Skills Flashcards

Question

103.1 Haemorrhage Control: Arterial Tourniquet

Answer 1

Indications: Haemorrhage (Hhg) control where 1. Extreme life threatening arterial limb Hhg due to penetrating trauma or limb amputation. 2. Limb arterial Hhg not controlled by direct pressure. 3. Hhg inaccessible and life-threatening arterial Hhg suspected e.g. trapped. 4. Mass/Multiple casualties with life threatening arterial Hhg in triage mode where direct pressure cannot be provided without compromising other patients. NB Direct pressure (digital is better) : Elevation : Tourniquet Tourniquet = pain, pt will require strong analgesia after application of tourniquet. Reassess and tighten or add another proximal to first as required. Tourniquet remains in place until arrival at definitive care. If loosened: possible reperfusion injury causing hypotension or pain causing hypertension. Ensure appropriate PPE.

Answer 2

Principles: 1. Immediate high-quality chest compressions + reduce time to defibrillation = priority. 2. Minimise interrupts to compressions, rotate roles every 2min. 3. Teamwork + designate team lead. 4. Initial phase (up to 6min) of cardiac arrest with minimal resources focus on effective chest compressions and defibrillation. ``` Indications: Perform C-A-B (circulation, airway, breathing) 10s assessment. Cardiac Arrest Criteria: 1. Unconscious. 2. Absent / gasping respirations. 3. Absent central pulse. ``` NB - 360degree access. - Notify Control Centre Code 2 + request resources. - Standardised equipment placement. - Setting up defibrillator shouldn't interfere with effective chest compressions. - 2 minute timer + metronome. - Rotate compressor every 2 min. - Tactile tap on / tap off. - Chest pulse ONLY to differentiate between PEA/ROSC with potentially perfusing rhythm. - Bougie assisted intubation. - Ventilate on room air if attaching O2 causes a delay. - 2 person BVM only if difficulty achieving a seal. - Compressions continue if any delay ventilating pt. - BVM : pause compressions to allow ventilations. - i-gel, ETT : no pause between compressions. - Tidal volume: 4-6ml/kg. Minimal chest rise = good indicator of adequate ventilations. >=9y.o 30:2 0-9 15:2 Newborn 3:1 - Event mark medications. - Use the HP-CPR checklist. - Phase change: pause and reassess plans and task allocation. - Identify team leader: temporary delegation when undertaking complex tasks. - Closed loop exchange of information. - Graded assertiveness. ``` REVERSIBLE CAUSES (HHHHTTTA): Hypoxia Hypovolaemia Hyperkalaemia Hyper/Hypothermia Tension Pneumothorax Thrombosis Toxins/poisons/drugs Anaphylaxis ``` ROSC: - Palpable central pulse. - Turn off metronome. - Full primary assessment.

Answer 3

Indication: 1. Cardiac arrest (unconscious, absent or gasping respirations and absent central pulse). 2. Children 1-8 : unconscious with pulse < 40. 3. Children < 1 : unconscious with pulse < 60. Patients with ventricular assist devices VAD may not have pulses, perfusion determines treatment. NB Palms off chest to ensure full recoil. Coronary perfusion occurs during recoil phase of CPR. Compression : Ventilation ratios >= 9 yrs old is 30:2 0-8 yrs old is 15:2 Newborn is 3:1

Answer 4

Aim: Safe and effective defibrillation in cardiac arrest with shockable rhythms. Indication: Cardiac Arrest : unconscious, absent or gasping respirations and absent central pulse. NB >=9 yrs : Anterior - Lateral pad placement <8 yrs : Anterior - Posterior pad placement >8cm from pacemaker / internal cardiac defibrillator [Consider Anterior - Posterior placement]. Person operating LifePak runs COACHED. "Tap on" / "Tap off" Use EVENT button to record interventions and medicine administration. "print" "print" captures 3sec prior to memory. peri-arrest? Apply pads but only connect to defibrillation cable if the pt arrests. If unsure of rhythm with machine charged for shock and hands off chest, cancel charge, print 6s strip, recommence chest compressions while others interpret ECG printout...if VF/VT recharge and deliver shock, if not VF/VT continue CPR. Deliver shock while looking at patient!.

Answer 5

``` Aim: Monitor patients with 1. Non cardiac pt using 4 leads e.g. trauma, asthma. Progress to 12 lead where indicated. 2. All pt with suspected ACS. ``` NB Transmit "Meets ST Elevation MI Criteria" and/or "Consider Acute Infarct" DO NOT place limb leads on pt torso (deltoids and thigh) Failed transmission (automatically redials 3x), check devices turned on and connected, transport and attempt another transmission from inside ambulance (10min later).

Answer 6

NIBP NIBP measurement takes ~40sec Initial default pressure is 160mmHg consider decreasing for paediatric pt. Consider manual BP if NIBP reading appears unusually high/low. ETCO2 Monitor performs auto zero routine as part of initialisation self-test, DO NOT connect ETCO2 FilterLine to pt ventilation system until monitor has completed self-test, via nasal prongs, maximum flow rate 4L/min. SpO2 Observe pulse bar fluctuation. Preferred site: ring finger of non dominant hand. Amplitude of pulse bar indicates relative signal quality. Use HIGH sensitivity setting for low perfusion states. Code summary will detail HR, ETCO2, SpO2 each time NIBP taken. Caution: 1. DO NOT apply cuff to limb with fistula. 2. DO NOT apply cuff on same side as mastectomy. Apply cuff to contralateral arm to the: 1. SpO2 sensor 2. IV fluid/medication infusion site.

Answer 7

Aim: To safely and efficiently convert tachy-dysrhythmias causing haemodynamic compromise into sinus rhythm. ``` Indication: Confim patient: 1. Unconscious (LOC = P or U). 2. Rhythm SVT or VT. 3. Haemodynamically compromised. 4. >= 16 yrs : Heart rate >= 160 5. 1 - <16 yrs : Heart rate >=180 ``` ``` Contraindications: 1. LOC = A or V. 2. < 1 yr of age. 3. ECG indicates Sinus Tachycardia, rapid Atrial Fibrillation or Atrial Flutter. ``` ``` NB Print/Record pre-shock rhythms. Limb leads can remain in situ and connected. Check for Pacemaker/ICD. Apply pads >25mm from pacemaker. >= 9 yr old Antero-Lateral placement <9 yr old Antero-Posterior placement Confirm SYNC & sync marker appears on R wave. ``` Joules >= 16 yrs old: 1st shock - 100 joules 2nd shock - 150 joules 3rd shold - 200 joules Joules 1 - < 16 yrs old 1st shock - 1 joule/kg 2nd shock - 2 joules/kg 3rd shock - 4 joules/kg Immediate defibrillation if VF or pulseless VT. Print/Record post-shock rhythms. ``` PMHx is important to differentiate SVT. Tachycardia with hypotension is more likely to present from: 1. Hypovolaemia 2. Anaphylaxis. 3. Sepsis 4. Tension Pneumothorax ``` Adult > 180 likely to be SVT. Adult ~150 may be SVT but more likely to be a mimicker.

Answer 8

Aim: Management of SVT (rapid narrow QRS complex < 0.12s) in conscious pt (LOC=A or V) and symptomatic where other causes of tachycardia have been excluded. Reversible causes of Tachycardia: 1. Torsades de Pointes 2. Anaphylaxis and Allergic reactions 3. Sepsis 4. Hypovolaemia (medical or trauma) 5. Tension pneumothorax. Contraindications: Do not perform Carotid Sinus massage due to risk of brady-dysrhythmias or possible dislodgement of carotid plaque potentially leading to stroke. ``` NB Explain procedure. IV access. ECG continuous monitoring and document start/end of procedure on ECG. 45deg angle Syringe plunger 1/2 way Blow 15s Cease abruptly Elevate legs 45deg for 45s Repeat once. ``` Alternatively: Interlock curled fingers. Hold deep breath. Try to pull hands apart for 15s Beware SVT mimickers 1. Dehydration 2. Hypovolaemia 3. Sepsis 4. Exertion 5. Medications/Drugs

Answer 9

Aim: Awareness for management of significant presentation, physiological and treatment differences with implanted devices. NB Default to pt/carers providing expert guidance/advice for treatment/management. Confirm connections and battery status. Default to primary treating hospital (bypassing others). Transport > 1-2hrs consult with AMRS. Pt with LVAD/artificial heart not eligible for VOD by paramedics. ``` Primary Assessment: Perfusion determines treatment. 1. Check flow rate 2. Pulses may not be present. 3. Pulse oximetry may not be accurate. 4. Blood pressure cannot be measured. 5. Pt may be in VF but conscious. ``` Treatment Algorithm: 1. Commence CPR if flow < 1.5L/min 2. VF : DO NOT defibrillate if conscious! Only if unconscious with prolonged VF and flow rate < 1.5L/min. 3. Do not sedate for cardioversion.

Answer 10

Aim: Safe and efficient chest compressions in medical cardiac arrest. Contraindications: 1. Traumatic cardiac arrest. 2. Pt has known "not for resuscitation" status. 3. Pt <9 yrs old 4. Pt >= 9yrs old and too small / large for Lucas to fit. 5. Pt has Ventricular Assist Device VAD insitu.

Answer 11

Aim: Management of haemodynamically unstable symptomatic bradycardia (>=16 yrs old) unresponsive to IV Atropine and Adrenaline Infusion. Indications: 1. >= 16 yrs old. 2. HR < 40 bpm and haemodynamically unstable i.e. - BP < 90mmHg - Poor skin perfusion. - Poor cerebral perfusion. 3. Pt has failed to respond to pharmacology. Contraindications: 1. Pt in cardiac arrest in Asystole / PEA. 2. Overdrive pacing of a ventricular dysrhythmia. 3. <16 yrs old. 4. Haemodynamically stable. 5. HR >= 40 6. Unable to complete Conscious Sedation Checklist. NB - 12 lead ECG, limb leads must remain in situ (if not connect Lifepak will revert to Non Demand pacing). - Check for pacemaker/ICD. - Explain procedure. - Pad placement: Antero-Lateral preferred, and >8cm away from pacemaker/ICD. - IV line (preferrably 2x) - Medication for conscious sedation. - IV fluids TKVO - 1:10 000 Adrenaline drawn up in case of TCP failure. - Complete Conscious Sedation Checklist. - Do not cease Adrenaline infusion until confirmed mechanical capture. - If TCP fails resume Adrenaline infusion and consider Adrenaline IV bolus per pharmacology. - Starting rate 80PPM - Starting current 30mA - Increase current slowly to achieve electrical capture, then increase as required to achieve mechanical capture, then set current 10mA above minimum mechanical capture threshold. - Electrical Capture: Wide QRS complex following the pace marker. - Mechanical Capture: increased LOC, palpation of a radial/femoral pulse, improvement in cardiac output / SpO2. Most common reasons for failure to pace: 1. Failure to increase current high enough to obtain electrical capture. 2. Failure to confirm presence of mechanical capture (increasing LOC and a radial/femoral pulse that matches the speed of pacing). 3. Failure to monitor patient to ensure ongoing mechanical capture. Post initiating pacing provide analgesia as required/indicated. Pt should only require conscious sedation if distressed by the process.

Answer 12

Principles: 1. Three common causes of preventable early death in trauma: - Haemorrhage. - Airway obstruction and inadequate ventilation. - Tension pneumothorax. 2. In cardiac arrest due to trauma, correction of the reversible causes (above) should have priority over chest compressions. However, if sufficient resources available then chest compressions can be performed simultaneously provided they do not interfere with treatment of suspected reversible causes. 3. Unless injuries are incompatible with life, resuscitation of traumatic cardiac arrest is not always futile and should be attempted. NB - Confirm traumatic cause of cardiac arrest. - Provide MIST + "Mechanism & traumatic code 2" - If drowning, hanging, asphyxia, hypoxia or isolated head injury : treat per medical cardiac arrest. - Prioritise treatment using MARCHE algorithm: M assive (external) haemorrhage control A irway management R espiratory C irculation H ead injury / H ypothermia E verything else ``` Massive (external) haemorrhage: Arterial tourniquet or direct, sustained and forceful wound pressure. Airway Triple airway management + suction Circulation Pelvic binding Large bore IV/IO as a priority if exsanguination is a likely cause of cardiac arrest. IV fluids + blood products from medical team / nearby ED. Chest compressions. Head injury/Hypothermia Ventilation/Oxygenation : SpO2, EtCO2 IV fluids Remove pt from cold/Remove cold (wet clothing) from pt & dry pt. Minimise heat loss and warm pt Everything else Burns Crush injury ``` Reason to cease resuscitation: no ROSC after 20min following treatment of likely reversible causes. Early code 3 BEFORE departing scene. Do not delay transport waiting for backup to arrive. Traumatic cardiac arrest due to penetrating trauma: early code 3 with treatment enroute.

Answer 13

Aim: To clear and maintain a pt airway. Causes: - Tongue falling back : decreased LOC / supine - Foreign bodies - Swelling - Laryngeal spasm ``` Diagnosis: - Open and inspect mouth for obstruction - Listen + Feel for movement of air (Silence: complete obstruction Stridor: incomplete obstruction Noisy breathing is obstructed breathing) - Look + Feel for chest rise and fall - Look for paradoxical see-saw breathing ``` Remove foreign bodies: - Back blows / chest thrusts - Position lateral / turn head to side - Sweep with tip of Yankauer sucker - Laryngoscope / Magill's forceps - Oral suction Triple Airway Manoeuvre: - Hand on forehead, extend head. - Hold chin between thumb and index finger, lift verticall allowing mouth to open slightly. - In spinal injury minimise extension but airway takes precedence. - Jaw thrust in place of chin lift if preferred. - Jaw thrust can be used on pt with suspected spinal injury. - Positioning lateral is an effective form of basic airway manoeuvre. Regurgitation is the passive flow of stomach contents into mouth and nose. It is often unrecognised because it is silent. In infants the trachea is soft and pliable and may become occluded with excessive head tilt. Padding under the shoulders may assist to achieve a neutral head position.

Answer 14

A chaperone must be present for children and is advisable for adults. Consent for genital/breast examination must be obtained from patient/parent/person responsible if child <14 yrs old. Discuss potential needs/benefits with your partner. Document that assessment was performed; name of person who provided consent; examination findings. ``` Reasons for assessment: 1. Multi trauma: affecting multiple regions, reveal then cover as you go. 2. Localised trauma to genitalia/breast 3. Localised complaint: eg. rash/burns 4. Use of equipment e.g. 12 lead ECG ``` Use simple/age specific language and allow pt to verbalise their concerns. Provide reason for examination + expected findings as well as a description of the procedure.

Answer 15

``` Newborn 120-160 Infant 120-140 1-3 yrs 100-120 3-5 yrs 80-100 10-15 yrs 60-90 ```

Answer 16

Indication: As part of pt assessment where measurement of respiratory status is indicated. NB - Explain procedure and posture the pt - Observe adequate respiratory rate and depth. - Equality of chest movement: thumbs bilateral mid- clavicular line and observe rise and fall of both sides of the chest. - Assess accessory muscle use. - Look and feel for lacerations, swelling, deformity, tenderness, flail segments. - Auscultate: pt to breath through the mouth, compare pairs of auscultation points, min 2x breath cycles per auscultation point.

Answer 17

Indication: Examination of abdomen during secondary assessment. NB - Reassure and explain procedure. - Posture supine, expose abdoment. - Looking for lacerations, swelling, deformity, presence of penetrating injury, distension, rigidity, tenderness. - The most reliable indicator of intra-abdominal bleeding is unexplained shock. - Use fingers in a kneading motion, palpate across quadrants from top working downwards.

Answer 18

Indications: Where blood pressure of a pt is required. NB - Reassure and explain procedure. - Elbow slightly bent, palm up. - Do not take blood pressure on an arm with an arterio/venous fistula, mastectomy or haemophiliac pt. - Arrows on cuff over brachial artery. - Width of cuff should be 2/3 size of pt upper arm. - Inflate 30mmHg above cessation of peripheral pulse (brachial or radial). - Deflate slowly until pulse sounds begin (systolic) continue until pulse sounds cease (diastolic).

Answer 19

Indication: As required NB - Reassure and explain procedure. - Posture 45 degrees, pt to turn head away. - When not distended: occlude jugular where it emerges above clavicle then remove pressure to determine whether it remains distended.

Answer 20

Aim: To determine the percentage oxygen saturation SpO2 in a patient's arterial blood. NB - LEDs emit light at red (660nm) and infrared (905nm) through the capillary bed to a photodiode detector. - The amount of light absorbed by oxyhaemoglobin and carboxyhaemoglobin in the blood determines the oxygen saturation. - The pulse oximeters used by NSWA do not differentiate between oxyhaemoglobin and carboxyhaemoglobin. Any pt with suspected Carbon Monoxide poisoning should be administered 100% O2 regardless of SpO2 readings.

Answer 21

NB - Dispose lancet in sharps bin. - To assist blood flow posture hand/arm down. - Lance the side of the finger to prevent finger pad neuropathy. - Be aware of accidental activation of lancing device. - Avoid squeezing sample site. - Fingertip capillary samples are preferred. - Do not use alcohol swabs on site this can lead to incorrect readings. - LO : < 3.9mmol/L - HI : > 13 mmol/L - Meter range : 1.1 - 27.8 mmol/L

Answer 22

Summary: 1. Raise alarm, Reconnoitre, Report and take command. 2. Move victims from danger + basic field treatment. 3. Move to triage point for labelling. 4. Move to treatment area. 5. Transport to hospital. Raise alarm: - Leave one person permanently attending to radio to relay information. Reconnoitre the whole scene: - Number, severity, position of victims - Presence of danger: fire, electricity ... mobilise special resources. - Use "eyeballs not hands" : under NO circumstances stop to treat a victim. Report: - with detailed account of the situation. Take command, liaise and direct later arrivals. Move from danger: - Move victims from physical danger to safety, irrespective of their injuries. Basic Field Treatment: - Arrest haemorrhage: direct pressure, elevation, tourniquet. - Basic Airway: remove liquids/solids, head tilt, jaw lift, Guedels, recovery position if unconscious (use bystanders). EARLY in the multi-casualty situation, if a pt has stopped breathing or is pulseless, NO attempt should be made at rescucitation. Move pt's to Triage point for labelling: - Red : life threatening injuries. - Orange : non life-threatening injuries. - Green : walking wounded. - White : dead. ``` Red labels to right side of treatment area all others to the left. Red label treatment: - Airway control (guedel, LMA, ETT) - Suction - Oxygen - Haemorrhage control (pelvic splint) - Cannulation, IV fluids - Pain relief - Splinting / bandaging - Cervical collar Details of Rx can now be written on red labels. No red label pt should be left unattended. ``` Transport hospital: - Red labels have priority - Remove corner of tag of pt being Tx. - Marshall green label pt away from site, medically assess and register before allowing them to leave. Little place for ECG monitoring, cardiac drugs etc in disaster situations.

Answer 23

NB - Scene assessment commences as soon as visual contact is made with the scene: provide a brief preliminary report. - Park in a safe location, beacon and parking lights on, headlights off. Lock when unattended unless at a major scene then leave keys in ignition. - Safety: yourself, then bystanders, then casualty. - Reconnoitre scene and triage patients: eyes not hands. - Request additional resources as required. - Helicopter requested? Include patient condition and GPS coordinates. - Sitrep using ETHANE E xact location T ype of incident H azards A ccess / Egress N umber of patients E mergency services (present or required)

Answer 24

Indication: Situations where pt is suspected of experiencing a mental health emergency and requires assessment/ongoing care. Diagnosis: Mental health problems may present as: - Bizarre behaviour / speech - Confusion - Hyperactivity, grandiose or elevated moods - Depressed, sad, withdrawn or distressed mood - States of nervousness, anxiety, panic or excessive concern for health and wellbeing. - Self harm or suicidal behaviour. - Aggression or threatening violence - Physical symptoms without and identifiable organic cause. Assess Scene Safety: Safety of paramedics, bystanders and patients is a priority. - Hx of violence? - Observable threats / inappropriate gestures? - Hx of substance abuse? - Indication weapons may be present or Hx of weapon use? Assess Risk of Violence (assess for signs of impending aggression): - Violence: use of physical/emotional force to harm self/others. - Aggression: threatening harm to others - Hostility: attempting to force people to accept their view even it it entails harm to others. - Anger - Anxiety: state of distress/uneasiness caused by fear of danger/misfortune. - Calm Also look for Hx of violence/agitated behaviour/current disturbed mental state (mania, hallucinations, delusions, paranoia). COMMUNICATION is the first line of management for de-escalation of risk of violence. LISTEN to pt concerns and establish a rapport: - Calmly identify yourself to the pt. - Ask their name and main concerns. - Confirm you are listening/understand by paraphrasing their statement back to them. - Reassure and reaffirm that you want to help. - Communicate with simple words and sentences. Assess current STATE of mental health: S igns and Symptoms indicating abnormal/unusual state of mental health. T houghts indicating delusions, hallucinations, suicidal ideation or illogical thinking. A ppearance T hreats potentially harmful to self / others. E motions indicating sadness, distress, anger or hopelessness. ``` Assess current risk of suicide, THREAT indicators: T hinking of suicide H istory of previous suicide attempts R easons and circumstances E motionally depressed : circumstances hopeless / out of control? A ccess to lethal means T actics and plans ```

Answer 25

Aim: Triage when number of patients exceeds paramedics or patients may have multiple carers recording vitals/treatment. Multiple casualties? "Greatest good for greatest number" - if a pt has stopped breathing or is pulseless, no attempt should be made at resuscitation. NB Clinical resources overwhelmed? State HASFAC authorises "EXPECTANT" category of smart tag ie "expected to die". Fold over corner of Red tag to expose Blue coloured corner. - Record number of pt (of each category) on casualty count card. - After Rx pt is ready for Tx, Loading Point officer removes transport slip from tag and places them in Commander's Folder. - Deceased pt tagged, covered, left in situ. Record date/time/paramedic name/employee number on tag. - CBRN/HAZMAT: fold so CONTAMINATED is facing out. Used in all situations of potential contamination. - Pt identification at night: crack light stick and place into main pocket of plastic sleeve to identify RED pt at night. - Paediatric SMART Tag Tape for use on children <10yrs old.

Answer 26

Aim of Analgesia and Conscious Sedation: Enhance pt comfort whilst facilitating completion of the planned intervention (Limb Realignment / TCP for Bradycardia). NB - gain informed consent where feasible - Limb Realignment: Conscious Sedation - TCP for Bradycardia: Anxiolysis Agency for Clinical Innovation (ACI) Levels of Sedation: - Anxiolysis / Minimal Sedation: pt responds normally to verbal commands & cardiovascular/respiratory function is unaffected. - Conscious / Moderate Sedation: drug-induced depression of consciousness: pt responds purposefully to verbal commands or light tactile touch. - Dissociation: Ketamine dissociative at higher doses: amnesia, catalepsy, nystagmus. Commonly maintain protective airway reflexes and cardiovascular stability but cardiorespiratory depression is possible. - Deep Sedation: pt cannot be easily roused and/or only to painful stimuli. May depress respiratory effort and airway reflexes. - General Anaesthesia: LOC, not rousable even to pain. Can profoundly depress respiratory effort and airway reflexes. ``` - Full pt Assessment: AMPLE A llergies M edications P ast medical Hx L ast ate E vents leading up to ``` - Airway Assessment: ``` - Risk Assessment for high risk pt: MOANS M ask seal (eg beard) O bstruction / Obesity A ged pt N o teeth S tiff lungs / chest ``` LEMONS L ook externally E valuate mouth opening / Thyromental distance M allampati score (not validated in supine pt) O bstruction N eck mobility S pace, Scene, Skill - 360deg access - ear to sternal notch - optimise pt haemodynamics: admin medications/fluids - vocalise emergency plans: in case of deterioration, identify roles - Observations: EtCO2, RR & Effort, SpO2, HR (ECG), BP cycling 2/60 - BP cuff contralateral arm to SpO2 & IV cannula - Prepare all resus equipment - O2 levels, admin via nasal cannula, test suction - Identify Who's responsible for managing airway. - 2x IV access: TKVO - Draw up analgesia and sedation, brief team on dose in mg and ml. - position procedure equipment next to pt: pelvic binding, CT6, spineboard... Roles: Lead + Medications: - Clinical lead - administer medications - respond if monitor & airway technician identifies an adverse event (cease procedure until pt stable). Monitor + Airway: - monitor airway and vital signs Proceduralist: - perform the procedure: TCP for Bradycardia or Limb Realignment. Final Pause Point (shared mental model and CRM): - Are we ready to proceed? - Any concerns? - record time of sedation and perform procedure. Post Procedure: - continue monitoring airway and vital signs + closely monitor pt respiratory / cardiovascular status. - Significant risk of airway obstruction, continued assessment of LOC required.

Answer 27

Indication: Situations where envenomation is suspected. NB - Explain - Pain relief - Apply gauze to bite site - 2x locking turns OVER THE BITE SITE, medial to lateral aspect. - Firm but not tight, check distal pulse / cap refill. - Continue to the distal tip then back up the limb until the entire limb is covered. - Immobilise affected limb, check distal pulse.

Answer 28

Aim: Complete assessment of the spine and neurological status of the patient. ``` NB - Explain - Initial Assessment: AVPU - Secondary Assessment: GCS - Pupil reaction to light: nystagmus, deviated, dilated, non-reactive. - Motor Function * Upper Limbs - Pull, push away, push out - Assess strength, compare left/right * Lower Limbs - Feet: pull up, push down - Lateral Tibia: push out ``` - C4 Shoulder shrug - C5 Bend Elbow - C6 Open/Close hands - L1/L2 Flex hip - L3 Extend Knee - L4 Pull foot up - L5/S1 Push foot down - Use FOREHEAD as guide to gauge normal sensation. Light touch, upper/lower limbs, hands/feet - Midline spine: gentle circular motion with opposing thumbs on spinous processes. Dx of Spinal Cord injury in Unconscious pt: - Paradoxical respiration - Flaccid limbs - Loss of response to pain below level of lesion. - Loss of reflexes. - Erection (unconscious male) - Low BP but normal pulse of bradycardia.

Answer 29

Indication: Forearm, wrist, fingers require splinting NB - Explain - Pain relief - Expose - Distal pulse & realign - Dress wounds if necessary - Pad anatomical hollows ``` 4x Triangular bandages - Narrowfold proximal to # - Narrowfold distal to # - Narrowfold around hand unless splint is for hand/wrist then broadfold distal to elbow. - Check distal pulse/perfusion. ```

Answer 30

Indication: Lower leg # requires immobilisation. NB - Explain - Pain relief - Support # site - Normal alignment. - Expose - Check distal pulse. - Splint extends from upper thigh to heel. 5x Triangular bandages - Narrowfold proximal to # - Narrowfold distal to # - Broadfold upper proximal thigh - Narrowfold figure 8 around foot - Broadfold around knee - Patella # similar except 4x triangular bandages, and none around knee. - Periodically check splint tension. - Monitor distal pulse.

Answer 31

Aim: Immobilisation of # femur where knee / neck of femur injuries have been excluded. Contraindications: - Suspected pelvic # where pelvic binding is not in place. - Fractured hip / neck of femur. - Knee, lower leg and ankle injuries should not have traction applied. NB - Explain. - Pain management. - Expose, remove footwear. - Check distal pulse, cap refill, motor-sensory function. - Measure splint beside leg: just below ischial crest - 15cm beyond foot. - Ischial strap : buckle on top. - Pad ischial strap and ankle hitch. - Velcro straps do not wrap around tubing. - Velcro strap: 1. Above #. 2. Above knee 3. Below knee. 4. Above ankle hitch. - Support #, apply traction slowly until # reduced. - Recheck distal pulse, cap refill, motor-sensory function. - Irrigate and remove all debris from compound # and cover with saline moistened sterile dressing prior to reduction. - Reduction of a compound # is in line with trauma guidelines to reduce neurological damage, shock and infection risk. - CT-6 can be used to immobilise knee and # below the knee without traction if cardboard box splints are not feasible. - Pelvis AND femur # : pelvic splinting PRIOR to applying CT-6.

Answer 32

Aim: To reduce a pelvic #, provide mechanical stability to pelvis and reduce blood loss. Indication: ALL pt with ANY: - Primary survey positive to C - circulation: haemodynamically unstable and/or hypovolaemic shock. - Signs of pelvic # including pain in pelvis, hip, groin or lower back. - Suspicious mechanism (even if currently haemodynamically stable). High risk groups: - Motor vehicle crash especially with pt side impact. - Vehicle v pedestrian / cyclist - Motor bike crash - Crush or compressive force - Pt >65 yrs of age - Fall from height >3m or 2x child's height for paediatrics. - Fallen from / trampled / crushed by livestock. Increased index of suspicion: - Abrasions and contusions around the pelvic area. - Superficial haematoma above inguinal ligament, scrotum and thigh. - Limb length discrepancy and deformity. - Examination of rectal / vaginal areas for bleeding. - Pt with decreased LOC or Hx of LOC - Drug or alcohol affected - Significant distracting injury. Contraindication: - T-Pod not designed for classic #NOF: leg shortening and rotation (the device will compress the # site). - Pelvis must NOT be sprung or compressed, gentle palpation. - ALWAYS apply pelvic binding when indicated even in urgent Tx situations. Blood loss from a pelvic # can exceed 2L. - Align - Remove clothing, pad between ankles and knees - Secure legs with triangular bandage, protect modesty - Position with Greater Trochanters to middle of belt. - When pt lying supine, wrist is inline with greater trochanters. - Attach exterior XRD tab to tension applicator on same side as history is recorded. Record information on Hx label. - Periodically recheck tension. - Concurrent pelvic and femur splints should be applied (in that order) if indicated. In this case position ischial strap of CT-6 low and horizontal to the leg as possible to avoid disrupting pelvic #. - Apply T-Pod alone if pt haemodynamically unstable and/or pt has a deteriorating airway requiring time critical transport. - When considering a T-Pod also consider a collar and vice versa. - Do NOT remove T-Pod for another device and question any decision to remove pelvic binding. - Bariatric pt: join 2x T-Pods together. Small paediatric: broad triangular bandage should suffice instead of a T-Pod.

Answer 33

Aim: Stabilisation of the head and neck in a pt with a suspected cervical spine injury. Contraindications for moving pt head to an in-line position: If ANY of these occur, pt head/neck should be stabilised in the position found. - Resistance to movement. - Neck muscle spasm - Increased pain - Presence or increase in neurological deficits during movement. - Compromise of the airway or ventilation. NB - Provides a degree of stability to the cervical spine prior to application of a cervical collar. - Adult: padding under the head - Paediatric: padding under the upper torso.

Answer 34

Aim: Support cervical spine in neutral position. NB - Explain - Apply manual in-line stabilisation. - Remove clothing/jewellery that may interfere. - Fingers to measure: trapezius to angle of mandible: matches bottom plastic edge to size window on collar. - Apply collar while maintaining neutral head position. - Adult: Padding under occiput - Paediatric: Padding under shoulders - 10deg upper body elevation acceptable with concurrent head injury management. - Sandbags : prevent lateral movement. - In trauma 40% of cervical # have another spinal # as well. - Oversized collar may hyperextend pt cervical spine. - With clavicle injury do not persist with application of collar if pain / distress / non-compliance. The aim is just to minimise movement and it defeats the aim if it causes pt to move more. Warning: - Do NOT adjust size of collar whilst on pt, remove and resize. - Do NOT transport on extrication board: do not support neutral alignment, pressure areas, issues with restraining.

Answer 35

Aim: Immobilise cervical, thoracic and lumbar spine to prevent movement during pt extrication. Contraindications: - Urgent transport situations eg head injury with decreased LOC. NB - Explain - Manual in-line stabilisation. - Cervical collar. - Safe working load = 130kgs - Top of NIEJ no higher than top of pt head. - Red/Grey pads to fill space between occiput and NIEJ.

Answer 36

Aim: To avoid movement and provide stabilisation of the injured spine while pt is assessed and moved. ``` NB - Explain - PPE - Utilise principles of CRM + teamwork and communication. - Arms across chest, legs together. - Cervical collar. - Axial alignment of the head and neck. - Team leader manages cervical spine alignment and is in control of the roll. - Physical examination of the spine. - If pt lying prone, (if possible) raise arm over head to allow a flat roll. - Remove any foreign objects eg glass. ``` Complications: - Possible airway compromise in pt with decreased LOC positioned supine. - Log roll may exacerbate orthopaedic injuries and pain.

Answer 37

Aim: To safely move pt with possible spinal, multiple injuries or general pt movement. NB - Explain importance of minimal movement - Remove excess clothing, jewellery and obstacles. - Pain management. - Manual inline stabilisation (MILS) and collar. Immobilisation of pt spine to be maintained throughout procedure. Sandbags to minimise lateral movement. - Adjust length of scoop. Ensure both ends are locked. - Pull clothing taut to reduce risk of pinching. - 2x straps across chest, 2x straps across pelvis, 1x strap across ankles.

Answer 38

Aim: Extrication of a pt in difficult circumstances and movement from ground to stretcher when spinal immobilisation is required. Complications: - Pressure points. - Misalignment of the spine. - Pain and discomfort NB - Explain importance of minimal movement - Maintain MILS and spinal care throughout procedure. - Stretcher flat, brakes applied. - Arms across chest. - Log roll up, log roll down onto extrication board. - Non compressible padding under occiput (adult) torso (paed) . - Straps + immobilise head. Extrication of a sitting pt: - If indicated apply NIEJ. - Spineboard under buttock, rotate 90deg, lower onto board then slide up the board. - Ensure spine and head is kept in constant alignment. - Proper lifting technique. - Sufficient personnel available and briefed. - Aware of skin pressure areas. - Spineboard NOT to be used during pt transport.

Answer 39

Indication: Where open wounds require haemorrhage control and protection against infection. NB - Explain - Pain relief - Dressing should extend well beyond wound area. - Dressing should be adequate to absorb exudate. - Irrigate wound with saline. - Clean intact skin around wound with moistened sterile gauze swabs. Swab from wound edge outwards. - Remove foreign bodies. - When removing sterile dressing from packaging CAREFUL not to contaminate the side of the dressing that will be in contact with the wound. - Apply additional dressings of the same size if dressing becomes saturated with exudate. - Do NOT attempt to push protruding viscera back into abdomen. Eye injury excluding penetrating foreign bodies: - Place dressing lightly over injured eye. A sterile dry light dressing may be placed over first dressing. - Use NO pressure over eyes. - Do NOT bandage uninjured eye. ``` Extruded eyeball: - Cover with moist dressing. - Do NOT handle or attempt to replace eyeball into socket. - Protect eyeball with cup/cone. ```

Answer 40

Aim: Stop burn process, cool burn, apply appropriate dressing, pain management. Caused by heat, cold, gases, friction, radiation. - Partial: superficial, mid, deep dermal - Superficial Dermal: severe sunburn, blisters, erythema - Mid-Deep Dermal: creamy colours, mottled - Full thickness: whitish leather / charring ``` Cooling: - cool running water minimum 20min - submerge - soaked sterile dressings refreshing water in dressing every 2-3min. ``` - Chemical burn: remove/brush dry chemicals from skin prior to cooling. - Be alert for hypothermia (especially if large TBSA) - Remove jewellery, burnt or wet clothing unless melted/stuck onto skin. - Sterile burns dressing: apply shiny non stick side to burn. Maintain sterility when removing from packaging. - After cooling, pat dry with a sterile dressing. - Apply plastic film longitudinally. Do NOT wrap circumferentially. Do NOT inhibit swelling. Do NOT apply to facial burns. Do NOT apply to chemical burns. Hydrogel: - enough to cover BSA and ~50% of surrounding non burnt area. - Only if no water/other fluids and only if TBSA < 20% ``` Airway Involvement HISSCA: - Hoarse - Inspiratory Stridor - See-Saw breathing - Singed facial and /or nasal hair - Carbonaceous material around the mouth/ nose or in sputum. - Anterior burns to the neck. ``` Significant burns: - burns with inhalation injury or trauma - All circumferential burns - Partial or Full thickness: Adult > 20%, Paed >10% TBSA. - Special areas: head, face, neck, hands, feet, genitalia, perineum and major joints. - Electrical / Chemical - Burns in very young and older patients. - Pregnant patients. - If possible elevate burn area to reduce swelling.

Answer 41

Aim: Removal of impacted/superficial/simple fishhook from a safe body location with minimal pain/further damage to tissue. Exclusions: - Deep structure involvement: nerves, tendons, arteries, cartilage, bone (refer, may require antibiotics) - Wounds into joints - Loss of function - Face or neck. - Eyelid considered penetrating eye injury until proven otherwise. - Multiple barbs in situ must be referred. LAP exclusions: - Diabetes - Hx impaired wound healing - Hepatic disease. - Immunosuppressed eg. steroid, chemotherapy. Safety PPE - Goggles - Thick gloves - Long sleeves Procedure: - Sight a hook from the same packet - Swab/clean site and fishhook. - Wrap string around midpoint of shank - Shank/Eye must be depressed to elongate entry hole. - Quick firm jerk while continuing to exert downward pressure on shank/eye (elongates entry site). - EVERYONE should remain out of line of flight of the hook. - Clean /dress wound area, checking for foreign bodies (bait/sand/shell grit) Tetanus up to date? Advise re Infection: - Temperature - Redness - Swelling - Pain

Answer 42

Aim: Remove tick without leaving parts in situ. - Engage tick twister by approaching from the side. - Lift tick twister lightly and twist. - Clean wound with antiseptic wipe. - In some areas Anaphylactoid reactions may occur, monitor for 20min post tick removal. If Hx reaction have Adrenaline and resus equipment ready. - Tetanus immunisation status? Seek medical advice if following symptoms: - Rash, fever, muscle and joint pain, arthritis, headache, swollen glands, flu-like symptoms (24-48hrs) For multiple small ticks (more likely to release toxins) 1x cup of Bicarbonate of Soda in the bath.

Answer 43

Aim: Wound cleaning and dressing to promote healing and prevent infection. - Hand hygiene. - PPE - Gather equipment, prepare environment. - Hand hygiene. - Open dressing pack using edges. - YELLOW (dirty) forceps unpack contents into tray. Store them at the edge of the sterile field. - Sterile paper dressing towel under wound/dressing site. - Fill tray with irrigation solution. - Drop sterile items from their packaging into sterile field. - YELLOW (dirty) forceps = patient contact only. - BLUE (clean) forceps = used within the sterile field. - BLUE pass gauze from sterile field to YELLOW forceps. Do NOT allow two forceps to touch or contaminate each other. Cleaning wound: - Soak gauze in NaCl - Clean wound with circular motion from inside to out. - After one swipe of wound discard swab into clinical waste bag. - If contact with wound/fluid/blood, re-gloving is appropriate.

Answer 44

Aim: Aseptic non touch technique to clean skin tear would and apply dressing to aid in healing and prevent infection. - Hand hygiene. - PPE - Analgesia - Explain procedure. - Gather equipment, prepare environment. - Hand hygiene. - Open dressing pack using edges. - Drop sterile dressing onto sterile field. - Do NOT touch the sterile pad of the dressing. - Sterile gauze, dry wound. - Approximate wound edges, do not stretch skin flap. - Ensure adequate coverage of wound edges. - Date, draw arrow in direction of skin flap. - Allevyn Gentle Border dressing can remain in situ for up to 7 days. - Advice re signs/symptoms of infection.

Answer 45

Aim: Accurately measure and administer IV fluids and medications. - Ensure infusion set and fluids are intact, in date, without discolouration or sedimentation. 1. Pump Set - Compound Sodium Lactate >= 16 yrs - Drip Factor = 20 drops/ml - All clips and regulators are closed, then insert spike into fluid bag. 2. Burette Micro-drip (with IV line) - Precise infusion - should ONLY be used if syringe driver is not available. - Oxytocin Infusion (post-partum haemorrhage) - Adrenaline Infusion (anaphylaxis, bradycardia, cardiogenic shock, post ROSC) - Drip Factor = 60 drops/ml - Burette air vent is open. - All clips and regulators are closed, then insert spike into fluid bag. - Fill Burette with required amount of Compound Sodium Lactate (measure from top of swim valve): * Adrenaline Infusion : 90ml * Oxytocin Infusion : 59ml - Swab injection port, add medication (Adrenaline / Oxytocin) and label burette. Ensure solution is adequately mixed. - Squeeze lower half of drip chamber until half full. - Prime the line until ALL air expelled. Medication MUST be added prior to priming. 3. Burette Flow-Through (metered infusion without IV line) - Compound Sodium Lactate <= 16yrs - 10% Glucose (Adult / Paediatric) - Drip Factor = 20 drops/ml - Filtered vent open (fluid will not flow if vent closed). - Fill chamber with 100ml to prime giving set. - Top of fluid is the measured amount. - Insert pumpset spike. - Prime infusion line - Top up chamber to dose required. Complications: - Air in the infusion line. - Introduction of infection - Increased risk of extravasation injury when using a pumpset and administering medications/fluid under pressure. Labelling: - A burette label (blue) must be attached to the burette chamber after a medication is added. - Text must be upright, graduations not obscured. - Label infusion line close to pt: small infusion label and medication label.

Answer 46

Aim: Safe preparation and administration of medications via SC and IM routes. - Reassure - Explain and gain consent. - Hand hygiene - Select and clean site - Contraindications, 5 Rights, cross-check - PPE - SC: Deltoid. - IM: mid third of thigh, deltoid is second option. - SC: 25g x 25mm (Orange) - IM: 23g x 25mm (Blue) - Hand hygiene - Sharps container as close as practical to point of generation and use of sharp. Subcutaneous (volumes <= 1ml): - Squeeze up fold of skin - Insert needle 45deg, bevel uppermost, 2/3 length of needle. IM (volumes <= 5ml): - Pull skin taut - Insert needle 90deg Both: - Ensure no blood is aspirated. - Inject. - Dispose of sharp with a single hand motion in to sharps container. - Apply direct pressure with gauze or alcohol swab. - Hand hygiene. - If blood aspirated, withdraw slightly, rotate 180deg, and re-aspirate. - If second aspiration contains blood, withdraw, discard needle and syringe, new site, fresh dose. Gloves must be worn when performing a BGL or IV Cannulation - reduces risk of acquiring blood borne virus after needle stick injury. However, gloves are not required when performing IM or SC injections.

Answer 47

Aim: Safe effective delivery of treatment without discomfort or tissue damage. ``` Complications: - Extravasation: Do NOT remove cannula. Aspirate as much of the residual medication as possible. Determine amount of medication extravasated / infiltrated. - Thrombophlebitis - Haematoma - Venous air embolism - Disconnection ``` Cannula Removal: - Remove adhesive dressing - Sterile gauze over insertion site - Pull out cannula in one motion, inspect for completeness. - Firm pressure ~60sec, confirm bleeding ceased. - Apply dressing Procedure - Explain - Obtain consent - Select site - Tourniquet - Consummables - Protective eyewear - Hand hygiene - Gloves - Clean site (2+ swabs): circular, outwards - Place upright sharps containers as close as practical to the point of generation. - Inspect all sterile items: packaging intact, in date. - Bluey for clean field to work on - Do NOT touch site between cleaning and insertion. - Remove tourniquet then withdraw needle from hub in single controlled motion (blood leakage may occur if needle withdrawn too slowly or pt on anticoagulants). - Transparent dressing: insertion site visible. - One strip across hub. - Second strip across reflux valve. - Date / time - Swab reflux valve injection port, flush to confirm patency. - Hand hygiene - Secure sharps container. ``` Veins to avoid: - Thrombosed, Sclerosed, Fibrosed - Inflamed, bruised, thin, fragile - Near bony prominence, areas of flexion - Prefer upper limbs - Arteriovenous fistulae/shunt - Arms on the side of: Chest trauma Previous lymph node dissection Mastectomy Affected by stroke Infection eg cellulitis Multiple previous punctures. ```

Answer 48

Aim: Administration of medication via a Nebuliser. - Load medication through top opening (without disassembling device). - O2 at 8L/min - T-piece between resus mask and resuscitator bag or attach inline using a flexible catheter mount (for LMA/ETT). - Severe/Extreme Asthma: hyperinflated chest, difficulty exhaling. If they require inspiratory assistance they often also require expiratory assistance.

Answer 49

Aim: Administration of drug therapy via atomised particles through the nasal mucosa. - Explain procedure - Ensure pt can breathe freely. - PPE: eye protection, respiratory mask, gloves should be worn at all times when administering an atomised medicaiton.

Answer 50

IM / SC injections: - Draw up entire dose - Attach giving needle then discard excess (accounts for dead space in giving needle prior to administration). ``` Confirm: - Correct medication - In Date - No sedimentation - Cross check with partner (5 Rights: Patient, Medication, Dose, Time, Route) ``` When dissolving Benzyl Penicillin, Hydrocortisone, Glucagon: - Ensure total dilution has occurred prior to drawing up. This will then exceed total volume of diluent originally added. Glass Ampoules: - Wear safety glasses when opening glass ampoules. - Break Ampoule head with dot facing AWAY. - If not using an ampoule breaker, place a barrier between neck of ampoule and your finger before opening to reduce risk of injury. - ALL medications must be labelled EXCEPT when preparation and bolus administration of a SINGLE medication are one uninterrupted process: syringe does not leave hands of person who prepared it, same person administers the medication immediately. - Prepare and label only one medication at a time. - Place label parallel with long axis, top edge flush with graduations.

Answer 51

Aim: Administration of medications / fluids in paediatric patients when IV access is unavailable. Proximal Tibia: - 1-2cm inferior to tibial tuberosity, middle flat surface, medial aspect of the tibia. Distal Tibia: - medial surface of the tibia just above medial malleolus. Contraindications: Defect the cortex of the chosen tibia: - Fracture of that bone, or - Previous attempts which penetrated the cortex of the bone. - Infected skin overlaying insertion site. Complications: - Extravasation, check site frequently for signs of swelling and needle displacement. - Infection - Damage to bone growth plate - Possible fracture of the site if excessive force applied. Procedure: - Eye wear - Hand hygiene - Gloves - Clean site - Inspect packaging: intact, in date - Lay out items on a clean field - bluey - Do NOT touch between swabbing and insertion - Insert at 90deg - Hold needle in palm with fingers extended to tip of needle: moderate forward pressure + slight twisting motion. - Angle needle away from growth plate - Do NOT wobble, a "V" shaped hole = extravasation - Placement confirmed by sudden loss of resistance and needle independently standing + infusion of 10ml of fluid without extravasation. - To remove needle: rotate counterclockwise, do NOT pull! - Secure infusion line with hinged tape technique. - ALL fluid to be measured and administered by a 10ml syringe.

Answer 52

Aim: Emergency vascular access in critically ill or injured pt where other methods are impossible within an appropriate timeframe. i.e - 2x previous failed cannulation attempts - access not established within 2min of the first attempt. - IO may be route of choice for shocked, paediatric or burn pt. Authorised IO insertion sites: - Proximal / distal tibia - Proximal Humerus may only be used in major abdominal, pelvic or lower limb trauma (VCP must be submitted). Proximal Tibia: - ADULT: 2cm medial to tibial tuberosity on flat aspect of the tibia. - PAED: 1cm distal, 1cm medial to tibial tuberosity on flat aspect of the tibia. ``` Distal Tibia: - ADULT: 3cm proximal to medial malleolus. - PAED: 1-2cm proximal to medial malleolus. ``` Proximal Humerus: - Greater tubercle of the humeral head. - Adduct elbow and internally rotate humerus: - Arm by side, thumb under buttocks - Forearm across abdomen - Ulnar aspect of hand anterior axillary line - Ulnar aspect of hand middle of upper arm laterally - Thumbs together = vertical line for insertion - Palpate surgical neck (like a golf ball): most prominent aspect of greater tubercle 1-2cm above surgical neck. - IO Needle at 45deg to anterior plane Contraindications: - Fracture in targeted bone - Previous IO attempts which penetrated the cortex of the bone. - Inability to locate bony landmarks at insertion site. - Infected skin overlaying insertion site. - Prosthesis / previous othopaedic procedures near insertion site. - IO must NOT be placed in the sternum. Complications: - Extravasation, check site frequently for signs of swelling and needle displacement. - Permanent injury may result from placement of IO into growth plate. - 1% Lignocaine as local anaesthetic prior to insertion is not essential but may be considered. - ANY limb where IO was attempted must be labelled with bracelet/anklet from IO kit. 3-49kg : 15mm Pink >= 3kg : 25mm Blue >= 40kg (or excessive tissue) : 45mm Yellow Prepare: - Hand hygiene. - Attach needle to driver - Prime extension set - Dressing - Sharps container Procedure: - Explain - Hand hygiene - PPE - Clean site Insertion: - Control pt movement prior/during insertion - Insertion 90deg to bone - Push (not drill) needle through skin until tip contacts bone. - 5mm of catheter visible ie 1x black line: if <5mm insufficient cannula will penetrate cortex = poor flow, extravasation or dislodgement. - Squeeze driver trigger and apply gentle steady pressure until loss of resistance (1-2cm). Do NOT use excessive force. Hub should be close to/or in contact with skin. PAED: "pop" or "give" as needle enters medullary space. - Remove driver, support catheter and unscrew stylet. - Secure catheter with dressing - Attach primed extension set to catheter hub luer lock. - Confirm placement by aspiration / flush. NO FLUSH = NO FLOW - Monitor for extravasation. - Document EZIO needle size and insertion site in emr.

Answer 53

Aim: Safe administration of medications and fluid. ``` Procedure: - Provisional Dx, establish need to admin medications with your partner. - Check allergies, contraindications - Name the medication you're about to give and ask if they've had any reactions - Check 5 Rights: Patient Medication Dose Time Route ``` ``` Pre Admin Check - Expiry date - Integrity of packaging (at start of shift) - Sediment - Partner to read out: Name of medication Weight and Volume Expiry date - Extra care cross checking: Look alike Sound alike High risk medications - Confirm repeat dose with partner ``` - Write strength on medication label - Do NOT resheath drawing up needls. - Partner to witness administration and disposal of (unused) medications - Document medication administration/disposal in emr. - Record in medications register. National Standard for User Applied Labelling of Injectable Medications, Fluids and Lines: - ALL medications must be labelled EXCEPT when preparation and bolus administration of a SINGLE medication are one uninterrupted process: syringe does not leave hands of person who prepared it, same person administers the medication immediately. - Prepare and label only one medication at a time. - Place label parallel with long axis, top edge flush with graduations.

Answer 54

Aim: Administration of continuous fluid / IV medications during inter-facility transfers. ``` Setup: - Turn ON - Green connector in green slot - Blue clamp in blue slot - Unit conducts self test - Use Up/Down arrows to select Volume/Flow Rate then OK. - Check for air in line - Connect IV to patient - Press Start or C to modify volume/rate ``` ``` Pressure Management Downstream Occlusion: - check line and cannula, usually caused by: * Kinked line * Blocked cannula * Small cannula - Default pressure = 400mmHg - Maximum pressure * 750mmHg Adult * 450mmHg Paed * 100mmHg Neonate - 'menu', access pressure management, define upper pressure limit. ``` Upstream Occlusion: - Always : * Closed clamp * Kinked line - Release clamp, unkink line, restart ``` Air Bubble: - remove line from pump - move air bubble to top of line: roll around pen until air rises into drip chamber - use syringe at port to expel air ``` - Internal battery 8hrs @ 125ml/hr - 25ml fluid in total length of line

Answer 55

Aim: Administer IV Enoxaparin Sodium via Microbore Extension Set. Procedure: - Hand hygiene - Fill 10ml syringe with NaCl - Check reflux valve firmly attached to extension set. - Attach 10ml syringe to reflux valve - Prime line with 1ml NaCl, leave 9ml in syringe connected. Reflux valve is NOT fixed to extension set, take care when removing syringe. Place on sterile surface of packaging. - Priming will prevent air embolism and reduce clot formation. - Cannulate - Attach primed Microbore Extension Set. - Flush - Secure cannula - Loop extension set between luerlock and injection port and secure reflux valve with tape. ``` IV Enoxaparin Sodium: - ONLY use injection port for administering IV Enoxaparin Sodium...ALL other medications / flush / fluids must be administered via reflux valve. - Flush - Insert needle through injection port. - Inject dose. - Discard sharp. - Flush through reflux valve. ``` Dose: - 18 - 74 yrs: 30mg / 0.3ml Enoxaparin Sodium. Pre-filled SC syringe (orange plunger) 60mg / 0.6ml is the IV dose only.

Answer 56

Aim: Delivery of Salbutamol via an MDI and spacer. (Reduces the risk of droplet inhalation by paramedics) Contraindications: Severe / Life-threatening presentations where administration of nebulised Salbutamol / Ipratropium Bromide is indicated. Assembly: - Hand hygiene - Press down and lock top inhaler port panel. - Squeeze middle of long sides to make spacer pop up fully and side panels snap into place. - Inspect mouthpiece and chamber to ensure no foreign bodies. Preparation: - Hold MDI upright and shake well. - Prime MDI: release 2x metered doses into the air. - Insert MDI mouthpiece into spacer inhalation port. Administration: - Close lips firmly around mouthpiece and form a good seal. - Gently exhale. - Release 1x puff of Salbutamol into spacer. - Each puff contains 100mcg Salbutamol. - Pt to breath IN/OUT 4x without removing mouthpiece between breaths. - Repeat for required dose. NB MDI and spacer are single pt use only and must be disposed of after use. MDI is NOT to be left with the pt. Remove MDI canister from plastic holder and place in sharps container.

Answer 57

Aim: To administer IV infusion of medications requiring continuous delivery at a precisely controlled infusion rate. Adrenaline: 1mg/1ml + 49ml NaCl ie 1mg in 50ml Oxytocin: 10IU (1ml) + 49ml NaCl ie 1ml in 50ml Prepare: - Connect syringe to extension set and manually prime to remove all air. - Label infusion line close to pt end: small 'infusion' label and blue medication label. - Label syringe: blue infusion label. Install syringe: - ON ensure all LED lights blink. Unit must be on when syringe is installed so syringe size is detected. ONLY done when pt is NOT connected. - disengagement lever down, plunger driver to right - fit syringe into cradle with ml increments facing outwards, flanges correctly inserted into slot. - Secure syringe - Move plunger driver to left until in contact with plunger. ``` Settings: - Select profile: adult, paed, neonate - Select syringe, OK to confirm - Navigate drug library - Select medication - Select infusion flow rate Adrenaline 5mcg/min = 15ml/hr Oxytocin 50ml/hr - OK to confirm, C to change - Connect to pt, must be dedicated infusion line, do NOT connect to pump set line. - Check infusion settings - 'Start' to commence infusion ``` To adjust infusion rate: - 'Stop' - press arrow keys to adjust rate - 'Start' to recommence infusion End of infusion (<5ml or <10% of syringe capacity remaining): - audible alert, yellow lights flash - 'Stop' - 'ON / OFF' and hold until pump powers down. Pressure alarms: - Identify and rectify any issue with line eg occlusion - Detach infusion, rapidly flush with 10ml NaCl - Reconnect infusion and prepare to increase pressure if necessary - Increase Pressure Alarm: * press the gauge symbol * 'Enter' * use arrows to increase pressure limit * 'OK' twice to accept - IV access is preferable, IO should only be considered where IV access not possible. IO route, pressure alarm may sound due to increase resistance of the IO space. - Continually monitor infusion site for extravasation. - NIBP on contralateral arm to infusion, set to 2min intervals during infusion. - Adrenaline - slowly incr/decr flow rate to maintain pulse/BP within normal ranges.

Answer 58

Aim: Administration of continuous fluid or IV medications during inter-health facility transfers. - Does NOT include blood products unless paramedic has completed Blood Safety Training (My Health Learning) - Medication being infused does NOT need to be within the paramedic's skill level or a medication used by NSWA. - It is the responsibility of paramedics to ensure a comprehensive clinical handover ... to ensure they understand all care requirements for the patient during transport, including discussing what to do if alarm problem solving fails. - It is the responsibility of the referring hospital to ensure remaining dose medication is prepared and connected without the need for paramedics to change syringes during transport. - Run infusion per instructions from sending facility. BEFORE accepting care of a patient the following questions should be asked: - Is the infusion necessary or could it be stopped for the duration of the transport? - Details of medications being infused: name, dose, strength. - Infusion rate (ml/hr)? - Possible complications from the medication? - Monitoring required during the infusion (BP, HR, ECG etc)? - What to do if infusion finished: flush, disconnect, continue with Hartmanns? - If unresolvable issues, can infusion be ceased until arrival at destination? - Name and direct contact number from sending hospital, to contact if issues arise (cannot be general department / switchboard number)? - Power cord? If not, what is battery life? NB - Lower level alarms, orange lights, infusion continues. - Higher level alarms, red lights, infusion stops. - Alarms must be silenced before they can be rectified. Downstream Occlusion: Increased pressure between device and patient: - kinked line - blocked / kinked cannula - dislodged cannula - closed clamp Upstream Occlusion: Increased pressure between Infusion bag and device: - kinked line - closed clamp - infusion bag has run out ``` Air: - Clamp line at patient end - Remove line from device Either: - move air bubble to end of line - run air out of line until removed OR: - attach syringe at side port - clamp distal to side port - draw out air and discard ```

Answer 59

Indication: Motorcycle accident where mechanism of injury suggests likelihood of spinal damage/compromised airway. Process: - Reassure - Emphasise minimal head movement - Remove any glasses in situ - Log roll lateral - Cut helmet head strap - Adjust helmet so back of head/neck exposed - Support chin/cervical area, maintain neutral head alignment. - Remove helmet by pushing superiorly on rear of helmet. - Cervical collar spinal immobilisation.

Answer 60

- Shocked patient unless dyspnoeic. - Spinal injuries - Diving emergencies - Cardiac Arrest

Answer 61

Severe Hypovolaemic Shock

Answer 62

Abdominal Injuries

Answer 63

- Unconscious (non intubated) - Syncope - Continuous vomiting OR upper airway bleeding with decreased LOC - Chest injuries with severe flail or pulmonary haemorrhage with AFFECTED SIDE DOWN.

Answer 64

- Pregnant, >20 weeks gestation, if hypotensive - Venous air embolism from lacerated major neck veins - Dialysis emergencies

Answer 65

Prolapsed umbilical cord

Answer 66

- Respiratory distress (conscious) - Facial / Neck injuries unless major neck veins are lacerated. - Eye injuries - Suspected myocardial ischaemia - Hypertensive crises - Epistaxis - Croup and Epiglottitis - Vomiting (conscious)

Answer 67

Cardiogenic Pulmonary Oedema

Answer 68

All head injuries

Answer 69

Aim: Ferno Descender Tracks...assist in transporting a person down steps. Load Capacity of carry chair: 150kg Tracks can be attached with/without a person already sitting in the chair + brakes applied. It is mandatory to have 2 operators guiding the chair down the steps at all time. Procedure: - Weight of the pt assists with the locking mechanism. - 2 audible clicks: * catch locks on the axle * pins lock in place in the anchors - Ensure pt is securely restrained - Lock wheel brakes - Deploy tracks - Extend handles - Tilt chair - Engage track belts, establish glide angle by moving chair slowly downwards. - Descend steps, maintaining guide angle. - Push down on closing bar to fold linkage. - Detach tracks from carry chair - Clean: remove visible soil - handbroom

Answer 70

Aim: Engage Gluteal and Hamstring muscles to produce greatest amount of force and strongest lift. Safely lift heavy weights from shin height and above. Used For: - Carry Chair - Spineboard / Combi-carrier (not from ground) / Patient movement. Procedure - Keep load close to body - Firm grip - mixed grip is stronger - Push hips back - engages gluteal and hamstring muscles. - Chest over top of arms - Pull shoulder blades back and down - ensures load remains close to body and takes load off lower back. - Full foot contact with ground - NO heel lift. - Deep breath and brace abdominal muscles - spinal stability.

Answer 71

Aim: Used to carry light/moderate loads held by the side: medical kits / Lifepak 15. Engage shoulder girdle and forearm muscles. Procedure: - Ensure load as close to the body as possible. - Pull shoulder blades back and down - safe position, prevents them from rolling forwards and ensures load remains close to body. - Don't cross steps or take large steps Used For: - Kit bags Complications: Failure to keep load close to the side of the body will increase stress on the shoulder girdle and lower back.

Answer 72

Aim: Lateral lunge ensures safe weight shift. Used when space is limited to help sit a pt upright. Engage quadriceps, adductors, gluteals and hamstring muscles for strongest possible lift. Safely pick up/shift moderate weight from a shin/knee starting position. Procedure: - Load being lifted is close to front leg. - Push hips back, shift weight towards leg closest to load. - Hips back allows for greater range of movement and safe distribution of weight. - Do NOT use this lift for heavier patients. - Front knee is behind toes: front knee over toes indicates potential lack of proper technique and might not engage stronger muscles - Chest forward - Pull shoulder blades back and down: load remains close to body and takes stress off lower back. - Full foot contact, NO heel lift. Used For: - Kit bags - Patient movement. Complications: Failure to keep load close to the side of the body will increase stress on the shoulder girdle and lower back.

Answer 73

Aim: Similar to treating position stance. Used when space is limited or load is close to the ground. Engage quadriceps, adductors, gluteals and hamstring muscles for strongest possible lift. Maintain balance and stability in the treating position. Procedure: - Load being lifted is close to front leg. - Drop back knee towards ground: encourages upright torso and greater range of movement. - Hands in a comfortable position: underhand, overhand or mixed grip. Mixed grip is STRONGER, encourages safe shoulder positioning of leading arm. - Front knee ~90deg angle - Chest forward. - Pull shoulder blades back and down: load remains close to body and takes stress off lower back. - Full foot contact, NO heel lift. - Deep breath and brace abdominal muscles. - Ensure load close to body once in standing position: maintains spinal stability and reduces load on lower back. Used For: - Carry chair - Spineboard / Combi-carrier - Carry sheet - Kit bags - Patient movement.

Answer 74

Aim: Lift used when space is limited / reach over an obstacle. Engage gluteals and hamstring muscles for strongest possible lift. Lift moderate weight from a shin/knee starting position. ``` Procedure: - Ensure load is close to the body. - Hips back - to prevent lower back rounding. Engage hamstring and gluteal muscles. - Chest towards the ground. - Pull shoulder blades back and down - Mixed grip. - Full foot contact, do not lift heel. - Deep breath, brace abdominal muscles: maintain spinal stability. ``` Used For: - Carry chair (top) - Spineboard / Combi-carrier - Kit bags - Patient movement.

Answer 75

Aim: Safely assist the ambulant bariatric patient onto the stretcher. Suitable for patients able to weight bear and walk to the stretcher. 2-4 operators dependent on pt weight / girth. Procedure: - Explain - Reassurance - Lay stretcher flat, close to pt as possible and lower to pt knee height, wheels locked, brakes on. - Adequate 360deg access to stretcher - Hovermat on stretcher prior to loading pt if anticipated for later transfer at hospital. - Sheet perpendicular to stretcher on upper third of stretcher, 30cm of sheet should be on ground - Twist corners of sheet to provide better grip - Keep pt weight as close to your body as possible - Perform Hammock Transfer in one movement: * Pivot pt upper torso * Lift legs and position on stretcher - Raise the back rest, pt will slide down into correct position. Monitor bariatric pt during transfer as orthopnoea can occur rapidly. ONLY use NSW health hospital bedsheets as ordinary bedsheets can stretch and tear.

Answer 76

Aim: Lift used when load is very close to the ground eg spineboard. Engage gluteals and hamstring muscles for strongest possible lift. Lift heavy weight from a very low starting position. Procedure: - Ensure load being lifted is close to the body. - Drop hips towards ground, low enough to prevent over reaching. - Mixed grip = stronger. If walking with mixed grip have lead hand in underhand position. - Chest upright, unstable if not upright. - Pull shoulder blades back and down: ensures load remains close to body. - Full foot contact, do NOT lift heel. - Deep breath, brace abdominal muscles: maintain spinal stability. Used For: - Carry chair (when lowering to ground) - Spineboard / Combi-carrier - Carry sheet - Patient movement.

Answer 77

Indication: Situations where Police officers have used a Tazer to incapacitate a person. Removal: - Probe 12mm long - Follow Police instructions for safety - Cut wires - Place one hand to support pt skin away from probe. NB Do NOT place probe between fingers - Gently but swiftly pull on the probe to remove - Ensure entire probe is removed (it may separate at barrel). - Probes are property and responsibility of NSW Police Post Removal: - Treat wound - IF pt has pacemaker or Internal Cardiac Defibrillator they should be monitored and transported for further assessment. - Document placement of probes and wounds in eMR. - IF probe has penetrated EYE, GENITALIA or CHEST, do NOT attempt to remove, cut the wire and leave probe in situ. Transport to hospital (specialist treatment may be required) - Check for pneumothoraces.

Answer 78

Indications: Implement standard infection control precautions for all patients receiving care regardless of Dx or presumed infection status. ``` Procedure: Standard Precautions involve use of safe work practices + protective barriers including: - Hand hygiene - PPE when indicated - Appropriate device handling - Appropriate handling of laundry - Respiratory hygiene / cough etiquette ``` Implement standard precautions for all patients Use PPE when touching (or potentially exposed to): - Blood (including dried blood) - All body substances, secretions and excretions (excluding sweat) regardless of whether or not they contain visible blood. - Non-intact skin - Mucous membranes including eyes

Answer 79

Rationale: Hand hygiene is the single most important practice to reduce transmission of infectious agents in healthcare settings. Hand hygiene with running water and soap or alcohol based handrub. Gloves do not eliminate requirement for hand hygiene. Perform Hand Hygiene: - When starting and finishing work - If skin is contaminated or visibly soiled with bodily substances. - Following contact with own mucous membranes - Following contact with non-intact skin / abnormal skin conditions (eg. rashes) - Before / After: * toilet, eating * before donning / after removing gloves * removing facial / eye protection * patient care procedures * direct patient contact * after removing a gown * after touching inanimate objects that are likely to be contaminated. * before food preparation or feeding patients * after touching animals Types of Hand Hygiene: Routine Healthcare interventions: - Liquid soap + water / water free skin cleanser: 10-15sec and until dry. Procedural (Non- surgical) - alcohol hand rub with residual effect (eg chlorhexadine) : 30sec minimum

Answer 80

Indication: PPE to be used as a barrier to protect HCW from contamination with blood or body fluids. Gloves: Must be worn: - both hands - situations where direct contact anticipated with blood, body fluid, mucous membranes or non-intact skin. - handling items / surfaces that've come into contact with blood or body substances. - performing an invasive procedure: venepuncture, finger stick. Gloves NOT required for SC, intradermal or IM injections unless exposure to blood is anticipated. Must be removed / discarded: - integrity has been altered (torn) - after care for a pt is complete and before providing care for another pt. - performing separate procedures on the same pt - before touching environmental items / surfaces - before writing in eMR, answering phones, using radio / MDT. Disposable fluid resistant gown must be worn if likelihood of splashing or splattering of blood / body substances to the uniform. Clothing contaminated with blood / body substances MUST be removed ASAP and before attending other pt.

Answer 81

Aim: Additional Infection Control Precautions where suspected / confirmed presence of infectious diseases / organisms represents an increased risk of transmission. - Reference R3 when a specific infectious disease is known or suspected. - PPE = barrier to protect HCW skin, airway and uniform from contamination. PPE Donning: - Hand hygiene - Gown - Mask - Eyewear - Hand hygiene - Gloves For known / suspected CONTACT / DROPLET / AIRBORNE disease: Contact Precautions: - Gown - Gloves - Don PPE prior to contact - Removed PPE + hand hygiene when no longer in physical contact with pt or contaminated objects. - When transporting a pt with contact spread infection through a healthcare facility, PPE is unlikely to be required. Removing PPE + hand hygiene will reduce chance of contaminating frequently touched surfaces within that facility. ``` Droplet Precautions: - Gown - Surgical mask + surgical mask on pt - Eyewear - Gloves - Prior to leaving pt zone: * Remove gloves * Hand hygiene * Remove gown * Hand hygiene - Leave pt zone: * Remove eyewear / face shield * Hand hygiene * Remove surgical mask * Hand hygiene - Driving paramedic should remove gloves and gown and perform hand hygiene prior to entering front compartment of vehicle. ``` Airborne Precautions: - Gown - P2 / N95 mask - Eyewear - Gloves - Surgical mask worn by pt during transport - Prior to leaving pt zone: * Remove gloves * Hand hygiene * Remove gown * Hand hygiene - Leave pt zone: * Remove eyewear / face shield * Hand hygiene * Remove surgical mask * Hand hygiene - When disease has multiple modes of spread, implement all procedures from each type of precaution. PPE Doffing: - Remove gloves - Hand hygiene - Remove gown - Hand hygiene - Remove protective eyewear - Hand hygiene - Remove mask - Hand hygiene - One step doffing of gown and gloves is acceptable. - Transport of 2 pt with different contact spread infections should only be done when physical separation can be achieved. - Offer pt the opportunity to perform hand hygiene prior to transport. - Avoid contamination of pt documents during Tx. - Notify hospital when Tx pt with known airborne disease. - Outbreak of infectious disease detected in pre-hospital setting: notify local public health unit. - P2 / N95 respirator can safely be worn in a single session for up to 4hrs. Multi-resistant Organisms (MROs): - bacteria have developed resistance to common antibiotics. - Colonisation: organism present it pt body but not causing illness. - Infection: organism present and causing illness in pt.

Answer 82

Aim: Provide a safe environment for birthing and ongoing care for mother and newborn. Preparation: - Hand hygiene - PPE: gloves, eyewear - adult and neonate resuscitation equipment - Blueys under the woman - Control centre: imminent birth, request further resources - Develop rapport - Gather information: gestation, parity, complications in pregnancy or previous births. - "only push with a contraction" - NO opiates for imminent birthing woman. - Analgesia are NOT routinely administered or offered. Birthing: - Pt feels 'need to push' ? Visually assess for presenting part. - Assess progress with each contraction: should see more head with each push. - Once crowning, allow head to deliver SLOWLY. Woman to pant and resist forceful expulsive pushes ie "breathe the baby out". - Support the head. - Use index finger to check for cord around foetus' neck: run finger from ear down the neck towards shoulder. - Cord can be unwrapped after birth. IF cord tight and birth not progressed, loop cord over head. IF cord tight, birth not progressed and unable to loop cord over head: call Perinatal Advice Line. - Use gauze to clean membranes off face. - Restitution...next contraction, cup hands on either side of foetus' head (cover ears) to prevent rapid expulsion. - Inform pt head birthed, foetus will be born with next contraction. - Guide head towards woman's back: birth anterior shoulder, then towards abdomen to deliver posterior shoulder. Do NOT use undue force tractioning shoulders. - Support and take weight as foetus is birthed moving hand down over trunk surrounding arms to control the birth. - Deliver straight onto abdomen: bluey's probably soiled. - Note Time of Birth. Care of Newborn: - >32 weeks: Dry rubbing back and chest with firm tactile stimulation - <32 weeks: place WET in polyurethane bag - Cover exposed part including head with beanie: newborn prone to hypothermia which depresses breathing. - Feel base of cord: pulsations should stop 3-5min post birth. Stopped pulsing? 1st clamp 10cm from newborn. Milk cord away from newborn. 2nd clamp 5cm from 1st clamp. Cut between 2 clamps. 3rd clamp near the perineum. 3rd Stage of Labour (delivery of newborn to delivery of placenta): - IM Oxytocin while waiting for cord to stop pulsing. - Observe for signs of placental separation, encourage pt to push: * lengthening of cord (3rd cord clamp move further away from perineum) * gush of bright blood * return of contractions and urge to push (placenta in vagina). - Placenta visualised outside perineum, place between both hands, see-saw gently up and down (controlled delivery of placenta and membranes, minimises tearing). Never pull cord to force delivery. Anything expelled from vagina is kept and transported. When placenta is delivered place it in a zip-lock back and transport to hospital. - Check fundus: one hand at umbilicus above fundus one hand at pubic symphysis: palpate abdomen to assess position and tone of fundus: should be firm, contracted, central. - Fundal massage if deviated or soft or actively bleeding: firm downward pressure keeping lower hand still. Full bladder interferes with contracting uterus. Do NOT stop fundal massage if active bleeding. - Examine perineum for bleeding or clots. Estimate blood loss. First 24hrs after birthing = Primary Postpartum Haemorrhage: * >500ml vaginal blood loss after birth * any blood loss where mother becomes symptomatic of hypovolaemic shock - Cover vulva with peri pad. Recording Birth: - Time head delivered, time of birth - APGAR Appearance, Pulse, Grimace, Activity, Respiration at 1 and 5 min. - Newborn obs every 15min: HR, RR consider BGL. Asses tone, color, vigour. - Record complications: cord around neck, PPH, resuscitation required, shoulder dystocia, breech etc - Maternal obs: HR, RR, BP, Temp, SpO2, GCS, blood loss and pad checks every 15min for first hour. Transport soaked peri pads to hospital to quantify blood loss. Pregnancy history: - Gestation, Parity - Complications with this pregnancy: placenta praevia, breech presentation, pre-eclampsia, diabetes, multiple pregnancy, substance abuse, gynaecological disorders or Hx of obstetric emergencies. - Complications in previous pregnancies: lower segment caesarian section, PPH, shoulder dystocia.

Answer 83

Principles: Newborn resuscitation manoeuvres as part of a graded strategy to support newborn's physiological efforts to adapt after birth. ~85% delivered at term (37-42wks gestation) will initiate spontaneous respirations within 10-30s of birth. ~10% respond with drying and tactile stimulation ~3% require IPPV with BVM ~0.1% require chest compressions and/or Adrenaline - Newborns delivered via breech, shoulder dystocia, premature are at greater risk of requiring resuscitation. Assessment: - Clamp and cut cord - Rapid assessment (every 30s during resuscitation): * colour * tone * breathing * heart rate: palpated at base of umbilical cord (tap out so partner can count) - Do NOT delay resus to perform APGAR (1min, 5min) Tactile Stimulation < 32wks: - Do NOT towel dry - Place in polyurethane bag with head out - Wrap warmly to prevent evaporative heat loss - Stimulate once in bag Tactile Stimulation > 32wks: - Stimulate by drying: vigorously rub chest then back 30s each. - Once dried remove wet linen Airway Management: - Supine, head neutral, with 2cm padding under shoulders. - Only suction (briefly and with care) if visual signs of obstruction (meconium, blood, mucous or vernix). May cause cyanosis, delay onset of spontaneous breathing, laryngeal spasm, soft tissue trauma, bradycardia. - Consider OPA / NPA ``` Ventilation Commence IPPV with BVM if one or more of: - HR < 100/min - Apnoea or gasping respirations - RR < 40 - Hypotonia - Ventilate @ 40/min ie every 1.5sec - Continue ventilations while HR < 100 - Reassess every 30sec ``` CPR - Commence CPR if HR < 60/min, aim for 120 compressions per minute - Compression : Ventilation ratio 3:1, pause for ventilation - 2 Thumb method over sternum at nipple line - Continue CPR while HR < 60/min - Reassess every 30sec - Defib pads / IO access not indicated - IF HR > 100, RR > 40 and good tone complete physiological obs every 5min. - Ensure newborn is warm: cold newborn has increased O2 requirements, risk of hypoglycaemia and acidosis = increased mortality rate. - Rapid heat loss due to large surface area / weight ratio - Only suction oral cavity for a max of 5sec Newborns at HIGH risk of requiring resuscitation at birth: - Premature - Shoulder dystocia - Breech - Multiple birth - Congenital abnormalities

Answer 84

Principles: - Third Stage of Labour: birth of baby until birth of placenta and membranes. - Management of the 3rd stage of labour includes Oxytocin and management of placenta and membranes. - Oxytocin aids in delivery of placenta and membranes. - Oxytocin assists in contraction of uterus, reducing likelihood of PPH. - Management of delivery of placenta and membranes involves delivery using maternal effort with NO paramedic intervention. NO TRACTION on umbilical cord at any stage!. May take up to 90min Preparation: - Hand hygiene - Maternity kit, Blueys, Peri pads - Discuss procedures with pt Management - Advise pt of benefits of Oxytocin, potential adverse effects, risks of refusing Oxytocin [incr risk of PPH, incr length of time of third stage of labour]. - If no maternal compromise, leave umbilical cord unclamped and attached to baby until third stage complete. Cord cut after birth of placenta and membranes. - Pt to empty bladder if possible - Skin to skin contact, encourage breastfeeding: promotes release of endogenous oxytocin and fundal contraction. - Position upright if signs of placental separation. Gravity will assist third stage. Signs of Placental Separation: - Lengthening of the cord as placenta moves into vagina - Uterus becoming rounder, firmer and smaller - Trickle or gush of blood from vagina: bright blood loss is a sign placenta is separating from uterine wall. - Return of cramping / contractions - Urge to push Delivering Placenta / Membranes: - Push with a contraction - Non dominant hand under perineum when placenta is visible, placenta will be expelled into hand. Dominant hand on top of placenta. - Two hands to support and remove placenta with gentle twisting see-sawing motion to ease membranes slowly out of vagina. Do NOT pull, can take 90 min to deliver. - Note time of delivery - Placenta into plastic bag. ``` Cord clamping and cutting: - Wait for cord to stop pulsating - Clamp 10cm from newborn - Hold clamp, milk cord toward placenta (avoids splash injury) - Second clamp 15cm from newborn - Cut between first and second clamps - Place placenta and membranes into bag ``` Post delivery care: - Assess fundus is well contracted - Fundal massage if soft / non contracted / deviated - Estimate blood loss

Answer 85

Principles: Identification, Treatment, Management of PPH PPH = clots / blood loss > 500ml following birth (most common cause of maternal mortality) - Primary PPH < 24hr - Secondary PPH < 6weeks 4 Main causes of PPH: - Tone (atonic uterus) 70% - Trauma (genital trauma) 20% - Tissue (retained products) 10% - Thrombin (clotting factors) <1% Management of PPH: - Oxytocin - Fundal massage - Delivering placenta ``` Preparation: - Hand hygiene - PPE - Posture semi-recumbent - Gain conset, explain / describe physical assessment and treatment. - Maternity kit, Blueys, Peri pads and clinical waste bags - Equipment for adult resuscitation - Equipment for IV access and IV fluids ``` Identify PPH: - Obvious: blood on clothing, linen, bed, floor - Hidden: look under / behind woman - Internal: palpate abdomen for tone - Pt may / may not be symptomatic for hypovolaemic shock following PPH Check uterine fundus: - Assess and palpate abdomen, identify uterine fundus - Hand at level of umbilicus, inward pressure with side of hand. Fundus should be firm and in the middle of the abdomen. If fundus is firm and central at umbilicus, uterus is well contracted. - Commence fundal massage if uterus is soft, deviated or above level of fundus. - If uterus is well contracted AND abdomen feels firm above level of umbilicus = possible indication of internal bleeding: fundal massage should be discontinued. Fundal Massage: - One hand at pubic symphysis, the other at top of fundus at height of umbilicus (maybe higher if fundus not contracted) - Position uterus between hands. - Firmly massage fundus with upper hand while keeping lower hand still: downward and inward pressure: uterus should contract and become firm. - Contraction usually within 30s but can take up to 3-4min - Contraction may not occur if placenta still insitu - Examine perineum for bleeding and any clots that may have been expelled - Assess fundus every 15min after birth. If it relaxes resume fundal massage. - During fundal massage it's normal for blood to be expelled from the vagina. Bleeding should cease when uterus is well contracted. - Secondary PPH post caesarian section, fundal massage is still indicated. External Signs of Trauma: - Active bleeding from tears / abrasions to perineum / external genitalia. - Cover signs of trauma with peri pad, apply direct pressure. - Regularly reassess perineum for signs of further bleeding. Treating Hypovolaemia: - Supine, legs elevated - 2x Large bore IV cannulae - IV Fluids (large volumes may be required) - Oxygen Postnatal care: Reasses: - that uterine fundus (every 15min) remains contracted: position (center of abdomen or just below umbilicus) and tone (should feel like a cricket ball) Fundal massage may have to be continuous. - Blood loss (look behind the back). Change bluey every 15min so continuing trick of blood is not missed. - Concealed haemorrhage may occur: blood collects in vagina / uterine cavity / abdominal cavity. There may be a rapid expulsion of large amounts of clots. - Blood loss from clots is often underestimated, take them to hospital for assessment. - Vital signs: every 15min in first hour after birth, more often if concerned about woman's condition / signs of deterioration. - Blood volume incr by 40% during pregnancy, postnatal woman may compensate and appear haemodynamically stable ie drop in BP may occur later than for a non pregnant pt. Increasing RR then HR are first signs pt is not compensating for blood loss. ``` NB - PPH is the most common cause of maternal mortality. 70% from poor uterine tone. Clinical Features - If symptomatic, blood loss >500ml - Soft, boggy uncontracted uterus - Tachypnoea - Tachycardia - Hypotension - Pale ```

Answer 86

Principles: - Rapid recognition of breech presentation: notify control and request additional resources. - Limited manipulation of foetus unless required - Gentle but timely with necessary techniques - Buttocks (Frank / Complete ) or feet (Footling) are presenting first - Uncommon, 3-4% of births, most will birth themselves with little intervention. - Common with premature births <37 weeks gestation. - Cord prolapse is also common. Summary - Hands off breech - Foetus should progress with each contraction / maternal effort. - If required, gently rotate foetus so "spines opposite" AT ALL TIMES for optimal flexion of foetal head and ease of birth. - No progress with pushing? Assisted shoulder / head manoeuvre to deliver shoulders / head. - Newborn may require initial resuscitation but usually responds well to stimulation and oxygen. - Meconium likely. Preparation: - Hand hygiene - PPE - Maternity kit - Prepare neonate resus equipment Posture: - Standing, squatting or kneeling: use gravity to assist flexion of head and delivery. ``` Position of foetus: - Hands off / Eyes on - Note time breech is visualised. - With each contraction pt should push (ONLY push with a contraction) and more breech should be seen. ``` Rotation: - SPINES OPPOSITE: avoid touching except to rotate so spines are opposite. - Rotation: "Thumbs on bum" and fingers around femurs. - Do NOT hold by abdomen: rupture internal organs. - Do NOT pull Birth: - Support: hands around foetus chest and under buttocks. - Allow foetus to hang and birth slowly until nape of neck is visualised. - Pant NOT push to facilitate slow controlled birth of head - Note time of birth - At NO time should any traction be applied to aid in birthing the head. - If breech starts to birth during transport, stop ambulance, call for backup. - Letting foetus hang downwards creates flexion of head which is optimal for delivery. Assisted Shoulders Manoeuvre (these manoeuvres should be completed in ONE contraction): - IF no descent / progress seen and shoulders still in vagina after 2 contractions (~90sec) assistance may be required to deliver shoulders. - Position pt semi recumbent with bottom at the end of the bed. Anterior Arm Release: - During contraction, pt push, gently rotate foetus on its side. - Apply gentle traction (thumbs on bum) towards pt back to birth anterior shoulder and arm. Gentle flexion on foetal elbow may assist in birthing arm. Posterior Arm Release: - Traction the foetus towards abdomen to allow posterior arm to birth. - Rotate foetus back into "spines opposite" position - Remove hands. - Allow foetus to "hang" while awaiting birth of the head. Assisted Head Manoeuvre (adapted Mauriceau Smellie-Viet Manoeuvre): - IF head not easily born with in 2 contractions with good maternal effort assistance may be required to birth head. - Rest foetus on non-dominant forearm. - Ensure umbilical cord is not compressed. - Place dominant hand on foetuses' back. Place middle finger on foetuses' occiput. Careful w.r.t pt clitoris and urethra. - Next contraction: push downward on occiput to flex head. - When foetal face visible at perineum place index and middle fingers of non-dominant hand gently on foetus cheekbones (avoid eyes and mouth). - Bottom hand guides face upwards. Helps control speed of head being birthed to prevent rapid expulsion and keeps head flexed. Do NOT twist the foetus. - Chin and mouth emerge first, head will follow. - As face delivers, tell pt to stop pushing and start panting to allow head to come out slowly. - Guide face out of vagina, as head is born through this flexing motion, lift (not pull) foetus upwards and place on woman's abdomen. - Controlled delivery of the head minimises risks of perineal trauma and trauma to blood vessels in the foetal brain. - Note time of birth Incorrect manoeuvres or rough handling: - Spleen / Liver damage - Spinal damage - Fractures / Dislocations - Soft tissue injuries - Cerebral haemorrhage if birth is too rapid Complications of Breech Birth: - Foetal hypoxia - Prolapsed umbilical cord - Head entrapment - Meconium aspiration - Postpartum haemorrhage - Inversion of uterus Document: - APGARs - Lack of progression during birth - Time breech is visualised - Time head is delivered - Interventions: manoeuvres or resuscitation.

Answer 87

Principles: Diagnose and assist with delivery when anterior shoulder has become impacted under the woman's pubic symphysis. - Treatment aims to dislodge shoulder from under symphysis to aid in delivery of foetus. - Shoulder Dystocia = Time Critical obstetric emergency, detrimental effects include: foetal hypoxia, brachial plexus injuries, fractures, foetal death. Causes foetal arterial pH to drop rapidly. - Rapid identification, interventions and urgent transport - Deliver foetus within 4 minutes to minimise potential adverse effects. Risk factors for Shoulder Dystocia: - Previous birth involving shoulder dystocia - 50% recurrence. - Macrosomia (large baby) - particularly if there's a large difference in maternal / paternal size / height. - Maternal diabetes - Incidence of shoulder dystocia ~ 0.3 - 1.5% of all births - Correct external manoeuvres alleviate shoulder dystocia in almost 70% of cases. Identify Shoulder Dystocia: - Visualise presenting part, assess for signs of shoulder dystocia: * Shoulders fail to be delivered despite good maternal effort with contraction within 60sec. * Head fails to restitute * Anterior shoulder not visible externally after effective pushing and gentle traction. * Face and chin may retract towards vagina (turtle sign) - Sign of shoulder dystocia present = CRITICAL obstetric emergency, urgent extrication / transport, code 3. Preparation: - Hand hygiene - PPE: gloves, protective eyewear - Maternity kit - Prepare neonate resus equipment - Inform pt of urgency of the situation and procedures required. Gain trust for better compliance. McRobert's Manoeuvre (incr diameter of pelvis): - Effective in releasing anterior shoulder in ~67% of cases. - If already positioned on all fours or upright then Gaskin manoeuvre first. - Position supine, "knees to nipples": knees towards chest, legs together (not out towards side) with a person on each side if possible. - Push with or without contraction. - Apply gentle downward traction to foetal head. - Max 30sec, if unsuccessful, next procedure. Gaskin Manoeuvre: - pt likely tiring / distracted, escalate from kind to firm / direct / blunt: time critical situation. - Position "on all fours". - Push with or without contraction. - When pushing, gentle upward traction to foetal head. - Max 30sec - if both manoeuvres unsuccessful, URGENT extrication / transport / code 3. Extrication: - Explain need for urgent extrication - Stand, walk with lunge type steps to stretcher (may change diameter of pelvis and relieve dystocia). - Extrication requires close and constant observation of woman and foetal head. - Pt to verbalise any changes felt or contractions during extrication. Urgent Transport, McRobert's Manoeuvre with Suprapubic Pressure: - McRobert's manoeuvre + suprapubic pressure (to decrease diameter of foetal shoulders) with the heel of the hand, constant, downwards, ~30sec. - If unsuccessful change to rocking motion for ~30sec. - If contraction / urge to push cease suprapubic pressure. - NEVER use fundal pressure, may increase impaction of foetal shoulder and cause uterine rupture. - Repeat McRobert's with constant downward / rocking suprapubic pressure ~30s each during urgent transport. - Pt stretch legs for short periods, decrease trauma to pelvic nerves. Foetal Complications: - Foetal hypoxia may result in cerebral palsy. - Brachial plexus injuries, due to tension on brachial nerve, may cause permanent paralysis of the limb. - Fractures to clavicles - Foetal death Maternal Complications: - PPH - Extensive perineal trauma - Uterine rupture if fundal pressure used - Psychological trauma - Neurological trauma (prolonged McRobert's manoeuvre) NB - Focus on performing each manoeuvre in the desired time frame, if unsuccessful proceed to next manoeuvre immediately. - Expect newborn to require resuscitation following shoulder dystocia. - Clamp and preserve umbilical cord for blood gas analysis at hospital.

Answer 88

Aim: Immobilisation of fractured femur where knee and neck of femur injuries have been excluded. Prepare Patient: - Explain procedure - Provide adequate pain management prior to limb realignment. - Expose limb, remove footwear - Check: distal pulse, capillary refill, motor-sensory function. Prepare Equipment: - ankle strap with end cap - extension pole with groin strap - velcro support strap Apply Splint: - Wrap ankle strap to fit firmly, ensure end cap positioned laterally and facing upwards. - Place extension pole next to lateral thigh with groin strap near upper thigh. - Apply groin strap: male end under thigh and around top of groin. Female end over lateral thigh with padding against patient. Ensure strap not twisted. Adjust strap as high as possible. Buckle and tighten. Traction: - Loosen black clamp thumb screw - Extend splint to desired length, connect distal end in receiver socket of ankle strap. - Tighten black clamp thumb screw while holding pole in position. - Apply fine traction: * Hold traction cord at top of splint and loosen red clamp thumb screw. * Pull on traction cord until effective traction is obtained. * Hold traction cord, tighten red clamp thumb screw. Release cord. - Reassess distal pulse, cap refill, motor-sensory function post application of splint. - If readjustment required: hold traction cord before loosening red clamp thumb screw. - Velcro support strap used to secure fractured limb to other limb. Padding between knees. If detrimental or # site close to hip or knee, remove support strap. Contraindications: - Suspected pelvic injuries where pelvic binding is not in place. - Fractured hip / neck of femur - Significant injury to the knee - Lower limb injury where no calf muscle mass is left. Pelvic and Femur Fractures: - If pelvic splinting is indicated, apply pelvic splint prior to traction splint Bilateral Fractured Femurs: - Apply 2 splints Open Fractures: - Irrigate and remove all debris from compound fractures and cover with saline moistened sterile dressing prior to reduction. Paediatrics: - STS can be used NB - STS can be used with lower leg amputation as long as ankle strap can be applied below knee. - STS can be used with concurrent ankle injury as long as ankle strap can be applied above calf muscle.

Skills Flashcards

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