Adult Cardiac Arrest Shout for Help/Activate Emergency Response Legend EMT A EMT-A A P EMT-P P M MC Order M Yes No 2 9 3 Shock 4 A CPR 2 min * IV/IO access A No 5 Yes Shock P CPR 2 min *Epinephrine every 3-5 min *Consider advanced airway, capnography P P CPR 2 min *IV/IO access *Epinephrine every 3-5 min *Consider advanced airway, capnography P 10 No Yes 7 Yes P CPR 2 min *Amiodarone *Treat reversible causes P Shock 11 P CPR 2 min *Amiodarone *Treat reversible causes P No Yes
Cardiogenic Shock History: Cardiac ischemia (MI, CHF) Medications Allergic reaction Signs/Symptoms: Restlessness, confusion Weakness, dizziness Weak, pulse Pale, cook, clammy skin Delayed capillary refill Hypotension & pulmonary edema on exam Differential: Dysrhythmias Vasovagal Pearls: Be cautious of impending pulmonary edema Hypotension can be defined as systolic pressure of less than 100 Consider performing orthostatic vital signs on patients in nontrauma situations if suspected blood or fluid loss fluid bolus and reevaluate lung sounds Meds: Dopamine 5 – 20 mcg/kg/prn titrate SBP>100 Epinephrine mix 1mg 1:1000 in 250 NS titrate to SBP>100 drip 2-10 mcg/min Legend EMT A EMT-A A P EMT-P P M MC Order M A Obtain IV Access A A Fluid Bolus NS A P 12 lead ECG P P Dopamine Or Epinephrine P M Contact Medical Control M Adult Bradycardia Legend EMT A EMT-A A P EMT-P P M MC Order M (With Pulse)
Pearls: Barotrauma is caused by the over-ventilation of Reactive Airway Patients Consider NIPPV if available Meds: Albuterol- 2.5 mg SVN Atrovent- 0.5 mg SVN Epinephrine- 1:1,000 0.1-03ml IM Magnesium- 2 g/100mg IV over 10-15 min Methylprednisolone- 125 mg IV p Magnesium p M Contact Medical Control M Pulmonary Edema History: • Congestive Heart Failure • Past Medical history • Medications (Digoxin, Lasix) • Viagra, Levitra, Cialis • Cardiac history – past Myocardial Infarction Signs/Symptoms: • Respiratory distress, rales • Apprehension, Orthopnea • Jugular vein distention • Pink, frothy sputum • Peripheral edema, Diaphoresis • Hypotension, shock • Chest pain Differential: • Myocardial Infarction • Congestive Heart Failure • Asthma • Anaphylaxis • Aspiration • COPD • Pleural effusion • Pneumonia • Pulmonary Embolus • Pericardial Tamponade Mild Moderate- able to speak sentences, crackles base only, 0₂ sat ≥ 92% Severe- respiratory distress, crackles throughout, 0₂ sat <92% Near Death- Decreased LOC, cyanosis, dropping sats, ineffective respiratory drive Legend EMT A EMT-A A P EMT-P P M MC Order M Universal Patient Care Protocol A Obtain IV Access A P ECG / 12 Lead P P Consider Capnography P A Nitroglycerin if SBP> 100 A P And / or Furosemide P
Treat per Bradycardia Protocol P Consider Dopamine or Ephinephrine P P Midazolam or Lorazepam prn p M Contact Medical Control M Notes: *Sedate as needed Meds: Lorazepam 1-2 mg IV/IN/IM May repeat PRN Midazolam 2.5-10mg IV/IO over 2 minutes Dopamine IV Start at 5-20mcg/kg/min and titrate to SBP of 90-100 mmHg Epinephrine mix 1mg 1:1000 in 250mL NS, titrate 2-10 mcg/min for SBP> 100mmHg Abdominal Pain History: Age Past Medical / Surgical history Medications Onset Palliation / Provocation Quality (crampy, constant, sharp, dull, etc.) Region / Radiation / Referred Severity (1-10) Time (duration / repetition) Fever Last meal eaten Last bowel movement / emesis Menstrual history (pregnancy) Pain (location / migration) Tenderness Nausea Vomiting Diarrhea Dysuria Constipation Vaginal bleeding / discharge Pregnancy Differential: AAA Ectopic pregnancy Bowel obstruction Cardiac Pregnancy (ectopic?) GI Bleed Appendicitis Cholecystitis Pancreatitis Kidney stones Universal Patient Care Protocol of shock Yes No A Obtain IV Access A Legend EMT
Pearls: · Signs of shock include SBP <90 · The shorter the onset from contact to symptoms, the more severe the reaction. · A single dose of Epinephrine may not reverse the effects of Anaphylaxis. Administer additional as needed. · Obtain ECG tracing during pharmacological administrations. · EMT may assist with patients own MDI Meds: Epinephrine 0.1=0.3 cc IM; 0.1-0.3mg SQ, SL Repeat Epinephrine PRN Diphenhydramine 25-50 mg PO/IM/IV Albuterol 2.5.mg Pt.’s MDI per prescription SVN Albuterol 2.5 mg & Atrovent 0.5 mg SVN Methylprednisolone 125 mg IV History: diabetic, medic alert tag Drugs, drug paraphernalia Report of illicit drug use or toxic ingestion Past Medical history Medications History of Trauma GI History Syncope Signs/Symptoms: Decreased mental status Change in baseline mental status Bizarre behavior Hypoglycemia (cool, diaphoretic skin) Hyperglycemia (warm dry skin; fruity breath, Kussmal resps: signs of dehydration) Diabetic Syncope Differential: Head Trauma CNS (stroke, tumor, seizure, infection Cardiac (MI, CHF) Thyroid (hyper/hypo) Shock Diabetes (Hyper/hypoglycemia) Toxicologic Acidosis / Alkalosis Environmental exposure Pulmonary (Hypoxia) Electrolyte abnormality Psychiatric disorder Syncope Altered Mental Status/Diabetic Emergency Legend EMT A EMT-A A P EMT-P P M MC Order M A Obtain IV access A Blood Glucose check A Normal Saline A Administer Oral Glucose A Normal Saline A Yes No P Thiamine P A Dextrose A A Naloxone prn A P Glucagon prn P
P ECG / 12 lead P Pearls: · Be aware of AMS as presenting sign of an environmental toxin or Haz-Mat exposure and protect personal safety. · It is safer to assume hypoglycemia than hyperglycemia if doubt exists. · Do not let alcohol confuse the clinical picture. Alcoholics frequently develop hypoglycemia · Low glucose (,60), normal glucose (60 – 120), high glucose (>250). · Consider Restraints if necessary for patient’s and/or personnel’s protection per the restraint procedure. Meds: Dextrose - D50% 25-50 g IV Glucagon- 1 mg IM Naloxone- 0.4-2 mg IV /IM (Start with lower dose) M Contact Medical Control M General Illness Fever / Nausea / Vomiting / Unknown History: · Age · Duration · Past medical history · Last Oral Intake · Medications · Immunocompromised · Blood emesis/diarrhea · Menstrual history · Environmental exposure Signs / Symptoms: ·Warm ·Sweaty · Flushed · Pain · Radiation · Abdominal distension · Chills/Rigors · Constipation · Diarrhea Differential: · Infections / Sepsis · Cancer / Tumors / Lymphomas · GI or Renal disorders · Heat Stroke · Medication or drug reaction · Vasculitis · Hyperthyroid · CNS disease/trauma · Myocardial infarction · Diabetic ketoacidosis · Gynecologic disease (ovarian cyst, PID) · Electrolyte abnormalities · Pregnancy · Psychologic Legend EMT A EMT-A A P EMT-P P M MC Order M Universal Patient Care Protocol Check Blood Glucose * Perform Cincinnati Stroke* Test A Obtain IV Access A A Fluid Bolus NS prn A P ECG / 12 lead prn P P Zofran or Diphenhydramine P Nausea/Vomiting? No P Acetaminophen P Consider Cooling measures No P Lorazepam P Consider
M Contact Medical Control M Notes: Individual’s normal body temperature differ with 98.6°F (37°C) being average. Generally a temperature over 100°F (38°C) is considered a fever. If shivering or hyperthermic give Lorazepam *If indicated **Contact Medical Control Meds: Acetaminophen- 500-1000mg PO Diphenhydramine- 25-50 mg IV/IM/PO Zofran- 4mg / 2ml IV/IM Overdose/Poisoning History: · Ingestion or suspected ingestion of a potentially toxic substance · Substance ingested, route, quantity · Time of ingestion · Reason (Suicidal, accidental, criminal) · Past medical history, medications Signs / Symptoms: ·Mental status changes · Hypotension / Hypertension · Decreased respiratory rate ∙ Tachycardia, dysrhythmias ∙ Seizures Differential: · Tricyclic antidepressants (TCAs) · Acetaminophen (Tylenol) · Depressants · Stimulants · Anticholinergic · Cardiac medications · Solvents, Alcohol, Cleaning agents · Insecticides (organophosphates) Poison Control 800-222-1222 Universal Patient Care Protocol Legend EMT A EMT-A A P EMT-P P M MC Order M <60 mg/dl Glucose Gel A Obtain IV Access A A Dextrose prn A Above 60 mg/dl No Yes A Obtain IV Access A M Contact Medical Control With nature of toxic exposure M A Respiratory depression? Naloxone PRN A Opiates Tricyclic Calcium Channel Blockers Beta Blockers Organophosphates CNS Stimulants P PRN Excess Airway Secretions? Atropine P P Sodium P P Calcium Chloride P P Lorazepam or Midazolam P A Naloxone A P Consider TCP P P Dopamine P P Dopamine P P Glucagon P Pearls: Do not rely on patient history of ingestion, especially in suicide attempts. Meds: Atropine 2mg IVP q 5-15 min. Max 20 mg Calcium Chloride- 500-1000 mg IV-Slowly Dextrose- 25-50 g IV PRN
P EMT-P P M MC Order M Position patient on side to prevent aspiration Blood Glucose A Dextrose A P Glucagon P A Obtain IV Access A Active Seizure Yes Yes P Consider IM Medications P P Lorazepam Or Midazolam P Assess for of seizure A Obtain IV access A Treat per appropriate protocol M Contact Medical Control M No Notes: • Be prepared to assist ventilations especially if a Benzodiazepine is used • If Evidence or suspicion of trauma, spine should be immobilized. ● In Status Epilepticus , If IV access not obtainable consider IO/IM Meds: Dextrose 12.5-25 g Glucagon 1 mg IV/IM Lorazepam 1-2mg IV/IM Midazolam 2.5-5 mg IV/IM Repeat seizures? Stroke History: · Previous CVA, TIA’s · Previous cardiac / vascular surgery · Associated diseases: Diabetes, Hypertension, CAD · Atrial fibrillation · Medications thinners) ∙ History of Trauma Signs / Symptoms: ·Altered Mental Status · Weakness / Paralysis · Blindness or other sensory loss ∙ Aphasia / Dysarthria ∙ Syncope · Vertigo / Dizziness · Vomiting · Headache · Seizures · Respiratory pattern change · Hypertension / hypotension Differential: · See Altered Mental Status · TIA (Transient Ischemic Attack) ∙ Hypoglycemia · Thrombotic stroke · Embolic stroke · Hemorrhagic stroke · Tumor · Trauma Universal Patient Care Protocol A Obtain IV or IO access A Glucose A Dextrose prn A If no IV access Glucagon ≤60 Cincinnati Stroke Test
Legend EMT A EMT-A A P EMT-P P M MC Order M Consider other appropriate protocol as needed Notes: • Onset of symptoms is defined as the last witnessed time the patient was symptom free (i.e. awakening with stroke symptoms would be defined as an onset time of the previous night when patient was symptom free) • The differential listed on the Altered Mental Status Protocol should also be considered. • Be alert for airway problems (swallowing difficulty, vomiting) • Hypoglycemia can present as a localized neurologic deficit, especially in the elderly. Meds: Dextrose 12.5-25 g IV PRN Glucagon 1 mg IV/IM Hyperglycemia can be very dangerous in ischemia P Prehospital Thrombolytic Screening P M Contact Medical Control “Code Stroke” M Eclampsia History: · Past Medical history · Prenatal care · Medications/drugs · Familial incidence · Primigravida ∙ Renal Disease Signs / Symptoms: ·Seizure · Hypertension · Tachycardia ∙ Edema ∙ Headache · Visual disturbance · Abdominal pain · Amnesia and/or other change in mental status Differential: · Hypertension · Multiple fetuses ∙ Gestational diabetes · Micro thrombi · Embolic stroke · Improper placental implantation Universal Patient Care Protocol Place in left lateral recumbent position A Obtain IV A
Maintain Spo₂≥90% GCS GCS ≥14 GCS 3-8 GCS 0-13 A Obtain Iv access (maintain SBP≥90 mm Hg A Treat S/S Per Appropriate Protocol A Obtain Iv access (maintain SBP≥90 mm Hg A P Intubate (RSI) prn P P Capnography P P Zofran Lorazepam Versed P No Yes P Capnography where available (maintain EtCO₂ 32-37 mmHg) P M Contact Medical Control M Trauma History: · Time and Mechanism of injury · Damage to structure or vehicle · Location in structure or vehicle · Others injured or dead · and details of MVA · Restraints / protective equipment · Past medical history · Medications Signs / Symptoms: ·Altered mental status or unconscious ·Hypotension or · Arrest Deformity Contusions Abrasions Punctures/Penetrations Burns Tenderness Lacerations Swelling Differential: · Chest Tension pneumothorax Chest Pericardial Tamponade Open wound Hemothorax · Intra-abdominal bleeding · fracture · Spine fracture / Cord injury · Extremity fracture / Dislocation · HEENT (Airway Obstruction) · Hypothermia Universal Patient Care Protocol Legend EMT A EMT-A A P EMT-P P M MC Order M Expose injuries Arrange transport according to the Washington State Trauma Triage Tool Spinal Immobilization Procedure
A Obtain Iv access A Signs of Shock? Yes No NS bolus: repeat as needed to prn Maintain BP of 80-90 systolic Reassess Airway/Ventilation P Advance Procedures as Needed P Reassess Airway/Ventilation Appropriate Protocol M Contact Medical Control M “Full” or “Modified” Trauma Code based on criteria – Providence Centralia Emergency Department Notes: · Exam: Mental Status, Skin, HEENT, Heart, Lung, Abdomen, Extremities, Back, Neuro · Mechanism is often a good indicator of serious injury ∙ Do not overlook the possibility of associated domestic violence or Legend EMT A EMT-A A P EMT-P P M MC Order M Pediatric BLS Healthcare Providers Unresponsive Not breathing or only gasping Send someone to activate emergency response system, get AED/defibrillator
Doses/Details CPR Quality * Push hard (≥⅓ of diameter of chest) and fast (at least 100/min) and allow complete chest recoil. * Minimize interruptions in compressions. *Avoid excessive ventilation * Rotate compressor every 2 minutes * If not advanced airway, 15:2 compression-ventilation If advanced airway, 8-10 breaths per minute with continuous chest compressions. Shock Energy for Defibrillation First shock 2 J/kg, second shock 4 J/kg, subsequent shocks ≥4 J/kg, maximum 10 J/kg or adult dose. Drug Therapy *Epinephrine IO/IV Dose 0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration). Repeat every 3-5 minutes. If no IO/IV access, may give endotracheal dose: 0.1mg/kg (0.1 mL/kg of 1:1000 concentration). *Amiodarone IO/IV Dose: 5 mg/kg bolus during cardiac arrest. May repeat up to 2 times for refractory VF/pulseless VT. Advanced Airway *Endotracheal intubation or supraglottic advanced airway. *Waveform Capnography or capnometry to confirm and monitor ET tube placement *Once advanced airway in place give 1 breath every 6-8 seconds (8-50 breaths per minute) Return of Spontaneous Circulation (ROSC) and blood pressure *Spontaneous arterial pressure waves with monitoring Reversible Causes -Hypovolemia -Hypoxia -Hydrogen ion (acidosis) -Hypoglycemia -Hypo-/hyperkalemia -Tension pneumothorax -Toxins -Thrombosis, pulmonary -Thrombosis, coronary -Trauma Pediatric Cardiac Arrest Shout for Help/Activate Emergency Response Legend EMT A EMT-A A P EMT-P P M MC Order M 1 Rhythm Shockable? Yes No Shock No Rhythm Shockable? Yes Shock Rhythm Shockable? Yes Rhythm Shockable? Yes Shock Rhythm Shockable? Yes posterior
BEHAVIORAL TOOL Face 0 No particular expression or smile 1 Occasional grimace or Frown, withdrawn, disinterested 2 Frequent to constant frown Clenched jaw, quivering chin Legs 0 Normal or relaxed position 1 Uneasy, restless, tense 2 Kicking, or legs drawn up Activity 0 Lying quietly, normal position, easily 1 Squirming, tense, shifting Back and forth 2 Arched, rigid or jerking Cry 0 No cry (awake or asleep) 1 Moans or whimpers; Occasional complaint 2 Cries steadily, screams, sobs, frequent complaints Consol ability 0 Content, relaxed 1 Reassured by “talking to” Hugging; distractible 2 Difficult to console Or comfort Relative percentage of body surface area (%BSA) affected by growth AGE Body Part 0 yr 1 yr 5 yr 10 yr 15 yr a = ½ of head 9 ½ 8 ½ 6 ½ 5 ½ 4 ½ b = ½ of 1 thigh 2 2/3 3 ¼ 4 4 ¼ 4 ½ c = ½ of 1 leg 2 ½ 2 ½ 2 3/4 3 3 ¼ Venous Access Intraosseous Pediatric Clinical Indications: Life threatening illness or injury in a child <6 years of age (72 months) after effective ventilation is established. Procedure:
or cardiac arrest patient. The CO₂ detector shall remain in place with the airway and monitored throughout the Prehospital care and transport. Any loss of CO₂ detection or change is to be documented and monitored as procedures are done to verify or correct the airway problem. Tube placement should be verified frequently and always with each patient move or loss of color change in the End-Tidal CO₂ detector. Document the procedure and the results on/with the Patient Care Report (PCR). Airway Intubation Orotracheal Clinical Indications: An unconscious patient without a gag reflex who is apneic or is demonstrating inadequate respiratory effort. Any patient medicated for rapid sequence intubation. Procedure: Prepare all equipment and have suction ready. Preoxygenate the patient. Medicate according to appropriate RSI procedure. Open the patient’s airway and holding the laryngoscope in the left hand, insert the blade into the right side the mouth and sweep the tongue to the left. Use the blade to lift the tongue and epiglottis (either directly with the straight blade or indirectly with the
Cardiac Defibrillation – Automated Clinical Indications: Non-traumatic cardiac arrest in patients older than 1 year of age Procedure: Confirm the cardiac arrest. Instruct partners or First Responders to initiate CPR while the defibrillator is set up. If defibrillation is underway by Frist Responders, continue resuscitation as outlined. Turn the defibrillator on and begin documentation. Attach the cables to the appropriate pads and then apply the pads to the patient’s chest in the proper position. Stop CPR and clear the patient prior to rhythm analysis. Analyze the patient’s rhythm by pushing the “analyze” button. Assertively state “CLEAR” and visualize that no one, including yourself, is in contact with the patient prior to defibrillation. Defibrillate if appropriate by depressing the button. The sequence of defibrillation charges is preprogrammed for monophasic defibrillators. Biphasic defibrillators will determine the correct joules accordingly. Immediately resume CPR for two minutes and then repeat steps 4 – 7 three more times if indicated. If “no shock advised” appears, perform CPR for two minutes and then reanalyze. Transport and continue treatment as indicated. Cardiac Defibrillation – Manual Clinical Indications: Cardiac arrest with ventricular fibrillation or pulseless ventricular tachycardia Procedure:
CPR and Child (Puberty and older) Child (I year old to puberty) Infant (Less than one year old) Establish Unresponsiveness Consider/call for additional resources Open the Airway Head tilt – chin lift (suspected spinal trauma: Jaw thrust) Check Breathing Open the airway- look, listen and feel. Take at least 5 seconds and no more than 10 seconds 2 breaths Give 2 breaths (1 second each) Check Pulse At least 5 seconds and no more than 10 seconds Carotid Pulse (if no pulse, chest compressions) Carotid Pulse (if no pulse or pulse < 60 bpm with signs of poor perfusion, chest compressions) Brachial Pulse (if no or pulse < 60 bpm with signs of poor perfusion, start compressions Start CPR • Compression location Center of breastbone between nipples Just below nipple line on breastbone • Compression depth Heel of 1 hand, other on top (or 1 hand for small patients) 2 fingers (thumb-encircling hands for 2- person) • Compression 1 ½ to 2 inches 1/3 to ½ depth of chest ● Compression rate 100 per minute • Compression- ventilation ratio 30:2 15:2 Discontinuation of CPR Do not attempt Resuscitation Determination of Field Death Procedure: ALS/BLS Treatment: CPR may be discontinued without Base Station contact and the patient determined to be dead for the following reasons ONLY IF: 1. Upon further examination it is determined that the patient meets the “Determination of Death Criteria” and CPR was initiated prior to this discovery. a. Field EMS providers may declare apparent death but may not pronounce death. Once CPR has been initiated and there is no favorable response, consider discontinuation of CPR as outlined. Category I – Obvious • Decomposition of body tissue • decapitation
Afrin (Oxymetazoline) Indications Pre-medication for nasal intubation, Epistaxis ADULT Dose: 2-3 puffs each nostril (on inhalation) Contraindications: Known hypersensitivity Pediatric Considerations: Children 12 require diluted concentration Precautions: Hyperthyroidism Cardiac Disease hypertension Diabetes mellitus Simultaneous use of MAOI and ephedrine may result in Hypertensive crisis Adverse Effects: Cardiovascular collapse Hypertension Palpitations Onset/Duration: Immediate onset, 30min – 4hour duration Classification: Vasoconstrictor Action: Local vasoconstriction of dilated arterioles causing reduction of blood flow and reduction of nasal congestion.
from on scene law enforcement, only if it does not interfere with patient care. 2. TASER® REMOVAL – Taser® barbed darts may be removed from the patient upon Law Enforcement request only when the eye, face, neck, breast or are not involved. If in custody the individual must be adequately restrain by law enforcement for the protection of EMS Personnel. The patient must be thoroughly assessd for other injuries or medical emergencies. If the patient does not have any other presenting injuries/illness, they may be left in the custody/care of law enforcement. Document in detail on MIR. Law Enforcement must sign refusal of transport. Ten Critical Steps for Handling Possible Bioterrorism Events 1 – Maintain an of suspicion In an otherwise healthy population, some associations are very suggestive, especially when seen in clusters, high numbers, or unusual presentations “Clustered” Symptoms Potential Bioagents Hemoptysis Plague Flaccid Paralysis Botulism Purpura Viral Hemorrhagic Fevers (VHF) Wide mediastinum Anthrax Centripetal rash Smallpox 2 – Protect yourself and your patients. Use appropriate personal protection equipment (PPE). Prophylaxis; vaccines, if available; or antibiotics, if risks are known 3 – Adequately assess the patient. Review and assess the patient’s history. Also, ask: • Are others ill? • Were there any unusual events? • Was there an uncontrolled food source or other environmental factor? • Was there vector exposure? • Has the patient been traveling? • What is the patient’s immunization record? Perform a physical examination with special attention to the respiratory system, nervous system skin condition and hematologic and vascular status. 4 – Decontaminate as appropriate. Do not use bleach on exposed people. Soap, and shampoo are perfectly adequate for all biological and most chemical agents. Chemically contaminated clothes should be removed and discarded safely. Biologically contaminated clothes can be laundered with soap, water and perhaps, bleach .
contracciones? Tee-eh-neh kohn-track-see-ohn-ehs? (Don’t) push. (No) Empuje. (Noh) Ehm-poo-heh How many minutes do the contractions last? ¿Cuántos minutes le duran las contracciones? Kwahn-tohs mee-noo-tohs leh doo-rahn lahs kohntrahk- see-ohn-ehs? MNEMONIC’s Patient Assessment: Newborn Assessment: Medical: A: Airway A: Appearance M: Morphine B: Breathing P: Rate O: Oxygen C: Circulation G: Grimace (facial actions) N: Nitrates D: Disability A: Activity A: Aspirin History: E: Expose R: Respirations S: and symptoms P: Progression of symptoms A: Allergies A: Associated chest pain M: Medications S: Sputum productions, speech, P: Pertinent past medical word sentences history T: Temperature, tiredness L: Last oral intake M: Medications the patient is E: Events leading to injury or currently taking illness E: Exercise/Exertion normally tolerated D: Diagnosis (previous) Trauma Assessment: Trauma: Scene safety V: Vitals T : Tracks, Tags, Tattoos Spinal Stabilization O: Oxygen I : Instability LOC M: Monitor C : Crepitus Airway I : IV/Information S : Scars Breathing T: Transport decision Oxygen H: History Circulation A: Allergies