospital atmosphere, however there's an competencies to early administration. An example of an intravenous corticosteroid often utilized by means of EMS is methylprednisolone (Solu-Medrol).

    Magnesium Sulfate

       there's enough proof to suggest that IV or inhaled magnesium sulfate may furthermore benefit each adults and children with severe bronchial asthma.29,30 Magnesium acts as a spotless muscle relaxant and promotes bronchodilation, and the administration of magnesium has been proven to outcomes in diminished airway resistance and enhanced ventilation in adults. latest strategies posted in the country wide heart, Lung, and Blood Institute, countrywide Institutes of health's national asthma training and Prevention application professional Panel file three, guidelines for the analysis and management of bronchial asthma don't advocate a selected dose or route for magnesium within the newborn or pediatric inhabitants.

    table 1: asthma in the Pediatric affected person assessment device

      mildMODERATE excessiveFeeding standard much less terrible SaO2 on play air >/=ninety five% ninety%-ninety five% <ninety% degree of dyspnea Dyspnea only with endeavor Dyspnea interferes with or limits typical exercise Dyspnea at leisure, interferes with dialog Retractions None/minimalIntercostal Suprasternal accessory muscle use None huge excessiveWheezing None/minimal terminate expiratory moderate, vulgar the artery through expiratory severe inspiratory and/or expiratory wheezing audible devoid of stethoscope Presence of lung sounds Full and equal breath sounds bilaterally lowered breath sounds, bilateral or localized numerous areas of reduced breath sounds intellectual prestigeAlert Alert/stressed restless/lethargic Inspiratory/expiratory ratio 1:1 1:2 Exceeds 1:2

    This continuing training activity is authorised by artery of EMS World journal, an organization approved through the continuing training Coordinating Board for Emergency scientific functions (CECBEMS), for 1.5 CEUs. To earn your credits, Go to www.rapidce.com, or to print and mail a replica, down load the test prerogative here.

    References

    1. Henrickson KJ, Hoover S, Kehl KS, Hua W. countrywide sickness affliction of respiratory viruses detected in tiny ones through polymerase chain response. Pediatr Infect Dis J 23(Suppl):eleven, 2004.2. centers for ailment ply and Prevention. Respiratory Sycytial Virus an infection: an infection and Incidence. www.cdc.gov/rsv/about/infection.html. updated January 25, 2010.3. chief S, Kohlhase k. concurrent trends in severe respiratory syncytial virus (RSV) among US infants, 1997 to 2000. J Pediatr 143(suppl):S127 -S132, 2003.four. Mullins JA, Lamonte AC, Bresee JS, Anderson LJ. huge variability in community respiratory syncytial virus season timing. Pediatr Infect Dis J 22:857-886, 2003.5. Thompson WW, Shay DK, Weintraub E, et al. Mortality linked to influenza and respiratory syncytial virus within the united states. JAMA 289(2):179-186, Jan eight 2003.6. corridor CB, Weinberg GA, Iwane MK, et al. The affliction of respiratory syncytial virus an infection in puerile babies. N Engl J Med 360(6):588-598, Feb 5, 2009.7. Purcell okay, Fergie J. Driscoll toddlers's hospital respiratory syncytial virus database: risk components, remedy and sanatorium direction in 3308 infants and younger infants, 1991 to 2002. Pediatr Infect Dis J 23:418-423, 2004.8. Welliver RC. overview of epidemiology and clinical desultory factors for severe respiratory syncytial virus (RSV) an infection. J Pediatr 143:S112-S117, 2003.9. Navas L, Wang E, de Carvalho V, et al. superior outcome of respiratory syncytial virus infections in a high-chance hospitalized inhabitants of Canadian toddlers. J Pediatr121:348-354, 1992.10. López-Alarcón M, Villalpando S, Fajardo A. Breastfeeding lowers the frequency and period of acute respiratory an infection and diarrhea in toddlers under six months of age. J Nutr 127(3):436 -443, 1997.eleven. Wright AL, Bauer M, Naylor A, et al. expanding breastfeeding fees to in the reduction of newborn sickness on the neighborhood stage. Pediatrics a hundred and one(5):837-844, 1998.12. facilities for disease manage and Prevention. Respiratory syncytial virus an infection (RSV).13. facilities for ailment ply and Prevention. 2007 national health Interview Survey Public expend facts File. www.cdc.gov.14. facilities for ailment ply and Prevention. countrywide Surveillance for bronchial asthma-u.s., 1980-2004. www.cdc.gov/mmwr/preview/mmwrhtml/ss5608a1.htm.15. Akinbami L. The status of childhood bronchial asthma, united states, 1980-2005. Adv statistics 381:1, 2006.16. Geelhoed GC, Landau LI, Le Souef PN. contrast of SaO2 as a predictor of outcomes in 280 toddlers featuring with acute asthma. Ann Emerg Med 23:1236, 1994.17. Gorelick MH, Stevens MW, Schultz TR, Scribano PV. efficiency of a novel scientific rating, the Pediatric bronchial asthma Severity rating (pass), within the evaluation of acute bronchial asthma. Acad Emerg Med eleven:10, 200418. Rodrigo G, Pollack C, Rodrigo C, Rowe BH. Heliox for nonintubated acute asthma patients. Cochrane Database Systematic stories 4:CD002884, 2006.19. de Klerk A. Humidified excessive-circulate nasal cannula: Is it the brand new and improved CPAP? Adv Neonatal care eight:ninety eight-106, 2008.20. Kubicka ZJ, Limauro J, Darnell RA. Heated humidified high-movement nasal cannula therapy: Yet yet another approach to carry continuous fine airway power? Pediatrics 121: eighty two-88, 2008.21. Lampland AL, Plumm B, Meyers PA, et al. Observational descry at of humidified high-circulation nasal cannula in comparison with nasal ceaseless nice airway force. J Pediatr 154:177-182, 2009.22. Sreenan C, Lemke RP, Hudson-Mason A, Osiovich H. high-flow nasal cannulae in the administration of apnea of prematurity: A evaluation with common nasal ceaseless wonderful airway power. Pediatrics 107:1081-1083, 2001.23. Thia LP, McKenzie SA, Blyth TP, et al. Randomised managed visitation of nasal continuous wonderful airway power in bronchiolitis. Arch Dis newborn ninety three:637-638, 2008.24. Larrar S, Essouri S, Durand P, et al. results of nasal continuous elevated trait airway compel air stream in children with severe acute bronchiolitis. Archives de Pediatrie 13:1397-1403, 2006.25. Yong SC, Chen SJ, Boo new york. Incidence of nasal trauma linked to nasal prong versus nasal masks vulgar over ceaseless efficient airway compel treatment in very low birthweight tiny ones: A randomized control descry at. Arch Dis infant Fetal Neonatal Ed 90:F480-F483, 2005.26. Schuh S, et al. Efficacy of time-honored nebulized ipratropium bromide brought to universal high-dose albuterol therapy in severe childhood asthma. J Pediatr, 1995.27. Qureshi F, Pestian J, Davis P, Zaritsky A. consequence of nebulized ipratropium on the hospitalization costs of toddlers with asthma. N Engl J Med 339:1030, 1998.28. Watts KD, Goodman DM. Wheezing, Bronchiolitis, and Bronchitis. In: Kliegman: Nelson Textbook of Pediatrics, 18th ed., Saunders, 2007.29. Rowe BH, et al. Intravenous magnesium sulfate remedy for acute bronchial asthma within the emergency department: a scientific evaluate of the literature. Ann Emerg Med 36:181, 2000.30. Cheuk DK, Chau TC, Lee SL. A meta-evaluation on intravenous magnesium sulphate for treating acute bronchial asthma. Arch Dis newborn ninety:74, 2005.

       Scott R. Snyder, BS, NREMT-P, is the EMS education supervisor for the San Francisco Paramedic affiliation in San Francisco, CA, where he is answerable for the original and carrying on with schooling of EMTs and paramedics. Contact him at scottrsnyder@me.com.

    Michael Santiago, DO, EMT-P, is an attending physician within the ED and director of prehospital care at Rochester commonplace health focus in Rochester, new york. Contact him at ems@rochestergeneral.org.

       Kevin T. Collopy, BA, CCEMT-P, NREMT-P, WEMT, is an educator, e-studying content material developer and creator of numerous articles and textbook chapters. he's furthermore a flight paramedic for Spirit Ministry clinical Transportation in imperative Wisconsin and a lead instructor for desert scientific associates. Contact him at kcollopy@colgatealumni.org.


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