EMT By-Complaint Quick Pages

In depth

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Chest pain: the 12-lead and the drugs

NASEMSO calls the 12-lead the primary tool for finding a STEMI and asks EMS to acquire it within 10 minutes of contact for every patient with possible ACS symptoms, to transmit it or have it screened, to repeat it if the first is not diagnostic and symptoms continue, and to send every tracing to the hospital. Interpretation is above EMT scope; acquisition and transmission are not.

• Placement: V4 in the 5th intercostal space at the midclavicular line, V5 midway between V4 and V6, and V4 to V6 on one horizontal line. Leads placed too low under the breast hid ischemia in a published case (Derkenne 2017). V1 and V2 sit in the 4th intercostal space either side of the sternum (classic teaching). Do not use breast tissue as a landmark.
• Atypical presentations (vague complaints, dyspnea, nausea, weakness) are more common in women, older adults and people with diabetes (NASEMSO); ACEP adds back and jaw pain in women.
• Aspirin: chewable, non-enteric-coated, 162-325 mg. NASEMSO defers aspirin and nitrates for chest pain that is likely non-cardiac; for a tearing pain with an arm pressure difference, ask medical direction before aspirin.
• Nitroglycerin: the patient's own 0.4 mg SL, repeated per protocol only while SBP stays over 100; never within 48 h of sildenafil, vardenafil or tadalafil, or with IV epoprostenol or treprostinil (NASEMSO). See prehospital-stroke-stemi for the right-ventricular infarct caution.
• Oxygen when dyspneic, hypoxemic or in heart failure, to 94-98%.

Shortness of breath: CHF and CPAP at the EMT level

• Fluid overload is suggested by JVD, crackles, peripheral edema and a history of heart failure, diuretics, missed dialysis or hypertension (NASEMSO). Edema is dependent: feet and legs in a walking patient, buttocks, genitals and back of the thighs in a bedbound one (Merck), so a bedbound patient can be overloaded with normal ankles.
• Many states let EMTs apply CPAP under protocol. NASEMSO: coach and reassure the patient, keep the mask sealed until the hospital device is ready (breaking the seal causes rapid collapse of lung units), and take it off and escalate if mental status worsens or the patient vomits.
• Treat anxiety on CPAP as hypoxia or poor ventilation first; NASEMSO advises against routine sedation for it.
• Pulmonary edema has other causes: opioid overdose, high altitude, kidney failure or missed dialysis, and toxic gases.

Syncope, aorta, clots and the LVAD patient

• NASEMSO high-risk causes of syncope: MI, aortic stenosis, hypertrophic cardiomyopathy (young patient, exertion), PE, aortic dissection, arrhythmia; stroke or bleed in the head; ruptured ectopic pregnancy, GI bleeding, aortic rupture. Syncope during exercise often means a dangerous cardiac cause.
• Collect what bystanders saw: shaking, color, pulse, how long, what ended it. Brief jerking is common in syncope; a long confused period favors seizure.
• Dissection (MedlinePlus): sudden sharp, tearing or ripping chest pain moving to the back, fainting, sweating, a pressure difference between the arms or between arms and legs, stroke signs. AAA (NASEMSO): unequal femoral or leg pulses, a pulsatile mass, back or chest pain, known aneurysm. NASEMSO advises considering a specialty surgical center when either is suspected. Flank pain from a leaking AAA can mimic a kidney stone (classic teaching; NASEMSO lists back pain with unequal pulses or a pulsatile mass as the aortic warning).
• DVT risks (MedlinePlus): recent surgery, long travel or bed rest, pregnancy or recent birth, age over 60, cancer, smoking, estrogen. Keeping the limb still and not massaging it is classic teaching.
• LVAD (NASEMSO): flow is not pulsatile, so a missing pulse, a failed cuff or a poor SpO2 trace is expected; the MAP, if a cuff reads one, is usually accurate. Low battery is the commonest alarm. Defibrillation and a 12-lead need no disconnection. CPR only if the pump has stopped, restart attempts failed and there are no signs of life, decided with the companion and VAD coordinator. Functioning pump with a non-cardiac problem: the hospital right for that problem, without touching the device; a pump or heart problem: the implant center if time allows.

Seizures, confusion and glucose

• NASEMSO treats any seizure still going on arrival, or a new seizure over 5 minutes, and asks the EMT to record onset, focal start and the direction of eye deviation. ACEP adds: call 911 for a first seizure, one lasting 5 minutes or repeating, injury, pregnancy, diabetes, or no return to alertness.
• Fever with a seizure under 6 months or over 6 years is not a simple febrile seizure; think meningitis (NASEMSO).
• Pain stimulus for GCS: nail-bed pressure or a trapezius pinch is standard GCS teaching (not in NASEMSO); NASEMSO discourages the sternal rub and says AVPU or the GCS motor score is often as useful as the full score.
• Overdose: AHA 2025 estimates that 1 in 6 to 1 in 3 out-of-hospital arrests involve overdose, mostly opioids. Ventilate first; give naloxone in the smallest effective dose, since sudden withdrawal can make the patient agitated (NASEMSO).
• Insulin pump with altered mental status: stop, disconnect or remove it at the site if the patient cannot take oral glucose or ALS is unavailable; leave it running if the patient can eat or ALS can give dextrose (NASEMSO).
• Recheck glucose if mental status has not returned to normal. Sulfonylureas (glipizide, glyburide) last 12-60 h, so a corrected patient can drop again in the ambulance.
• NASEMSO release after corrected hypoglycemia needs all of: repeat glucose over 80 mg/dL; diabetes treated with insulin or metformin, not a sulfonylurea; normal mental status with no focal signs; a carbohydrate meal now; a refusal the crew agrees with; a reliable adult staying; no chest pain, dyspnea, seizure or intoxication; and a clear cause such as a missed meal. A hypoglycemic seizure is always transported.
• DKA (ADA consensus 2024): glucose 200 mg/dL or more or known diabetes, plus ketones and acidosis; about 10% are euglycemic (under 200), mostly linked with SGLT2 inhibitors after fasting or illness. NASEMSO gives fluids for glucose over 250 with dehydration, vomiting, belly pain or confusion, which is ALS care.

Abdomen, early pregnancy and childbirth

• NASEMSO life threats: ischemic or perforated bowel (severe tenderness, pain on movement, fever, bloody stool, no stool or gas, distention); AAA; ruptured ectopic; appendicitis (right lower quadrant tenderness, Rovsing sign, fever, vomiting, poor appetite); cholecystitis; pyelonephritis (fever, urinary symptoms, flank pain). ACEP: pain that is sudden, severe or not easing within 30 minutes needs emergency care.
• Nothing by mouth for acute abdominal pain is classic teaching, since surgery may follow.
• Consider pregnancy in any female aged 10 to 60 (NASEMSO). Ectopic risk (MedlinePlus): prior ectopic, tubal surgery or scarring, pregnancy with an IUD. Rupture: sudden severe pain, fainting, low BP, shoulder pain. Shock can come with minimal bleeding.
• Do not put a hand or fingers into the vagina of a bleeding patient except for a prolapsed cord or a stuck breech; save all passed tissue; third trimester and hypotensive: left side or uterus pushed left (NASEMSO).
• Delivery (NASEMSO): control the head; check for a nuchal cord and slip it over the head, or over the shoulders and deliver through the loop, or double clamp and cut; do not routinely suction; clamp the cord after 1 minute; never pull the cord; the placenta usually comes in 5-15 minutes; massage the fundus. Plan resources by the number of patients: twins mean a second unit before the first birth, and NASEMSO transports between deliveries if twins are expected. Complications and postpartum bleeding: ob-emergencies.

Behavioral emergencies, restraint and assault

• NASEMSO excludes agitation caused by head injury, hypoglycemia or hypoxia from its behavioral guideline: check glucose, SpO2 and temperature first. Hypoglycemic and hypoxic patients can be violent.
• De-escalation: verbal reassurance before any restraint, family help if it calms the patient. One calm speaker, simple honest words and offered choices are classic teaching.
• Prohibited (NASEMSO): prone transport, hobbling or hog-tying, sandwiching between boards, anything that compresses the neck or airway. Straps must never limit chest wall movement.
• Physical restraint: soft devices that open without a key, all four limbs to the stretcher frame, no multiple knots; seated position reduces aspiration and strength; a resisting patient has one arm above the head and one below the waist, legs secured separately. Monitor airway, breathing, circulation, mental status and limb perfusion continuously and document each check.
• Handcuffs from police: replace with a device that needs no key, or have the officer with the key ride in the patient compartment (NASEMSO lists four options).
• Agitation can end in sudden death from positional asphyxia or exhaustion with acidosis; restrained patients usually also need ALS sedation (NASEMSO).
• Sexual assault: treat injuries and avoid investigating details (NASEMSO). MedlinePlus advises no showering, bathing, hand washing, nail cutting, changing clothes or tooth brushing before care, to keep evidence. Bagging clothing in paper, not plastic, and quoting the patient's words are classic teaching. Follow state reporting rules.

Bites, altitude and infection

• Snakebite (Merck, NASEMSO, CDC/NIOSH): move out of striking range; immobilize the limb loosely at about heart level; remove rings and watches before swelling; mark the leading edge of swelling with the time. Do not use a tourniquet, a tight elastic wrap, cutting, suction or ice. Dead snakes and severed heads can still bite: photograph from a distance, never bag one by hand. Rattlesnake, copperhead, coral snake, black widow and bark scorpion have US antivenoms, so choose a hospital that has it.
• Coral snake: little local swelling, but weakness and breathing failure can appear about 12 hours later; transport and observe for at least 12 hours even if well (Merck). Merck notes pressure immobilization may suit coral snake bites only; follow protocol and ask medical direction.
• Altitude (NASEMSO, Merck): descent is the definitive treatment; even 500-1,000 ft helps (NASEMSO), Merck advises 500-1,000 m for severe AMS. Oxygen to 90% or more. HAPE is the deadliest form and may need positive pressure ventilation. ALS drugs (dexamethasone for HACE, nifedipine for HAPE) and portable hyperbaric bags only bridge to descent.
• Meningococcal disease (CDC) can kill within hours and may look like flu first; septicemia brings cold hands and feet, fast breathing, severe aches and, late, a dark purple rash. CDC uses droplet precautions until 24 h after effective antibiotics.

Infants: SIDS, BRUE and button batteries

• SUID is the sudden, unexpected death of a baby under 1 year, often during sleep; about 3,400 US babies died this way in 2024 (CDC). Resuscitate unless death is obvious (rigor mortis or dependent lividity in a medical arrest, NASEMSO).
• Record the scene neutrally: position found, bedding, sleep surface, who shared it. Safe to Sleep risks: stomach or side sleeping, soft or inclined surfaces, loose bedding, bed sharing, smoke, overheating.
• BRUE (NASEMSO): under 1 year, under 1 minute, fully resolved, with a change in breathing, color, tone or responsiveness. Any abnormal finding now (fever, vomiting, labored breathing, injury) means it is not a BRUE. Transport every infant even if well. High risk (NASEMSO 2022 list): under 2 months, born at 32 weeks or less, more than one event, over 1 minute, or CPR given; consider a pediatric critical care center. Other lists, such as the 2016 AAP BRUE guideline, use different age and gestation cutoffs, so follow your protocol. Avoid the words SIDS or BRUE with parents.
• Button battery (Poison Control): children 12 or under need an immediate x-ray without waiting for symptoms, since an esophageal battery can burn in 2 hours. For a child 12 months or older within 12 hours who can swallow, honey 10 mL every 10 minutes up to 6 doses slows injury but never delays the ED. Nothing else by mouth; no induced vomiting. A magnet swallowed with it rules out home care. Poison Control: 1-800-222-1222.

Exam pearls

• A calm, pink diabetic woman with weakness and nausea can be having an MI: 12-lead, aspirin, transport.
• Tearing pain with an arm pressure difference: think dissection and hold aspirin.
• Older patient, flank pain like a stone, fainting, low BP: leaking AAA until proven otherwise.
• LVAD patient alert and pink with no pulse: perfusing; treat the actual complaint.
• Seizure: protect, time, nothing in the mouth; over 5 minutes is status.
• Oral glucose needs an awake patient who can swallow; a sulfonylurea low means transport.
• Restraint: never prone, never hobbled, never across the chest.
• Snakebite: still, splinted, rings off, marked; no tourniquet, ice or cutting.
• HAPE or HACE: go down.
• Swallowed button battery: x-ray now, even with no symptoms.