REC modules Flashcards
(172 cards)
1
Q
Primary survey steps
A
Danger
1.1 Assess for danger and minimise hazards
1.2 Apply appropriate PPE
Response
2.1 Identify the client’s response and establish their conscious state
Send for help
3.1 Using appropriate resources and means available to you in the context of the scenario provided
Airway with C spine considerations
4.1 ask about and consider mechanism of injury
4.2 decide if the client needs c-spine immobilisation based on MOI, and complete if required
4.3 determine if client can talk
4.3.1 if no, look for signs of airway compromise (open mouth and inspect - foreign body, blood, vomit/secretions, soft tissue swelling, laryngospasm, depressed LOC)
4.3.2 if no, demonstrate basic airway manoeuvres to help maintain the airway (considering MOI and c-spine protection) - head-tilt chin-lift, jaw thrust, OPA, NPA.
Breathing
5.1 RR - look, listen, feel; fast, normal, slow
5.2 assess chest expansion - identify possible underlying pathology
5.2.1 symmetrical (pulmonary fibrosis, reducing lung elasticity and restricting overall chest expansion) or asymmetrical (pneumothorax, pneumonia and plural effusion can cause ipsilateral chest expansion)
5.3 listen for abnormalities such as bronchial breathing, quiet/reduced breath sounds, wheeze, stridor and coarse crackles
5.4 apply oxygen to all critically unwell clients during your initial assessment. Use a non-rebreathe mask with an O2 flow of 15L.
Circulation with haemorrhage control
6.1 Assess the client’s central pulse (femoral or carotid) for rate, rhythm and strength
6.2 Inspect the skin - pallor (?haemorrhage or poor perfusion), oedema
6.3 assess temp - warm, cool, clammy
6.4 measure CRT (>2s suggests poor peripheral perfusion (hypovolaemia) and so need to assess central CRT)
6.4 assess for obvious signs of haemorrhage
6.5 Interventions - IV cannulation (insert at least 1 wide-bore IV cannula 14G or 16G), management of haemorrhage e.g. replacement of intravascular volume with fluid and blood products as well as measures to slow or stop bleeding such as applying pressure to the wound
Disability with neurological and BGL management
7.1 Assess the LOC using AVPU
- Alert (fully alert but not necessarily orientated)
- verbal (responds when you talk to them e.g. words or grunts)
- pain (responds to painful stimulus e.g. supraorbital pressure)
- unresponsive (no eye, voice or motor responses to pain)
7.2 assess pupils - size, symmetry, reactivity, equal and reactive to light?
7.3 blood glucose
Exposure/environment control
8.1 prioritise dignity and conservation of body heat
8.2 inspect skin for rashes, bruising, signs of infection or any life-threatening injuries
Reassess DRSABCDE
9.1 start from start to identify any changes in clinical condition and assess the effectiveness of previous interventions
9.2 recognise and respond to deterioration immediately
2
Q
Secondary survey
A
F - full set of vitals, focused interventions, family presence
G - give comfort
H - history and head-to-toe
I - inspect posterior surfaces
J - jot everything down
3
Q
History taking mnemonic for acute incidents and gathering critical info
A
DeMIST
De - description of the incident/illness
M - mechanism of injury
I - injuries sustained
S - signs and symptoms
T - treatment given so far
4
Q
History taking mnemonic for secondary survey and gaining further info
A
AMPLE
A - allergies?
M- medications?
P - past illnesses?
L - last meal?
E - event (what happened, MOI, injuries, interventions and response)
5
Q
What things should you do when attending an emergency at the roadside?
A
- park vehicle safely and put on a fluoro vest or jacket
- if on a road, send someone to manage the traffic and bystanders and put out hazard signs
- check if clients are lying on hot/cold bitumen roads
6
Q
Common hazards for vehicle crash
A
- Car engine still running
- Hazardous materials from leaking chemicals/battery/petrol
- Un deployed airbags
- Live broken electricity cables
- Toxic gases
- Traffic hazards
- Risk of fire or explosion
- Unstable vehicles
- Hazardous materials
7
Q
Common hazards for environmental dangers
A
- Unstable surfaces
- Water, ice
- Weather extremes
8
Q
Common hazards for crime scene
A
- Potential violence
- Potentially violent client or bystanders
- Guard dogs, wild animals
9
Q
Hazards within structures
A
- Low-oxygen areas
- Toxic substances, fumes
- Risk of collapse
- Risk of fire or explosion
10
Q
How to assess response
A
- Ask “how are you going?” or “what’s your name?”
- If no response, pinch ear lobe or gently shake shoulders (with child tap shoulder, with baby tap foot)
- If still no response, presume unresponsive and move on to airway
11
Q
What are you assessing for in Airway?
A
- inhalation injury
- penetrating injury
- partial or complete obstruction
- severe allergic reaction
- altered consciousness
12
Q
Airway assessment - what are you looking and listening for?
A
Look:
- vomit, tongue or other objects or swelling obstructing the airway
- burned nasal hairs or soot around the nose or mouth
- head or neck trauma
- assess for altered mental status
- tongue swelling
Listen for:
- talking or hoarse voice
- abnormal airway sounds: gurgling, snoring, stridor, noisy breathing
- wheeze
13
Q
What are the 4 main airway interventions?
A
If required: Cervical stabilisation: manual inline stabilisation and collar
- Open airway: look at client’s position, use a basic manoeuvre - head tilt chin lift or jaw thrust
- Clear airway: if conscious - can clear it? If not use suction if available to remove foreign body. To clear the airway the mouth should be opened and the head turned slightly downwards to allow any obvious foreign material to drain. Loose dentures should be removed (well fitting ones can be left in place). If unresponsive a finger sweep can be used if solid material is visible in the airway.
- Establish and maintain airway: if you have opened the airway do you need to maintain it with a simple adjunct? OPA or NPA or advanced - LMA?
- Monitor the airway; simple rule of thumb, if you have to intervene to establish or maintain an airway then it remains a priority to monitor the situation meaning someone should stay with the client at all times.
14
Q
GCS assessment
A
EVM
Eye opening
4 - spontaneous
3 - sound
2 - pressure
1 - none
Verbal response
5 - oriented
4 - confused
3 - words, not coherent
2 - sounds but no words
1 - none
Motor response
6 - obeys command
5 - localising
4 - normal flexion
3 - abnormal flexion
2 - extension
1 - none
15
Q
Causes of life-threatening airway obstruction or compromise. Including upper airway (5), pulmonary (8), cardiac (8), toxic and metabolic (7), neurological (2), miscellaneous (7).
A
Upper airway
- foreign body obstruction
- Angioedema
- Anaphylaxis
- Infections of pharynx and neck
- Airway trauma
Pulmonary
- pulmonary embolism
- COPD exacerbation
- Asthma
- pneumothorax
- Pulmonary infection
- Noncardiogenic pulmonary oedema (ARDS)
- Direct pulmonary injury
- Pulmonary haemorrhage
Cardiac
- Acute coronary syndrome
- Acute HF
- Acute pulmonary oedema
- High output HF (precipitated by severe anaemia, pregnancy, thiamine deficiency, and thyrotoxicosis
- Cardiomyopathy
- cardiac arrhythmias (
- valvular dysfunction (aortic stenosis, mitral regurgitation)
- cardiac temponade (due to trauma, malignancy, uraemia, drugs or infection)
Toxic and metabolic - poisoning
- salicylate poisoning
- carbon monoxide poisoning
- toxin related metabolic acidosis
- diabetic ketoacidosis
- sepsis
- Anaemia
Neurological - Stroke
- Neuromuscular disease
Miscellaneous - lung cancer
- pleural effusion
- Intra abdominal processes (bowel obstruction, ruptured viscous, peritonitis)
- Ascites (distends to abdominal cavity, placing pressure on diaphragm)
- pregnancy
- Massive obesity
- Hyperventilation and anxiety
16
Q
How might a compromised airway present?
A
SOB, stridor, drooling, or obvious facial injuries such as swelling or bleeding.
17
Q
How do infants and children differ from adults?
A
Smaller physiological reserves and increased risk of dehydration, hypoglycaemia and hypothermia
18
Q
NPA:
- benefits/when to use
- when to avoid
- what to do prior to insertion
- what to do after insertion to keep secure
A
-may be more easily tolerated than an OPA
- can be used when the client’s jaw is clenched, when they are semiconscious and can not tolerate an OPA, or when there is oral trauma.
- avoid in the presence of maxillary or base skull fractures
- lubricate prior to insertion
- place safety pain across tube against nostril to prevent it from slipping down
18
Q
LMA:
- benefits
- requirement for use
A
- safe and swift airway which is more secure than an NPA With less dead space
- only use if no gag reflex
18
Q
Presentations considered at risk of spinal injury + Precautions you can take if you are by yourself
A
- Blunt multi-system trauma, e.g. pedestrian vs car, high impact falls/collisions
- Significant injury above the level of the clavicles
- Impaired LOC
- New neurological defect
- Midline cervical tenderness
May decide to apply temporary steps e.g. encouraging them to lie still and sandbags/rolled towels either side of the clients head.
18
Q
Paediatric airway management: 3 most common airway issues
A
- Obstruction from foreign body (complete or partial)
- Inflammation - stridor (partial), croup, anaphylaxis
- Apnoea
19
Q
Pregnant women and airway considerations:
3 Anatomical changes that start to occur from 12w gestation
A
- Large tongue
- Large breasts
- Mucosal and airway oedema of the oropharynx (incr. circulatory vol.)
20
Q
3 considerations for pregnant women regarding airway management
A
- A smaller airway adjunct may be required
- Anticipate a difficult airway in a heavily pregnant woman
- Be prepared
21
Q
What constitutes adequate breathing in an adult
A
- RR 12-20
- Regular pattern of inhalation and exhalation
- Adequate depth
- Bilaterally clear and equal lung sounds
- Regular and equal chest rise and fall
22
How to insert LMA
1. Deflate LMA fully
2. Lubricate
3. Jaw thrust client and insert
4. Inflate LMA
Small is for infant and child
Medium is for adult
Large is for large adult (>90-100kgs)
23
Hand ventilation rates: adult, child, asthma.
Adult: 8-10 breaths/min (squeeze, release, release, release… repeat)
Child: 16-20 bpm (squeeze, release, release… repeat)
Asthma: 6 bpm (use your watch)
24
When to not use assisted ventilation
Do not hand ventilate a patient who is breathing spontaneously if there spO2 is ok.
25
Breathing assessment: look, listen and feel - for what?
Look:
- movement of chest or upper abdo
- colour
- RR (note: >25 or increasing = pt may deteriorate suddenly)
- Depth of breaths
- Chest deformity, tracheal position, symmetry
Raised JVP (indicates possible acute severe asthma or tension pneumothorax)
- WOB
- visible injury (bleeding, bruising, flail chest, imprints, seatbelt marks, penetrating injuries, burns)
Listen:
- escape of air from nose and mouth
- auscultate lung fields (2 point only) to confirm breath sounds present and equal
- absence of breath sounds on one side? Dull sound with percussion to the same side?
- audible breath sounds (wheeze, grunt, rattling noises, etc.)
Feel:
- For movement of air at the mouth and nose
- soft tissue and bony wall integrity
- chest retractions
- flail segments (multiple adjacent ribs are broken in multiple places, separating a segment so a part of the chest wall moves independently)
- trachea feel midline?
- crepitus, cracking and popping with palpation
26
Circulatory assessment: look, listen and feel for what?
Look:
- colour of skin (blue, pink, mottled)
- state of veins (under filled or collapsed = hypovolaemia)
- capillary refill >3s
- sweating
- distended neck veins
- internal and external bleeding
- reduced consciousness
Feel:
- cool, moist extremities
- pulse rate, strength, regularity
- damp clothing (sweat/blood)
- tenderness or guarding of abdo
Listen:
- heart sounds (normal? Muffled? Difficult to hear?)
- is the audible HR correspond to the pulse rate?
27
Testing capillary return in adults and infants/small children.
How to do and record
Adult: press nail bed for 5s then release
Infant/child: press on chest or abdo for 5s then release
Record as > or < 2s (I.e. time to say “capillary return”)
28
Signs of end-organ hypoperfusion (hypovolaemic shock)
Decreased urine output, acidosis, altered LOC and elevated lactate level
29
4 Common causes of unconsciousness
- profound hypoxia
- hypercapnia
- cerebral hypoperfusion
- recent administration of sedatives or analgesic drugs
30
What scale can be used as a quick assessment of disability in addition to checking the pupil size, symmetry and reactivity
AVPU -
Alert
Responsive to voice
Responsive to pain
Completely unresponsive
31
What does a deteriorating AVPU require of the clinician?
Reassessment of the ABCs and interventions to maximise brain perfusion and oxygenation and avoid secondary brain injury
32
In the presence of other evidence for head injury (e.g. altered AVPU/GCS) a dilated pupil is usually a sign of what?
A haematoma on the same side
33
What 3 things make up Disability assessment?
1. LOC - using AVPU
2. Check pupils
3. Check BGL
34
Trauma clients are prone to hypothermia. What should be done after completing the primary survey?
Cover them in dry warm blankets
35
In trauma, why must the whole body including the back and genitals be examined?
- to exclude life-threatening injuries
- to check for signs that would indicate a contraindication to inserting an IUC
36
Reminder: the WHOLE body, including the following body parts, should be examined during Exposure/Environmental control to prevent life-threatening injuries to be missed.
However, most commonly the client is log rolled in the secondary survey so only do this during the primary if:
Back of head
Buttocks
Back
Perineum
Axillae
Skin folds
If the condition of the client requires it to be done during the primary survey (e.g. large amounts of blood underneath the client, disruption to sensation or movement) or there are enough people to do a log roll
37
Why should clients be re-evaluated at regular intervals?
Deterioration in a client’s clinical condition can be swift. If in doubt, repeat ABCDE
38
What is involved in a full set of vital signs?
- RR
- Pulse
- Temp
- manual BP (+/- both arms)
- BGL (if not done previously)
- GCS and neurovascular observations if appropriate
39
When should you do neurovascular observations?
On any client in which there is concern about the status of a limb. E.g. any pale, cool limb, any limb with an obvious fracture or deformity and any limb subject to trauma either blunt or penetrating
40
When should you include a GCS in secondary survey?
On any client with a suspected head injury or altered LOC. however it is easy to do a baseline GCS regardless of MOI.
41
What is one of the earliest signs of shock? What are other signs?
Earliest - narrowing pulse pressure (systolic minus diastolic)
- Incr. HR
- Decr. BP
- Incr. RR
- Decr. SpO2
- central cap refill of >2s
42
What should you do if at the secondary survey there is any deterioration in a parameter?
Re-assessment of ABC.
43
6 focused interventions of secondary survey
- pulse oximetry
- cardiac monitoring
- IDC (if not contraindicated)
- gastric tube (oro or naso)
- point of care pathology investigations (CG4, chem 8, troponin if indicated)
- lab specimens (urine, blood, swabs)
44
Physical pain relief measures
1. Splint fractures (back slabs, box splints, inflatable splints, bits of wood, pillows, rolled up paper)
2. Cool/hot packs, cold water
3. Dressings to open wounds/burns
4. Touch (stroking, massage)
5. TENS
Others (used in Resus phase):
- provide reassurance
- provide info and explanation
- presence of family/friends allowing choices and control where possible
- diversion/relaxation strategies (deep breathing, meditation, imagery, music)
45
6 pieces of info that should be included when obtaining a History
- MOI (for probable injuries)
- Use of protective devices (e.g. seat belt, helmet, child seat)
- Time elapsed before the client received medical attention
- Injuries sustained or suspected by first responders. Initial responsiveness, any loss of consciousness, any seizure activity. Vital signs. Treatment (received prior to arriving at the clinic and response to those)
- Medic alert bracelet or other medical identification. If you are at the client’s home, look for medication bottles.
- The client’s age and previous general state of health
46
Head to Toe assessment:
What are you looking, listening and feeling for?
Deformities, contusions, abrasions, rashes, punctures, pain, pulses, burns, tenderness/pain, lacerations/leaks, swelling, needle marks, loss of peripheral pulses, swelling, deformity, impaired movement.
47
Sequence of Head-to-Toe assessment.
Use PPE:
Head
Neck
Chest
Abdomen
Pelvic region and genitals
Upper and lower limbs
Followed by Inspection of posterior surfaces (log-roll)
48
What is included in Inspection of posterior surfaces?
What to do if there are insufficient people for a log roll?
- Look for abrasions, lacerations, bleeding or penetrating injuries.
- Listen to lung fields
- Palpate the spine for any tenderness or steps between the vertebrae
Slip a gloved hand under the back of the neck, the small of the back and under the knees. Check for blood on withdrawing the hands. Take care in the presence of glass or other sharp objects.
49
Jot it down: what should documentation include?
- Date and time
- Demographic information (name, DOB, address, gender, etc.)
- A short history from DeMIST and AMPLE
- Primary survey (findings and interventions)
- Secondary survey (findings and interventions)
50
What 3 things are address in the secondary survey?
- Injuries are detected and accurately documented
- Urgent treatments, such as covering wounds and splinting fractures are provided
- Appropriate analgesia, antibiotics or tetanus immunisations are ordered
51
3 things to do following the secondary survey
- Reassess ABCDE and vital signs, ongoing
- Continual monitoring
- priorities for further investigation and treatment may now be considered and a plan for definitive care established
52
Four basic principles for best outcomes in any emergency situation
1. Preparation:
- prepare for the worst; focus on communication, role delegation, working within your scope of practice and local protocols;
- early notification to a retrieval network
2. Assessment and response:
- Send for extra help early, consider calling for assistance from colleagues, ambulance backup, emergency services, or activating emergency response teams if available
- Always consider MOI
- Seek info from the scene, bystanders and emergency responders, and the client
- treat life-threatening injuries as you identify them
- Fluid resus to preserve vital organ function until bleeding can be controlled
- control temp to avoid hypothermia
Review and Monitor:
- Complete primary survey, quickly recap the info you have and reassess ABCDE
- At completion of the secondary survey, reassess ABCDE and vital signs (ongoing)
- Document and complete Early Warning Tools
Transfer to Definitive care
- effective and efficient communication is critical
53
Which body region is commonly injured in major trauma but is difficult to diagnose and manage?
Abdomen. A high index of suspicion should be maintain for any multi-trauma client.
54
What are 6 examples of blunt trauma?
MVAs, falls, assault, industrial accidents, blast force and sports-related injuries
55
What are patterns of injury influenced by? (4)
1. Age (>55 or a child <16)
2. MOI
3. Pregnancy
4. Significant comorbidity (e.g. 1+ of diabetes, epilepsy, cardiac failure, angina, acute MI, symptomatic chronic obstructive airway disease, renal/liver failure, chronic liver disease, congenital coagulopathy)
56
Which MOIs indicate the need for careful evaluation of the client (due to high energy transfer)? (10)
- Vehicle crash over 60km/h
- Major deformation of the vehicle, entrapment >30mins
- Fatal injury in the same vehicle, ejection from the vehicle
- Fall from over 3m
- Unrestrained child in a MV crash
- Any mechanism causing injuries to multiple body regions
- Cyclist or pedestrian hit by a vehicle at over 30km/h, driveway run-over injuries
- CHILDREN: drive-way run-over injuries
- CHILDREN: caustic ingestion - liquid or powder
- Motorcyclist accident
57
What injuries would you expect from a fall of 5m from a building by a 42y/o male?
- Spinal injuries
- Fractures to lower or upper extremities
- Fractured ribs
- Fractured pelvis/hip
- Pulmonary injuries (pneumothorax/haemothorax or pulmonary contusion)
- abdo injuries
58
Types of energy (5) related to MOI
Kinetic, thermal, electrical, chemical, nuclear.
59
Paediatric considerations with respect to MOI
- Different injuries due to size and anatomy
- Hit by car: abdo injuries vs fractured long bones (adult) due to height
- Blunt trauma: significant injury to underlying tissues w/out fracture (due to cartilaginous bones) vs fracture in adults. NB lack of # does not mean absence of injury, esp. in chest trauma
60
3 types of compressive forces involved in MVAs
1. Vehicle collides with an object
2. Occupant collides with the car interior
3. Internal organs/tissues of the occupant collide causing rupture, shearing and bruising
61
When approaching an MVA scene, what should you observe to provide cues that may indicate the MOI? What should you pay attention to? (5) With children, what should you pay attention to? (3)
- Approaching scene, observe any skid marks and the situation of the car. Use all senses to notice any hazards and any victims that have been ejected or thrown from the vehicle
- Pay attention to: speed of vehicle, point of impact, type of impact, position of vehicle, use/non-use of restraints
- Children: wearing protective equipment such as helmets, knee guards, etc? Correct helmet size? Correct size car restraint for age/weight?
62
Predictable injuries: restrained driver or front seat passenger in MVA
Clavicle, sternum, cardiac injuries, diaphragmatic rupture, bruising/laceration of the liver/spleen/pancreas, pelvic injuries and bruising of the lower abdo, breast and shoulder.
63
Predictable injuries: unrestrained driver or front seat passenger in MVA
Head injury, facial injuries, cervical spine injury, larynx, clavicle, sternum, abdominal injuries, cardiac contusion, pelvic and lower limb injuries
64
Adult pedestrian hit by car - potential injury sites
Patella, tibia, fibula
65
Potential injuries resulting from side impact of someone in car in MVA
- Head jerked laterally (towards side of impact)
- Fractured clavicle
- Flail chest
- Fractured femur
66
Potential injury sites of unrestrained driver in MVA
- Skull (windscreen)
- Mandible/maxilla orbit
- Cervical spine
- Heart (steering wheel)
- Sternum (steering wheel)
- Abdomen (liver, spleen)(steering wheel)
- Pelvis
- Femur
- Tibia and/or fibula
67
Potential injury sites of unrestrained passenger in front seat in MVA
- Skull
- Heart
- Sternum
- Abdo (liver, spleen)
- Pelvis
- Femur
- Tibia
- Fibula
68
What should you do prior to leaving the clinic to go to a scene? (3)
- Have the correct equipment and resources to attend the scene
- Have the ability to maintain effective communication e.g. phone or radio
- Notify someone of where you are going and give them a rough estimate of time to get there and your contact number e.g. a colleague or the police
69
3 things to consider at the scene
1. Where are you? (At side of a road, in someone’s house, in a clinic?)
2. What hazards might be present? Do you need to wait for the scene to be cleared/secured?
3. The hazards will vary depending on the location, however the one constant hazard is blood and body fluids. WEAR PPE - GLOVES, GOGGLES, MASK, GOWN/APRON.
70
MVA: First on call, MVA 50km away from the community on unsealed road. One injured person. Predicted rollover.
1. What is your immediate preparation and response prior to attending the scene? (3)
2. What do you do as you approach the scene?
3. What potential or actual hazards could be at this scene?
1.
- Call all relevant personnel
- Ensure the clinic ambulance has fuel and all equipment has been checked
- Inform the appropriate health manager that you are attending the scene or follow your local health policy guidelines.
2.
- Approach with care
- Ensure you are free from danger
- Ensure you have a safe exit
- Don’t approach the scene if you think it is unsafe
- Notify police if not already done so
- PPE insitu
3. Environmental
- Hot/cold/raining
- Fire/gas/chemicals
- Unstable wreckage
71
What does CRANA stand for?
Context - your remote/isolated situation
Respond - using the primary survey
Assess - using the secondary survey
Next step - prepare for retrieval/referral
Assist team - regroup, reflect and support
72
When you arrive at the scene and check responsiveness, what should you do?
Check the time and record time and LOC
73
5 Signs of airway obstruction
- Agitation
- Reduced alertness
- cyanosis
- abnormal breath sound
- deviated trachea
74
In paediatrics, which manoeuvre should be used to clear the airway and why
Jaw thrust, due to subtle neck flexion and potential exacerbation of unstable cervical spine due to larger occiput
75
3 steps for managing the airway in unconscious pt
1. Open using jaw thrust
2. Clear any obstruction
3. Establish airway using simple adjunct
76
2 key questions in trauma
1. Is there any sign of airway obstruction?
2. Is there any sign of a spinal injury?
77
What are 5 situations/indications considered to be at risk of spinal injury?
1. Blunt multi-system trauma, e.g. pedestrian vs car, high impact falls/collisions
2. Significant injury above the level of the clavicles
3. Impaired LOC
4. New neurological deficit
5. Midline cervical tenderness
78
How to manage a potential spinal injury at a scene? And alternative for if client is too combative or agitated.
I’m managing a potential spinal injury at scene, decide whether to:
1. Initially manage with inline mobilisation, apply a collar so that you can progress through the primary survey know that for now the C spine is being protected
2. Negotiate and encourage to stay still, use rolled up towels or sandbags
79
Trauma patient - drs(A)bcde: if the unconscious client is breathing normally and there is no risk of spinal injury, what should you do?
- Put them in recovery position to help protect their airway, rest their head on extended arm to help neck alignment
80
Trauma - drsa(B)cde: If there is no breathing, what do you do?
Immediately commence BSL. Respiration will need to be supported.
81
Trauma - drsa(B)cde: how to exclude a tension pneumothorax in breathing?
- check for equal rise and fall of the chest
- listen for any signs of acute resp distress
- check for signs of a person that cannot speak and looks like they cannot breathe and are extremely scared, +/-
- a deviated trachea and distended neck veins
- On auscultation there will be no AE on the affected side but this will be difficult to determine if the pt is still in the vehicle so you may need to decompress the chest using a 14g cannula if clinically indicated
82
Trauma - drsa(B)cde: what injury(s) is a driver who is not wearing a seatbelt and collides with the steering wheel at risk of?
Serious chest injuries such as pneumothorax
83
Trauma - drsa(B)cde: how to check for major chest injuries other than pnuemothorax
- Look and feel chest wall for signs of acute chest trauma, abrasions, open wound, subcutaneous emphysema, flail segment, haemothorax or open pneumothorax
84
Trauma - drsa(B)cde: Oxygen.
What should all ill or injured victims receive? Concentration, flow rate and type of mask.
Adult vs paed.
Adult: High concentration oxygen via a non-rebreather mask. Flow rate adjusted to ensure the reservoir remains inflated during inspiration (12-15L/min)
Paediatric: high flow oxygen via a non-rebreather mask at 10L/min and titration to keep O2 stats >95%
NB: always inflate the reservoir bag prior to applying the face mask and remove the mask if there is no O2 flow for any reason
85
Trauma - drsab(C)de: what are the 2 questions for circulation part of assessment? What is the priority?
1. Is there any obvious external bleeding?
2. What is the client’s circulatory status?
Priority is to recognise and if possible, arrest ongoing bleeding.
86
Trauma - drsab(C)de: haemorrhage control.
What are 3 methods to control haemorrhage?
1. Direct pressure and wound packing with haemostatic dressings
2. Tourniquet application - NB: record time of application and ensure those taking over care are aware.
3. Tranexamic acid (TXA) - if supported by local protocols - NB: must be given asap and within 3 hrs of injury otherwise ineffective
87
Trauma - drsab(C)de: how to assess circulatory status in primary survey (a formal BP is not done until secondary survey)
Estimation using cap refill and peripheral pulses
1. Peripheral pulses:
- radial pulse implies systolic BP >90mmHg
- no radial pulse but femoral or brachial pulse, BP>80
- Carotid only BP >70
NB ESTIMATION ONLY
88
Concealed bleeding:
- what are some indications of internal bleeding?
- If there are signs of shock as well, what is required?
- A tender abdomen or pelvis, or evidence of chest trauma
- Urgent medical input; fluid boluses may be ordered; IV cannulation +/- blood sampling or intraosseous access should be performed at this stage
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Signs of shock in adults
- Weak and fast pulse (>100bpm)
- Low BP for age
- Restless, confused, drowsy, fluctuating LOC
- Pale, cool, moist skin
- Cap refill >2s
- Air hunger/increased RR
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Hypovolemic shock: what does the clinical presentation of shock depend on?
- Ideally, shock is recognised before hypotension develops
- Depends on:
* Rate, volume, and duration of bleeding
* The patient’s baseline physiology
* The presence of other acute pathologic processes (e.g. tension pneumothorax, myocardial ischemia)
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4 classifications of hypovolemic shock: approx. blood loss and clinical symptoms
1. Class I
- Blood volume loss of up to 15% (750mls for 70kg adult)
- Minimal clinical symptoms
- For an otherwise healthy patient this amount does not require replacement and blood volume is restored within 24hrs
2. Class II
- Blood vol. loss 15-30% (750-1500mls)
- Clinical symptoms: tachycardia, tachypnoea and decr. Pulse pressure, subtle mental state changes, positive cap refill test, urinary output decreased to 0.5mls/kg/hr
3. Class III
- Blood vol. loss 30-40% (approx 1.5-2L)
- Clinical symptoms: marked tachycardia and tahcypnoea, measurable fall in systolic BP, significant changes in mental state
4. Class IV
- Blood volume loss >40% (>2L)
- An immediate, life-threatening situation
- Clinical symptoms: pallor, feeling cold, sweating, severe tachycardia and hypotension, markedly depressed mental state, urinary output negligible
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Likely sites for blood loss in trauma: estimations of blood loss for: the ground, chest, abdomen, pelvis, femur, tibia/fibula/humerus, forearm, ribs.
NB: chest, abdominal, pelvis and long bone injuries can lead to significant loss of circulating blood volume
- The ground: up to 5L
- Chest: up to 2L
- Abdomen: up to 2L
- Pelvis: 2-3L
- Femur: 1.5-2L
- Tibia/fibula/humerus: 750mL
- Forearm: 500mL
- Ribs: 150mL
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How to manage hypovolaemic shock.
Hint: arrest bleeding, vascular access, fluid resus, monitor and reassess.
1. Arrest the bleeding
- Find the cause. (Beware esp. in elderly and youth, of perceived minor lacerations that can bleed++ and are often overlooked such as scalp lacerations)
- Apply direct pressure and elevate.
- Use haemostatic dressings such as quick clot or adrenaline soaked gauze
- Use a tourniquet in cases of amputation when other measures have not successfully controlled bleeding
- Reduce and splint long bone and pelvis fractures.
- Unstable pelvic fractures and and associated vascular injuries can cause hyopovolaemic shock. Preliminary stabilisation intervention includes applying a pelvic binder/sheet firmly around the pelvis to reduce bleeding.
- If the source of bleeding cannot be controlled, e.g. penetrating abdo trauma, the aim is to limit fluid resus, at least until haemorrhage is controlled - by natural haemostasis, external pressure or surgery.
2. Vascular access
- Access must be obtained promptly with 2 large bore cannulae (short and thick does the trick). A small size is ok initially if difficult cannulation but once some fluids are in then try for bigger IV.
- Suggested sites for peripheral venous access: cubical fossa (preferred size for resus), forearm, hand.
- If adequate IV access cannot be obtained, consider inserting an IO needle earlier rather than later.
3. Fluid resuscitation
- Normal saline is preferred, but Hartmann’s is acceptable. Hartmann’s is always used for burn injuries.
- Non-responders and transient responders need blood
- Aim for a urine output in adults of 0.5-1ml/kg/hr
- NB: keep emptied bags/units so that they can be double checked against the chart, as it is easy to lose track of volume of fluid given
- Early communication to medical teams is essential to discuss BP parameters and expedite retrieval to definitive care.
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Paediatric considerations in hypovolaemic shock
- What are the initial signs of circulatory failure in children?
- What is a late and sudden finding that requires an immediate response?
- Most efficient method of increasing CO?
- Absolute blood volume in children small or large?
- Compensation mechanisms
- Urine output
- Blood pressure
- Initial fluid resus for paediatric patients in ml/kg of crystalloid (i.e. normal saline)
- Maintenance fluids
- Tachycardia and poor skin perfusion
- Hypotension with uncompensated shock
- In children CO is regulated by HR only; therefore tachycardia is the most efficient method
- Relative is large but absolute is small (800mls in 1y/o)
- Due to smaller blood volume, children can compensate largely before becoming hypotensive. Severe shock due to fluid loss may have subtle signs initially
- Greater in children (1-2mls/kg/hr) due to immature kidneys
- More difficult to measure in children, cuff selection is important - ensure it fits a 2/3 width of upper arm
- 20ml/kg/hr
- Given as one of the dextrose-saline combinations e.g. 5% dextrose + 1/2 normal saline. The dextrose is required in children as they tend to become hypoglycaemic due to their higher metabolic rate
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2 methods for calculating maintenance fluid requirements
Method 1: maintenance fluid volume for a 24hr period
- weight less than 10kg = 100mls/kg
- weight >10-20kg - 1000mls for first 10kg + 50mls/kg for any weight over 10kg
- weight >20-80kg = 1500mls for first 20kg of body weight + 20mls/kg for any weight over 20kgs, max. 2400mls daily.
Method 2: maintenance fluid needed on an hourly basis
- weight <10kg = 4mls/kg/hr
- weight >10-20kgs = 40mls/hr for first 10kg of body weight + 2mls/kg/hr for any additional weight
- weight >20-80kg = 60mls/hr for first 20kg of body weight plus 1ml/kg/hr for any weight >20kg, max 100mls/hr, max 2400mls/day.
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Disability - drsabc(D)e: what is important?
The trend.
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Trauma: Exposure/environment - drsabcd(E): when must clothes be removed from the critically ill or injured person to look for other injuries and perform a thorough physical ax?
At the end of the primary survey in preparation for the secondary survey in trauma scenarios. Do this in stages to prevent hypothermia.
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How can hypothermia interfere with the trauma patient?
Interferes with clot formation and has a negative inotropic effect on the heart (reduces contractility)
99
Purpose of secondary survey in trauma context. What does it assess first? Followed by?
- Identify and manage problems that may become life threatening and problems that are limb threatening.
- Identifies limb-threatening injuries first (and manages them) and then other injuries.
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What must be remembered for trauma clients?
The trauma client’s condition must be monitored vigilantly, and should it deteriorate at any time, the ABCs must be repeated with the cause for the change identified and managed before continuing with secondary survey.
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Trauma: What should begin as you move through the head to toe assessment and as you gather more info that requires intervention?
Additional management such as:
- An additional IV line and IV fluids
- IV antibiotics
- Tetanus toxoid
- Splinters to fractures
- Dressings
- Suturing
- IDC to monitor urine output
- +/- chest tube if a tension pneumothorax was found and decompressed in the primary survey (if in scope of practice)
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Secondary survey F(ghij): what are the 3 actions?
1. Full set of vitals and calculate EWS
2. Focused interventions; aim for SpO2 to be 94-98%
3. Facilitate family presence; this is a time to gain more history. If considering evaluation, start talking to client and ensure a short visit by family members prior to retrieval.
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Trauma - Focused interventions: how do each of the follow help monitor the client’s condition. Pulse oximetry, cardiac monitoring/12 lead ECG, IDC, gastric tube, laboratory specimens.
- Pulse oximetry: monitors respiratory effect and effectiveness
- Cardiac monitoring/12 lead ECG (remember in indigenous communities cardiac co-morbidities are common and an ECG should be performed regardless of age)
- IDC (if no concern of pelvic fracture): urine output should be measured hourly to monitor the effect of your interventions, i.e. if you are giving a bonus of fluid you want to monitor urine output which will help determine ongoing fluid requirements
- Gastric tube (Oro or naso). NB: contraindication for insertion of NP if any concern of basal skull # or facial fractures
- Lab specimens (swabs, urine to check for haematuria). Point of care bloods - particularly looking for acidosis, CO2, lactate, potassium, sodium, calcium, glucose, haematocrit, haemoglobin.
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Trauma: facilitate family presence: when should family be allowed to see the client and what should a delegated staff member talk to the family about?
- Once the client’s condition is stabilised and before proceeding
- provide them with info about the condition of their loved one, the injuries, the treatment they have received and the plan for ongoing treatment
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Trauma - f(g)hij: what does “give comfort” aim to do?
- alleviate/control pain
- prevent a recurrence of the pain
- correct pathology
- achieve physiological advantages
- Prevent chronic pain syndromes
- Provide reassurance
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What pain management strategies could be used with trauma clients? Include non-pharmacological methods of pain relief
- Reassurance and explanation
- Avoid aggravating factors
- Specific treatment for condition
- Physical methods e.g. splinting of limbs
- Analgesia
- Anaesthesia
- Hot and cold packs
- Hot water for certain bites and stings
- Covering a burn
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There is no reason to delay giving pain relief to trauma clients unless…
- they have no known allergies to pain relief
- BP is not acceptable
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Trauma - history and head to toe, fg(H)ij: what should you always remember to ask about in trauma patients?
Immunisation status with a focus on tetanus. Tetanus should be updated in the case of significant or contaminated wounds. Give to patients who have not received a complete primary immunisation.
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Trauma - history and head to toe, fg(H)ij: where might you gain some information about the client’s history and the incident that brought them to your clinic?
- Look for medical alert bracelet or other medical identification in the home, medication bottles
- With a trauma client, assess forces involved, consider MOI
- Check scene for clues of what may have happened
- Consider environment
- Family
- Consider client’s age
- Do you already know the client and their medical history?
- Medical records
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Trauma - head-to-toe (fgHij): for each of the following body regions below, jot down some specific things you are looking, listening and feeling for. Head, neck, chest, abdo, pelvic region and genitals, upper and lower limbs.
- Head: facial symmetry and wounds; scalp wounds/lacerations; facial and skull deformities; external ear and tympanic membrane; drainage from ears or nose; periorobital injuries; ocular injury, foreign bodies; oral injury; dental injury
- Neck: penetrating wounds/lacerations; bruising; deformity; distended neck veins; tracheal position. Listening for hoarseness.
- Chest: reassess RR, effort, symmetry; chest wall wounds/lacerations/bruising; chest wall movement. Listening for breath sounds in all lung fields and heart sounds
- Abdomen: wounds/lacerations; bruising/blunt trauma; distension; scars. Listening for bowel sounds
- Pelvic region and genitals: wounds, bleeding at urethral meatus or from rectum; bruising of perineum or scrotum; priapism (persistent and painful erection, can be sign of spinal injury). Feeling for tenderness or deformity.
- Upper and lower limbs: wounds/lacerations/partial amputations; bruising;deformities; movement. Feeling for pulses
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Signs of compartment syndrome (5)
- Disproportionately severe pain
- Loss of function
- Pain on passive stretching
- Muscle group may feel firm/tight on palpating
- numbness and pulse lessens are late signs
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If there was a dangerous MOI you cannot clear the cervical spine if any of the following criteria are met: (5)
- Any new neurological deficit
- Any distracting injuries
- An intoxicated client
- A depressed LOC
- Numbness or pain
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Trauma - inspect posterior surfaces fgh(I)j - What are you looking, listening, feeling and smelling for when you inspect your client’s back?
Looking:
- Injuries
- Haemorrhage
- Bruising
- Lacerations
- Penetrating injuries
- Asymmetry
- General overall body appearance
Listening:
- air entry across all lung fields
Feeling:
- Soft tissues and bones for midline tenderness and obvious “steps”
- Warmth and movement of extremities
Smell:
- Alcohol
- Petrol
- Toxic fumes
- Urine
- Faeces
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Trauma - fghi(J): 6 things you must jot down
- Date and time
- Demographic info
- Short hx (from DeMIST and AMPLE)
- MOI
- Primary survey (findings + interventions)
- Secondary survey (findings + interventions)
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Things to consider when monitoring a trauma client?
- Neurological status
- Urine output
- Neurovascular status
- Pain
- Hypothermia
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What are some actions you might take to prepare a trauma client for retrieval?
- Ensure IDC is inserted and catheter bag emptied prior to transfer
- give an antiemetic
- consider nasogastric/orogastric tube
- if possible, have a spare well-secured IV access
- anticipate the O2, IV fluids and medication requirements before setting out
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What to include in ISBAR summary?
I - identification
For client: 3 identifiers; consider name, DOB, place; other options are hospital registration numbers, family connections i.e. daughter
For self: name, role, and if relevant contact details.
If communicating with another person, find out name, role and if relevant contact details
S - situation
What happened
If communicating with another person, what’s the critical point to communicate
B - background
Relevant history, what has been tried and the outcome
A - assessment
State what you think the problem is and what you think should happen
R - Request
What do you want them to do - advice, review, refer, evacuate
E.g. does this plan sound reasonable? Is there anything we have missed?
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Trauma case study - if you were called and informed of a car accident, what questions would you ask to gain as much info as possible.
Questions to ask on the phone to gain info:
- What happened? What type of vehicle? Were you in the car? How did you find out about the accident?
- Did the car hit anything? Did it rollover? Do you know if anyone was thrown out of the car? Was it on bitumen or dirt?
- When did it happen? Can you give me more info about exactly where it happened?
- How many people in the car and any children?
- Are they still at the scene or has someone brought them into the community?
- Have you notified the police?
- Is there anything else you want to tell me?
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Normal pupil size
3-5mm
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How to check pupils
- Check size and shape
- Direct response: shine light into pupil and see if it constricts
- Consensual response: shine light into pupil and see if the opposite pupils constricts with the opposite one
- Accommodation response: move pen/finger slowly towards nose and check that both pupils accommodate to that.
- Document PERLA
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Two main reasons why you have to remove an impaled object
1. If the object is going to interfere with CPR, if they are in cardiac arrest
2. It is actively causing an airway obstruction, e.g. knife in trachea blocking the airway.
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What do you do for: blunt force trauma, penetrating trauma, impaled object
1. Blunt force trauma = supportive measures only, e.g. pain relief, etc.
2. Penetrating trauma = apply occlusive dressing
3. Leave object in place and stabilise.
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Two factors determining the need for a tourniquet - volume and flow. What indicates serious bleeding that requires a tourniquet?
Volume - half a soda can
Flow - blood squirting, pooling on the surface, or continuously flowing
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Which parts of the body is a tourniquet used on?
Arms and legs only, NOT torso or head. Other parts of the body = direct pressure
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How to use tourniquet?
1. Provide pain relief
2. Apply tourniquet 2-3” above the wound, close to torso
2. Pull the strap tight, twist the stick (this will hurt) until bleeding stops. If bleeding does not stop you may have to apply a second tourniquet closer to the torso
3. Clasp the stick in place
4. Record the time applied.
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You receive a call from someone reporting an MVA accident. What questions do you ask to gain as much info as possible?
- What happened? What type of vehicle? Were you in the car? How did you find out about the accident?
- Did the car hit anything? Did it rollover? Do you know if anyone was thrown out of the car? Was it on bitumen or dirt?
- When did it happen? Can you give me more info about exactly where it happened?
- How many people in the car and any children?
- Are they still at the scene or has someone brought them into the community?
- Have you notified the police?
- Is there anything else you want to tell me?
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Causes of respiratory compromise
- Acute trauma or injury to the respiratory system
- neurological injury affecting the resp centre
- result of another condition such as cardiac disease, anaemia and infection
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3 primary goals for the emergency management of the SOB client
1. Optimise breathing, arterial oxygenation and removal of waste products (CO2)
2. Determine the need for emergency airway management and ventilation support
3. Establish the most likely causes of the SOB and initiate treatment
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Causes of SOB:
- Life threatening acute airway causes (5)
- Life threatening pulmonary causes (8)
- Life threatening cardiac causes (8)
- Life threatening neurological causes (2)
- Life threatening toxic and metabolic causes (7)
- Life threatening miscellaneous causes (7)
- Airway: tracheal foreign object, swelling, anaphylaxis, infections of the pharynx and neck, airway trauma (blunt or penetrating causing haemorrhage, anatomical distortion and swelling, such as facial burns, smoke inhalation, laryngeal fracture due to hanging)
- Pulmonary: PE, COPD exacerbation (infection), Asthma (acute exacerbation), pneumothorax, pulmonary infection (severe bronchitis or pneumonia), noncardiogenic pulmonary oedema (ARDS)
- Cardiac: acute coronary syndrome, acute heart failure, acute pulmonary oedema, high output HF, cardiomyopathy (resulting in pulmonary oedema), cardiac arrhythmias, valvular dysfunction, cardiac temponade
- Neurological: Stroke, neuromuscular disease (MS, Guillain-Barré syndrome, myasthenia gravis)
- Toxic and Metabolic: poisoning, salicylate poisoning (causing hyperventilation and respiratory alkalosis initially, followed by metabolic acidosis and/or pulmonary oedema), carbon monoxide poisoning, toxin related metabolic acidosis, diabetic ketoacidosis, severe sepsis, anaemia
- miscellaneous: lung cancer, pleural effusion, intra-abdominal processes, ascites, pregnancy, massive obesity, hyperventilation and anxiety
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What defines hypoxaemic respiratory failure (type I resp failure)
- PaO2 of <60mmHG or SpO2 <90%
- Most common form
131
What defines hypercapnic resp. Failure (type II)
- PaCO2 >50mmHg and indicates inadequate alveolar ventilation
- Hypoxemia is also common
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Classification and causes of hypoxia
Hypoxia hypoxia
- defective mechanism of oxygenation in the lungs (e.g. airway obstruction, smoke inhalation, abnormal pulmonary function, near drowning, etc.)
Anaemic hypoxia
- Inability of the blood to carry O2 in the presence of adequate circulation
Ischaemic/stagnant hypoxia
Histotoxic hypoxia
- inability of the cells to use oxygen
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Signs of hypoxia
- Altered brain function (agitation, confusion, drowsiness, coma) due to cerebral hypoxia
- Altered cardiac function (cardiac arrhythmias) due to cardiac depression leading to hypoxia
- Compensatory mechanisms including tachycardia, peripheral vasoconstriction and increased respiratory effort
- Cyanosis due to reduced O2 carriage on RBCs
- Sweaty extremities due to skin hypoxia
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What are the 2 goals in the primary survey when assessing breathing?
1. Ensure the client is breathing adequately
2. Exclude the 5 life-threatening trauma chest conditions
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What are the 5 life-threatening trauma chest conditions? How to recognise? How to manage
?
1. Tension pneumothorax
- Air enters the pleural space on inspiration but cannot escape on expiration; rising pressure collapses the lung on the side of the injury and causes compression on the uninsured lung as heart/vessels/trachea; venous return in impeded - cardiac output falls and hypotension results.
- Severe respiratory distress, anxiety and sense of impending doom, tachycardia, tachypnoea, hypotension, distended neck/head/upper extremity veins, hyper expanded chest; late signs are tracheal deviation away from side with tension, cyanosis. HIGH INDEX OF SUSPICION IN ANY TACHYCARDIC AND HYPOTENSIVE CLIENT
- Management: high flow O2 (15L/min non-rebreather mask), immediate needle thoracentesis or finger thoracostomy; second intercostal space, midclavicular line (converts it to a simple pneumothorax until back at clinic when intercostal chest catheter. Cover the wound with flexible thin dressing and seal 3 sides well. Analgesia.
2. Open pneumothorax:
- sucking chest wound associated with a chest wall defect/wound that allows air to move in/out of the pleural cavity resulting in impairment to ventilator function. On inspiration, air enters through the hole not through the trachea
- Recognised by: a wound in chest wall that appears to be sucking, anxiety and agitation, reduced breath sounds, increased percussion note, reduced expansion of the haemothorax, tachycardia
- Manage by: airway management and oxygen, cover the wound with thin flexible dressing and seal 3 sides well. Analgesia.
3. Massive haemothorax
- Defined by need for thoracotomy; indications are blood loss >1.5L or 1/3 blood volume, or blood loss >200ml/hr for 2-4hrs. Results from a wound through the chest wall that allows air to move in and out of the pleural cavity
- Recognised by: anxiety and agitation, hemorrhagic shock (pallor, tachycardia, hypotension, cool peripheries), external evidence of thoracic injury, decreased chest movement ipsilaterally, ipsilateral dullness, decreased breath sounds ipsilaterally, persistent blood loss following intercostal catheter insertion
- Management: require blood products, but in the meantime - High flow O2 (15L/min via non-rebreather mask), insert 2 large IV cannulas and commence fluids (guided by medical officer)
4. Flail chest
- recognised by: bruising, grazes on visible inspection; localised pain especially on inspiration; dyspnoea; may be crepitus associated with fractured ribs; paradoxical chest wall movement
- managed by: high flow O2 to maintain SpO2 target (15L/min via non-rebreather mask), analgesia as per orders; respiratory monitoring and support - close monitoring of SaO2 and resp efforts important due to tendency to gradually deterioration - may require intubation and mechanical ventilation, may benefit from non-invasive ventilation
5. Cardiac temponade
- commonly caused by penetrating trauma to the myocardium; most clients don’t survive. Increased pericardial pressure = reduced venous return = reduced cardiac output and BP.
- recognised buy: tachycardia, distended jugular vein, hypotension, narrowed pulse pressure, dyspnoea, weakening pulse on inspiration, cyanosis, muffled heart sounds
- Management: requires surgical management. Can provide high flow O2 (15L/min via non-rebreather mask), but client will likely die.
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Symptoms of asthma
- Respiratory: difficulty breathing, wheezing, breathing through mouth, frequent resp. Infections, rapid breathing, SOB at night
- Cough: can occur at night, during exercise, can be chronic, dry, with phlegm, mild or severe
- Also common: Chet’s pain or pressure, anxiety, tachycardia, throat irritation
- Wheezing: widespread, high-pitched, musical wheezes; usually begins suddenly, comes in episodes, may be worse at night or early mornings, getsworse with cold air, exercise, and reflux; relieved by bronchodilators; most common on expiration
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Conditions that can lead to wheezing
Allergies
Anaphylaxis
Asthma
Bronchiectasis
Bronchioloitis
Childhood asthma
COPD exacerbation
Emphysema
Epiglottitis
Foreign object inhaled
GERD
HF
Lung cancer
Medications (e.g. aspirin)
Obstructive sleep apnoea
Pneumonia
RSV
Resp tract infection
Smoking
Vocal cord dysfunction
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Acute asthma episode: mild/moderate vs severe vs life-threatening
Mild/Mod
- Can walk
- Can say a whole sentence in one breath
- Oxygen sat >94%
Severe:
- any of: use of accessory mm, tracheal tug, subcostal recession
- unable to complete sentences in one breath due to dyspnoea
- Obvious resp distress
- O2 sat 90-94%
Life-threatening:
- Any of: reduced consciousness or collapse;
Exhaustion
Cyanosis
Poor respiratory effort
Soft/absent breath sounds
O2 <90%
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How to manage acute asthma episode
1. Rapidly assess severity (mild/mod, severe, life-threatening) with the person in a sitting position
2. Measure pulse oximetry while the person is breathing air (unless life threatening)
3. Start bronchodilator according to severity and age
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Initial bronchodilator trx in acute asthma in adults and children 6+
Mild/mod
- give salbutamol 4-12 puffs (100mcg/actuation) via pMDI and spacer
- give one puff at a time followed by 4 breaths
- Repeat every 20-30mins for first hour if required, sooner if needed to relieve breathlessness
Severe
- Give salbutamol + ipratropium: 12 puffs (100mcg/actuation) via pMDI and spacer
- If pt unable to breath through spacer, give 5mg nebule via nebuliser, ipratropium 8 puffs (21mcg/actuation) via pMDI and spacer every 20mins for first hour
- Repeat 4-6hrly for 24hrs
- If salbutamol delivered via nebuliser add 500mcg ipratropium to nebulised solution every 20mins for first hour, repeat 4-6hrly
- Start O2 therapy if O2 saturation <92% in adults and titration to target: adults 93-95%
Life threatening
- Give salbutamol + ipratropium
- Salbutamol 2 x 5 nebulae’s via continuous nebulisation driven by O2
- Ipratropium 500mcg added to nebulised solution every 20mins for first hour
- Repeat 4-6hrly
- Maintain SpO2 adults 93-95%
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Acute asthma management in children, adolescents and adults
- what is started immediately?
- when is O2 therapy administered?
- what else is completed based on clinical priorities?
- what other medication is administered and when?
- period of observation post resp distress or increased WOB has resolved
- what must be arranged?
- Bronchodilator treatment started immediately whilst assessing severity
- if SPO2 <92% in adults or <95% in children
- observations and assessments
- systemic corticosteroids within first hour of trx
- at least 3 hrs
- providing post-acute care and arranging follow-up to reduce risk of future flare ups
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Safe handling of O2: must dos (12)
- use and store in well ventilated areas
- do not store near combustible products/sources of ignition
- Keep full and empty cylinders separate
- no smoking in close proximity
- undergo regular maintenance checks
- have a legible product label
- must use approved regulators and flow meters
- all valves must be closed when not in use
- should not be totally emptied
- must be safely secured in an upright position with restraint
- do not use force when opening or closing valves
- read labels before use
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Oxygen delivery systems: use and flow rates of nasal prongs, simple mask, non-rebreather mask, bag-valve mask, air-entrainment (Venturi) mask
1. nasal prongs:
- O2 needed for long periods, lets clients eat, drink, talk; or babies/young children with pneumonia who won’t tolerate face mask
- flow rate: 2L/min = 28% FiO2, 4L/min = 36% FiO2
2. Simple mask
- adults/older children with pneumonia or other moderate resp illness
- flow rate: 5-6L/min = 40% FiO2, 7-8L/min = 60% FiO2
- Give over 4L/min (child) or 6L/min (adult) to remove expired air from mask and prevent rebreathing of CO2
- Giving over 10L/min will not increase % of O2 given
3. Non-rebreather mask
- For high flow O2 ; critically ill but adequate breathing e.g. shock, major trauma and sepsis
- Flow rate: 15L/min = 85-90% FiO2
- before using, make sure reservoir bag full and mask seals properly around mouth and nose
4. Bag-valve mask
- for positive pressure ventilation, not breathing (apnoea), cardiac arrest, inadequate resp effort
- flow rate 15L/min = 90-100% FiO2
- before using make sure: valve opens properly, reservoir bag full, mask seals properly, airway open
5. Venturi mask
- Acute exacerbation of COPD
- Flow rate: gives 24%, 28%, 31%, 40% or 60% FiO2 depending on recommended flow rate required
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Assessing breathing in SOB clients: P.A.S.S.R.E.S.P. P.S.
P - posture of the patient (upright or restless may indicate problem)
A - appearance (distress, anxiety, air hunger indicate a problem; asymmetrical chest wall movement, signs of injury)
S - speech pattern (inability to talk or construct sentences)
S - sounds of breath (auscultate breath sounds)
R - respiratory (rate and rhythm)
E - effort (accessory mm, tracheal tug, nasal flaring, WOB)
S - skin perfusion (colour, temp, texture; sweaty, clammy skin and cyanosis)
P - pulse (tachycardia indicates incr. WOB and worsening hypoxia)
P - palpate (chest, tracheal position, tenderness, dullness to percussion and surgical emphysema)
S - conscious state (confusion and drowsiness)
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Identifying abnormal breath sounds: description and cause of: Absent sounds, crackles, gurgles, wheezes and pleural friction rubs
Absent sounds - silence; haemo/pneumothorax, tension pneumothorax
Crackles - crackling sound, fine/medium/course; air moving through fluid
Gurgles - low pitched; large airway partially obstructed by fluid
Wheezes - high pitched; airway narrowed by obstruction/inflammation/foreign body
Pleural friction rubs - grating sound; inflamed pleurae rubbing
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Assessing breathing in children: 1. Effort, 2. Efficacy, 3. Effects
1. Effort of breathing
- RR, Recession, stridor, wheeze, grunting, accessory mm use, gasping, nasal flaring
2. Efficacy of breathing
- chest expansion/abdo excursion, breath sounds (reduced or absent, symmetry on auscultation), SpO2 on air
3. Effects on other physiology
- HR, skin colour, mental status
147
Normal ranges of RR in children
<1y: 21-45
1-4y: 16-35
5-11y: 16-30
>12: 16-25
148
7 things you may need to consider when arriving at an MVA
1. How close can I safely park?
2. Is it safe to approach?
3. What can I see? Are there any bodies on the ground outside the vehicle? Are there many people at the scene?
4. Does it appear as if anyone is under the influence of alcohol or other drugs?
5. Will other people/road trains/vehicles be a danger to us?
6. Will the weather and dust impact on my care?
7. PPE?
149
In a roadside emergency, what must you remember to do?
- Park vehicle safely and put on a reflective vest or jacket
- Assign a person to manage any traffic and bystanders and put out hazard signs
- Determine if extrication of the client is required and who is responsible for that in this community
150
Which cervical nerves innervate the diaphragm?
3, 4 and 5 (keep the diaphragm alive)
151
Example prompts for ISBAR handover for retrieval.
I -
Hello, I’m Tess the RAN from community Y. Who am I speaking to please?
(Important to clarify who is on the phone first)
I’m calling about XYZ, a xyz year old M/F, location or direction of travel
S -
XYZ has been in a XYZ and I am worried about his/her XYZ (e.g. respiratory function). I think he will need retrieval.
(Sets scene and alerts them that this isn’t just a call for advice)
B - unavailable
A -
Only include abnormal findings, nothing NAD over the phone (however document this is your notes). Format: Airway, spinal precautions, obs incl. GCS, head/neck/chest/abdo/limbs, hydration, nil by mouth (and if known last meal), interventions so far (fluid resus and vol. of urine cleared, urinalysis), pain and what has been given.
R -
I am thinking that this man has XYZ. His (resp) function has deteriorated first being seen at site with an incr. WOB and he requires high flow O2 to maintain his SaO2 at 96%. He needs retrieval to an acute centre for further ax and mgmt. I would also appreciate you advice about IV fluids and pain management.
152
What do you need to do to prepare a client for retrieval?
1. Gain consent for evacuation
2. See if family can bring clothes, money, key cards
3. Remind them about luggage restrictions and dangerous goods such as lighters
4. Record details of NOK
5. Copy of all documentation, if possible summary of medical hx and usual meds, + summary of current incident
6. Any pathology to accompany the client is appropriately packed
7. Make sure they have toileted
8. Make sure all lines are secure and patent
9. O2 therapy
10. Consider pain relief
11. Consider anti-emetic
12. Make sure you know where to go to meet RFDS
153
Symptoms of anaphylaxis
- Angiodema
- Difficult/noisy breathing
- Swelling of tongue
- Swelling/tightness of throat
- Difficulty talking and/or hoarse voice
- Wheeze or persistent cough
- Persistent dizziness and/or collapse
- Pale and floppy (in young children)
154
What is usually the first sign of sepsis?
Increased RR
155
Signs of sepsis in adults
- Infection confirmed or suspected
+
- RR >20
- HR >90
- Temp >38.3 or <36 (not always)
- Acute confusion or decreased LOC
- Hyperglycaemia (BGL >7.7mmol/L in non-diabetic)
- Oliguria (urine output <0.5mL/kg/hr)
156
8 Interventions recommended for the management of sepsis
- Assess for airway patency and administer O2
- Obtain IV access, blood cultures and baseline blood tests including lactate
- Other diagnostic samples if they will not delay AB trx (sputum, urine, pus)
- Prescribe and administer ABs (should be administered in first hour)
- IV fluid bonus if client showing signs of shock/hypoperfusion; 250-500mL crystalloid (NS or Hartmanns)
- Seek senior help and transfer to ICU if transient or no response to trx
- Examination for source of sepsis if not already clear
- Monitor fluid balance and urine output
157
In the absence of trauma, the primary focus is exclusion of these 4 potentially life-threatening conditions:
1. Acute coronary syndrome (ACS), encompassing acute myocardial infarction and unstable angina (MOST COMMON)
2. Pulmonary embolism
3. Tension pneumothorax
4. Cardiac temponade
158
What must you triage chest pain as? (NB: all chest pain is considered cardiac until proven otherwise)
All clients who present with ACS must be seen within how many minutes and have what completed?
1. Cat 2
2. Must be seen within 10mins and have an ECG (should be reviewed by clinician with ECG expertise)
159
What 3 things should a client diagnosed with cardiac chest pain have?
1. Clinical story
2. Evidence of positive clinical bio markers
3. 12 lead ECG suggesting a cardiac cause
160
Step by step approach with chest pain presentations:
1. In absence of trauma, exclude the 4 potentially fatal conditions (ACS, PE, tension pneumothorax, cardiac temponade)
2. Now focus attention on chronic but serious underlying cardiac conditions that may req. additional evaluation e.g. stable coronary artery disease, rheumatic heart disease, renal and pulmonary disease
3. Now consider non-life-threatening acute conditions such as herpes and gastro-oesophageal reflux
4. Consider other diagnoses such as neuromusculoskeletal causes and psychological causes
161
Acute coronary syndrome (ACS) - what, risk factors and management
- Term that refers to a broad range of cardiac presentations: STEMI, non ST elevation acute coronary syndrome (NSTEACS), angina
- Risk factors not used to rule in/out diagnosis but include: family hx, smoking, then, hyperlipidemia)
- Ax and management: if client has had any ongoing symptoms within the preceding 24hrs, they should be referred immediately to an ED for ax.
162
Pulmonary embolism - what, symptoms, risk factors and management
- occlusion of the pulmonary vascular bed.
- Sx: SOB, tachypnoea, chest pain, cough/coughing up blood, fainting, low BP, fast/irregular HR
- other sx: swelling of one/both legs esp. calf, clammy skin, fever and sweating, feeling lightheaded or dizzy
- Risk factors: >80y, smoker, obesity, oral contraceptive pill or HRT, recent pregnancy or overweight, had major surgery, recent major trauma, recent immobility, recent LL # (<1m), active malignancy, severe illness such as heart disease, cancer or resp failure, thrombophilia. Can use Wells PE score to assess probability.
- Management:
1. Primary survey - identify and manage any life-threats
2. Prevention is the best strategy for managing a PE. If diagnosed, anticoagulant therapy +/- oral anticoagulants
3. If the PE is life-threatening, rapid transfer for a pulmonary angiography or surgical embolectomy may be required.
163
Tension pneumothorax: what, signs and symptoms, risk factors, management
- air accumulation between the chest wall and the lung, increasing pressure in the chest, reducing the amount of blood returned to the heart.
- S&S: chest pain, SOB, tachypnoea, tachycardia, followed by shock. Breath sounds absent on affected haemothorax and the trachea deviates away from the affected side.
- Causes: penetrating or blunt trauma, rib fracture, diving or flying, or iatrogenic causes.
- Management:
1. Primary survey
2. Urgent needle decompression by inserting large-bore (14 or 16 gauge) needle into the 2nd intercostal space midclavicular line of the affected lung. Or the 5th intercostal space midaxillary line
3. Penetrating chest wounds must be covered with an airtight occlusive bandage
4. Administer 100% supplementary O2
5. Following needle compression a chest tube is usually placed.
164
Cardiac temponade: what, S&S, management
- Usually caused by penetration of the pericardium; sac that surrounds heart fills with blood/body fluids to compress heart.
- Lack of blood getting back to heart due to less CO means eventually causes shock, organ failure and cardiac arrest.
- S&S: anxiety and restlessness, low BP, weakness, chest pain radiating to neck/shoulders/back, trouble taking deep breaths, tachypnoea, discomfort relieved by sitting or leaning forward, fainting/dizziness/LOC
- Classically, pts have Beck’s triad: hypotension, muffled heart tones, venous pressure increase (neck vein distension)
- Management:
1. Primary survey
2. Rapid transport to a facility to provide definitive care
3. Once temponade is diagnosed, management should be orientated toward urgent pericardiocentesis.
165
If a client presents to your clinic with chest pain, what do you do? (step by step)
1. Take the person into the emergency room and ensure you have access to O2 and resus equipment (especially a defibrillator)
2. Perform a rapid primary survey
3. Obtain a rapid history of chest pain (PQRST)
4. Obtain an ECG and send for review within 10mins
5. Obtain vital signs and monitor frequently using EWS and response tools
6. SpO2 monitoring and administer O2 if needed
7. Insert 2x IVC (large bore)
8. Give medications as per local protocols and pathways
9. Continuous cardiac monitoring
10. Repeat ECG every 10-15min
11. Continue to liaise with MO
166
Chest pain ax: primary survey
D: PPE
R: Check client’s response
S: Send for help. Call for a second responder
A: Assess for airway patency
B: Assess breathing and place high flow O2
C: assess and place an IV cannula. Point of care testing/troponin/BGL
D: AVPU
E: Only if relevant to the scenario.
Then secondary survey.
167
Chest pain ax: secondary survey
*F*
Full set of vitals
Focused interventions
1. Give aspirin oral single dose adult (300mg) unless allergic
2. 12 lead ECG (repeat every 10-15mins until pain free)
3. Maintain O2 stats to a target above 94%
4. Continuous cardiac monitoring
5. Take blood if not already done so
6. If systolic BP >10mmHg and no contraindications, give: nitrate therapy and 250mL bonus of normal saline and assess response
7. If client still has pain, continue to monitor pain response to medication
8. If ECG is abnormal with ST elevation, follow local cardiac clinical pathways.
9. If ECG abnormal with new ST depression or T wave inversion, follow local cardiac clinical pathways.
10. If ECG normal, review troponin result. If positive, go to local cardiac clinical pathway for managing ACS without ST elevation. If negative: treat likely condition (e.g. chest infection) and review. Repeat ECG and troponin 6 hours after pain started, organise medical consult.
Facilitate family presence.
*G* Give comfort
1. Reassure, check allergies, analgesia, assess response to meds using pain score, consider antiemetic (may have nausea from pain), nil-by-mouth
*H* Hx (relevant info should accompany the ECG for the MO to diagnose and treat)
1. AMPLE
2. PQRST
3. Identify/investigate cardiac risk factors (smoking, diabetes, HTN, obesity, hyperlipidemia, family history)
4. Ask relevant Qs for chest pain - SOB, oedema, cough, fatigue, leg pain, skin changes, swelling in limbs, hx past illnesses, hx cardiac disease, diabetes.
5. Head to toe
*I* Inspect posterior surfaces
1. Auscultate posterior lung fields for signs of cardiac failure.
2. Look for signs of pitting oedema
*J*
Jot everything down
168
When not to give nitrate therapy
- If the person has used drugs for impotence (within 24hrs if sildenafil or vardenafil, or within past 2 days if tadalafil)
- if systolic BP 100mmHg or less
169
Cardiogenic shock
TBC page 22.
