PA R TI C IP A N T W O R K B O O K B A SIC EM ER G EN C Y C A R E: A pproach to the acutely ill and injured APPROACH TO THE ACUTELY ILL AND INJURED BASIC EMERGENCY CARE APPROACH TO THE ACUTELY ILL AND INJURED Basic emergency care: approach to the acutely ill and injured ISBN (WHO) 978–92–4-151308–1 ISBN (ICRC) 978–2-940396–58–0 © World Health Organization (WHO) and the International Committee of the Red Cross (ICRC), 2018. Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. 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The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization, the International Committee of the Red Cross or the International Federation for Emergency Medicine concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization, the International Committee of the Red Cross or the International Federation for Emergency Medicine in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization and the International Committee of the Red Cross and the International Federation for Emergency Medicine to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization or the International Committee of the Red Cross or the International Federation for Emergency Medicine be liable for damages arising from its use. Design by Inís Communication – www.iniscommunication.com BEC | Contributors Editors Teri Reynolds, Nikki Roddie, Andi Tenner, Heike Geduld. Other contributors of written material Kalie Dove-Maguire, Vijay Kannan, Sean Kivlehan, Nelson Olim, Max Ritzenberg, Stas Salerno Amato, Morgan Broccoli, Farrah Kashfipour, Harald Veen, Lee Wallis Peer reviewers Annet Alenyo, John Brown, Emilie Calvello, Brendan Carr, Keegan Checkett, Matthew Cooke, Megan Cox, Anne Creaton, Rochelle Dicker, Shaheem De Vries, Stephen Dunlop, Rajith Ellawala, George Etoundi, Sabariah Faizah, Scott Fruhan, Nicolaus Glomb, Renee Hsia, Christina Huwer, Muhumpu Kafwamfwa, Joseph Kalanzi, Gamal Khalifa, Olive Kobusingye, Clifford Mann, Edgardo Menendez, Juma Mfinanga, Nee-Kofi Mould-Millman, Hani Mowafi, Andrew Muck, Brittany Murray, Marcos Musafir, Theresa Olasveengen, Gerard O’Reilly, Tom Potokar, Junaid Razzak, Anthony Redmond, Andres Rubiano, Kelly Schmiedeknecht, Chris Stein, Janis Tupesis, Vikas Kapil, and Benjamin Wachira. The following members of the International Liaison Committee on Resuscitation (ILCOR) Pediatric Task Force provided essential peer review on relevant sections: Ng Kee Chong, Allan de Caen, Ian Maconochie, and Remigio Véiz. The following members of the International Federation for Emergency Medicine executive committee provided essential peer review: Peter Cameron, James Ducharme, Jim Holliman, Bob Schafermeyer, and Andrew Singer. Focus groups and pilots We thank the nurses and doctors of Muhimbili National Hospital in Dar es Salaam, United Republic of Tanzania, for their invaluable input during early focus groups: Ally M. Akrabi, Prosper J. Bashaka, Avelina N. Ijumba, Jennifer Jamieson, Khadija H. Juma, Bernard Kepha, Said Kilindimo, Josephine Lazaro, Wendy Lukwambe, Peter S. Mabula, Deogratius Mally, Nyakanda Marwa, Juma Mbugi, Felix D. Mlay, Victoria Mlele, Brittany Murray, Kissa Mwampagama, Meera Nariadhara, Catherine R. Shari, Patrick J. Shao, Shahzmah Suleman, Renatus Tarimo, Tito William. We are grateful to the African Federation for Emergency Medicine for overall coordination of pilots conducted in 2015–2017. Uganda course pilots were led by Joseph Kalanzi, and course facilitators included Aliga Cliff Asher, Charmaine Cunningham, Heike Geduld, Nemganga Kizega, Namaganda Lukia, Grace Magambo, Alex Makupe, Juma Mbugi, Josephine Nabulime, Annet Alenyo Ngabirano, Muzaza Nthele. Participants: Halima Adam, Douglas Akibua, Muhwezi Amos, Beatrice Babirye, Andrew Balinda, Evans Bonabana, Kamara Francis, Alele Franco, Muduwa Grace, Jagwe Hakim, Henry Kagaba, Shadia Kaggwa, Andrew Kagwa, Peter Kavuma, Winnie Kibirige, Bazibu Musa Kireka, Brian Kisembo, Nakiyemba Margaret, Edward Mugisha, Linda Nalugya, Gertrude Namidembe, Joanita Namuddu, Denis Onyang, and Emma Tukehayo. United Republic of Tanzania course pilots were led by Hendry Sawe, and course facilitators included Charmaine Cunningham, Jimmy Ernest, Upendo George, Nemganga Kizega, Deogratius Mally, Juma Mbugi, Juma Mfinanga, Felix Mlay, Brittany L Murray, Suzanna Ngalla, and Nikki Roddie. Participants: Ntuli Abraham, Thomas Bwire, Hamza Haji, Agripina Hugho, Stella Ibrahim, Philomena Jumanne, Teonila Kamba, Neema Kayembe, Sikudhani Khamsini, Clemence Luambono, Raymond Makona, Rosemary Marishay, Rashidi Matitu, Vicent Mboya, Erick Mhaiki, Rashid Mhina, Asha Mkwachu, Frank Mlaguzi, Leonidas Mutakosa, Piensia Nanyimbula, Kiohombo Phim, Mary Shauritanga, and Ndamba Sigonda. Zambia course pilots were led by Muhumpu Kafwamfwa, and course facilitators included: Namasiku Chime, Chipoya Chipoya, Ngandu Hassan, Mwandameda Kabuku, Irene Lufunda, Alex Makupe, and Mzaza Nthele. Participants: Gloria Chambeshi, Maureen Chikwa, Azelina Chulu, Mwanza Jackson, Usaliwa Jere, Tina Malunga, Pidini Mary, Mable Nakazwe Mulenga, Joy Judy Mweshi, Chicco Siame, Ivan Sinaulieni, and Franko Zulu. We wish to thank Morgan Broccoli, Simon Charwey, Catherine Haeffele, Farrah Kashfipour for input on visual design and illustration, and Tein Jung for the original illustrations throughout. INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 The ABCDE and SAMPLE history approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Module 1: The ABCDE and SAMPLE history approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Module 2: Approach to trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 Module 3: Approach to difficulty in breathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75 Module 4: Approach to shock. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95 Module 5: Approach to altered mental status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 WHO BASIC EMERGENCY CARE [SKILLS]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 GLOSSARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 WHO sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214 Basic Emergency Care Quick Cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 Contents vi INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 1 INTRODUCTION Overview Health emergencies happen every day, everywhere. They affect adults and children and include injuries and infections, heart attacks and strokes, acute complications of pregnancy and of chronic disease. While specialised care may never be available at all times in all places, a systematic approach to emergency conditions saves lives. The Disease Control Priorities Project estimates that nearly half of deaths and a third of disabilities in low- and middle-income countries result from conditions that could be addressed by emergency care. The World Health Organization (WHO), in collaboration with the International Committee of the Red Cross (ICRC) and the International Federation for Emergency Medicine (IFEM), has developed the Basic Emergency Care (BEC) course for frontline providers who manage acute life-threatening conditions with limited resources. These may include students, nurses, pre- hospital technicians, clinical officers and doctors who are working in field (pre-hospital) or hospital settings. Emergency care providers must respond to ‘undifferentiated’ patients, those with acute symptoms for which the cause may not be known. This course introduces a systematic approach to managing acute, potentially life-threatening conditions even before a diagnosis is known. BEC is based on the clinical recommendations of the WHO IMAI District Clinician Manual, WHO Pocket Book of Hospital Care for Children, WHO Emergency Triage Assessment and Treatment (ETAT) and WHO Integrated Management of Pregnancy and Childbirth. It includes modules on: the ABCDE and SAMPLE history approach, trauma, difficulty in breathing, shock, and altered mental status. The practical skills section covers the essential time-sensitive interventions for these key acute presentations. The WHO BEC package consists of: Participant workbook: the main reference source for participants, this interactive workbook provides all the necessary course content, and includes an in-depth guide to essential skills, a glossary of terms, review questions and case scenarios. Quick cards: these simple reference cards organize key assessment and management points for use in clinical settings beyond the course. These are found at the end of each module and together at the end of the workbook. Facilitator guide: this is an annotated version of the BEC workbook intended for facilitators. Challenging concepts are highlighted, and notes on teaching strategy and lecture preparation provided on each page. This volume also includes a Coordinator section with information on course planning and logistics, and offers guidance for selecting and training facilitators. Presentation slide sets: these cover all course modules and are provided to support course delivery. INTRODUCTION 2 The BEC course may be implemented in many different ways to meet local needs, but a recommended 5-day schedule is described in detail in the Coordinator section of the Facilitator guide. The BEC content might also be spread across a few weeks as a module in undergraduate nursing or medical curricula. The BEC package is designed to support the efforts of governments, educational institutions, professional societies and others to train emergency care providers acting within their designated scope of practice. WHO does not certify or accredit courses, instructors or providers. Scope of the course Key acute presentations These modules teach a practical and systematic approach to four acute and potentially life- threatening presentations: Trauma Difficulty in breathing Shock Altered mental status Most life-threatening conditions, whether the original cause was medical or surgical, infection or injury, will present with one of these. In some cases the diagnosis may be known, while in others, intervention may be required before a diagnosis can be made, perhaps because of limited diagnostic resources, but often because of the acuity of the condition. These modules introduce a systematic approach to assessment and management that can be used whether or not a diagnosis has been made. Frontline health-care providers will face many more presentations than are covered in this course. This material is not meant to cover every acute condition, but to help providers address time-sensitive conditions where early intervention has the potential to save lives. The course is designed to lay a foundation for broader emergency assessment and management. Many participants may already, or will later, be trained to provide care beyond what is described here. Recommendations for handover to an “advanced provider” are meant to signal the need for care beyond the scope of this course. In some cases, participants themselves may already be trained to provide this additional care. Other emergency presentations There are other complaints that may represent a life-threatening condition requiring emergency care even before it progresses to any of the key acute presentations listed above. These include: chest discomfort; poisoning/ingestion/exposure; envenomation (bites/stings); any severe pain from an unclear source; INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 3 contractions, pain or bleeding in late pregnancy. These complaints may represent the early stage of a critical illness requiring rapid intervention even when the person appears relatively well. The complete assessment and management of these conditions is beyond the scope of this course, but they should always trigger transport to, or consultation with, an advanced provider. In addition, there are certain infectious exposures that require time-sensitive prophylaxis (preventive treatment) whose effectiveness may be reduced by delays. These include: needle stick injury in a health care worker; unprotected sexual encounter, including in the context of assault; exposure to the saliva of an animal with suspected rabies. These exposures should be evaluated as soon as possible at a center capable of providing timely prophylaxis. Special considerations for fever Fever is a very common complaint and may be a sign of a life-threatening condition, or simply a sign of a mild condition that will resolve itself. Because fever does not reliably indicate an emergency condition, it is not addressed in a separate module here, but is covered in each of the core modules. When associated with abnormal ABCDE findings (see “Approach to the emergency patient” section), or any of the acute presentations above (trauma, difficulty in breathing, shock, altered mental status), fever can be an important clue to severe illness and should be taken very seriously. There are many more causes of fever than can be covered in this basic course, but most causes of fever requiring emergency treatment are associated with one of the four key acute presentations. There is no single approach to fever that is right for all emergencies, but there are some general principles that can help in the assessment and management of emergency patients. • Always consider infection in a person with fever (e.g. malaria, meningitis, pneumonia). • Never use the absence of fever to rule out infection. People with overwhelming infection or immune system problems may not be able to produce a fever and may have a normal or low body temperature. • Fever with abnormal vital signs and/or any of the four key acute conditions listed above will likely require early antibiotic (and/or anti-malarial) treatment. • Always consider whether local screening protocols for infectious disease outbreaks (e.g. for haemorrhagic fevers) require further action (e.g. special reporting or management) in a person with fever. Obstetric delivery and neonatal resuscitation Management of obstetric delivery and neonatal resuscitation are critical topics covered else- where in existing WHO materials and are not covered in this course. See the WHO Maternal, Newborn, Child and Adolescent Health department website (http://www.who.int/maternal_ child_adolescent/documents/en/) for training materials on these topics. INTRODUCTION 4 Expected participant background knowledge This course assumes a basic knowledge in the following areas: Use of personal protective equipment Basic human anatomy Basic history taking Basic physical examination skills, including taking vital signs, chest auscultation and abdominal assessment Use of a glucometer Set up of an intravenous (IV) infusion Safe intramuscular injection Cardiopulmonary resuscitation (CPR) Cardiopulmonary resuscitation (CPR) The decision about whether or not CPR is appropriate for a specific patient depends on many factors, including understanding of the cause of the condition, knowledge of available resources, and awareness of relevant institutional protocols and practices. There are many situations where it may be appropriate to initiate and then terminate CPR after a certain interval, and others where it may not be appropriate to initiate CPR. While this course addresses several aspects of resuscitation, it does not cover general CPR protocols, as they may vary greatly by setting. Course facilitators should direct participants to the appropriate source for relevant CPR protocols. Medication The medications discussed in this course are widely available and appropriate for use by the frontline providers for whom the course is designed. They can be used in pre-hospital or facility- based settings and are important early treatments for emergency conditions. The included medications provide a foundation for initial emergency care, but almost every condition discussed in this workbook will require treatments beyond those listed. Many important emergency treatments used by advanced providers are not included in this course. Handover/transfer This course is designed to help providers identify and provide initial management for acute, life-threatening conditions. Most acutely ill patients will require care beyond this initial stage. This may be ongoing care delivered by the same provider, but more often will require handover to a more advanced provider or facility. This process of deciding the appropriate disposition – or next step of care – for the acutely ill patient is a vital part of emergency care. Choosing an appropriate disposition involves assessing severity; estimating how rapidly the condition may progress; considering whether transfer for a specific intervention (e.g. surgery, blood transfusion) is needed; and identifying any specific risks based on a suspected or known diagnosis (e.g. risk of recurrent seizure/convulsion, or worsening airway blockage). The special disposition considerations for each key acute presentation and its associated diagnoses are covered in the modules. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 5 Planning for handover/transfer requires communicating essential information with the receiving facility, creating a transport plan, and ensuring availability of the necessary supplies to protect providers and care for patients. These components will be covered in detail in “Transfer and handover” in the Skills section. Triage Triage is the systematic process of classifying patients by acuity to ensure the best match between available resources and user needs. Triage is an essential component of emergency care during routine and surge conditions, and is a higher-level process applied to all patients, allowing assessment of the individual patient in context. As such, it is not addressed in this course, but is often taught at the same time. WHO and ICRC, in collaboration with Médecins Sans Frontières (MSF) and the South African Triage Score (SATS) team, have developed a set of integrated triage tools and an associated open-access training module. Contact emergencycare@who.int to request these materials. Approach to the emergency patient The BEC course is intended for a wide range of frontline providers and offers a basic approach for life-threatening presentations. Emergency conditions often require urgent intervention long before a diagnosis is established, and a presentation-based approach is essential to managing patients effectively. The modules in this course teach the elements of a general approach that can be used for any emergency patient. Aaron The ABCDE approach allows rapid assessment and intervention for life threats using the following categories: A: AIRWAY B: BREATHING C: CIRCULATION D: DISABILITY E: EXPOSURE Essential ABCDE considerations are listed in the modules for each of the four key presentations. The SAMPLE history is a method of rapidly gathering the history critical to the management of the acutely ill patient. The SAMPLE history categories are: S: SIGNS AND SYMPTOMS A: ALLERGIES M: MEDICATIONS P: PAST MEDICAL HISTORY L: LAST ORAL INTAKE E: EVENTS SURROUNDING ILLNESS Essential SAMPLE questions are listed in the modules for each of the four key presentations. INTRODUCTION 6 The secondary survey is a complete physical examination based on the specific condition. The essential relevant components of the secondary survey are listed in the modules for each of the four key presentations. Further details are covered in the Skills section. How to use this Participant Workbook This Participant Workbook is linked with the WHO BEC course presentations and is designed to help participants prepare for each lesson to maximize learning. Each module provides reading material and exercises to complete before the lesson. Participants should not worry if there are elements they do not fully understand while reading alone, as all workbook content will be reviewed during the lessons. Before each lesson, participants should: write out the definitions for the Key terms of the relevant module by copying from the Glossary in the back of the workbook; complete all workbook review questions in the relevant modules. The multiple choice questions and case scenarios at the end of each module will be covered in the small group sessions during the course, but participants should read through them before the session. On completion of the course, participants can use this book for reference. Accompanying the book are reference quick cards. These cards provide a summary of the essential points from the course and are designed to be carried in the clinical setting to guide day-to-day practice. Module format This course includes one module on the general approach to all emergency patients (ABCDE and SAMPLE); one module on the approach to injured patients (trauma); three modules on other specific clinical presentations (difficulty in breathing, shock, and altered mental status); a skills section; and a Glossary. The modules include the following sections: Objectives: A list of things participants should be able to do by the end of the course. Essential skills: A list of skills relevant to the module (and later taught in the Skills section). Key terms: Important words and phrases needed to understand the module. All definitions can be found in the Glossary and should be written in the space provided prior to the lecture. Overview: A brief introduction to the clinical presentation being discussed in the module. Goals of initial assessment: The main purpose of the assessment of the clinical presentation. Goals of acute management: The desired result of the management of the clinical condition. ABCDE key elements: ABCDE findings and interventions related to the specific clinical condition addressed in the module. Key history findings (ASK): Specific SAMPLE history elements related to the clinical presentation that are critical for management. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 7 Secondary survey findings (CHECK, including Look, Listen and Feel): Relevant secondary examination findings to check for in the clinical presentation the module addresses. Possible causes: Specific diseases, injuries, or illnesses that can cause the condition presented in the module (along with their specific signs and symptoms). Management (DO): These sections describe management of specific conditions. Note that the ABCDE and Trauma modules have much longer lists of possible emergency conditions, and the Possible causes and Management sections are presented in tables. The Trauma module has a separate table for Primary Survey conditions. Special considerations in children: Important differences in the signs and symptoms and management needs of children. Disposition considerations: Specific things to consider when transferring or handing over patients. Facilitator-led case scenarios: These scenarios test participants’ ability to use what they have learned to manage a patient. These scenarios will be led by the instructor. Multiple choice questions (MCQ): There are five multiple choice questions to test your knowledge at the end of each module in preparation for the final written exam. Participant requirements Participants should confirm course requirements with their facilitator. When implemented in full, the Basic Emergency Care course requires completion of ALL components listed below. Pre-test. Before receiving the Basic Emergency Care course workbook, participants should have completed this brief confidential test, which helps facilitators understand their current knowledge level. Attendance report. Participants must sign in for both the morning and afternoon sessions each day. Participants must attend all sessions to pass the course. Workbook completion. As described above, participants should complete all key terms and workbook questions in the relevant module prior to each lesson. All key terms must be defined, and all workbook questions answered for the workbook to be considered completed. The workbooks will be reviewed each day by facilitators. Participants must complete the workbook to pass the course. Skill stations. During the skills day, facilitators will demonstrate skills at a practical station. Participants will have an opportunity to practise the skill at each station several times. Participants may practise a skill as many times as needed within the allotted station time. During practice, participants may use the workbook and skill checklist for reference, and may ask questions as needed of facilitators. During assessment, no reference materials will be allowed, so participants should also practise without references, and have another participant observe for any missed steps. Participants will have plenty of time to practise and feel confident with the skills prior to assessment, and when ready, should request that an instructor assess them performing the skill. All steps in the skill checklist must be performed to pass the assessment. Participants must pass the skill station assessments to pass the course. INTRODUCTION 8 Case scenarios. All participants must successfully lead and manage a case scenario to pass the course. These scenarios give participants an opportunity to practise an integrated approach to management in small groups of 3–4 participants. Facilitators will discuss with the group how to approach the case scenarios using the ABCDE approach. In the later modules, each participant will be assessed on the ability to lead and manage a case scenario. Leading a case scenario includes identifying critical aspects of assessment and management, as well as presenting a handover summary (see the Handover section in Skills). Facilitators will complete the checklist below to assess the participant leading the case. Participants who are unsuccessful in identifying and managing the critical conditions in the scenario will be given a second case in the same or a subsequent session. Assessments are based on a standardized guide and reported on the form below. Case scenario assessment Not identified Identified some Identified all Critical airway interventions Critical breathing interventions Critical circulation interventions Critical disability interventions Critical exposure interventions Critical medications (if needed) Gave appropriate brief handover summary Yes No Participant performed all essential components Yes No Comments (including notation of any missed elements): Written final exam To qualify to sit the final examination participants must: complete the pre-test; complete the key terms and workbook questions; attend all course sessions; lead a case scenario; pass all skill stations as examined by an instructor. The final examination will include multiple choice questions. Participants must score at least 75% to pass. Your input will help improve future training courses. Please send any comments, corrections or questions to emergencycare@who.int. We encourage all participants and facilitators to fill out a short pre- and post-course survey at www.who.int/emergencycare. PARTICIPANT WORKBOOK 9 The ABCDE and SAMPLE history approach 10 Notes ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 11 Module 1: The ABCDE and SAMPLE history approach OBJECTIVES On completing this module you should be able to: 1. list the hazards that must be considered when approaching an ill or injured person; 2. list the elements to approaching an ill or injured person safely; 3. list the components of the systematic ABCDE approach to emergency patients; 4. assess an airway; 5. explain when to use airway devices; 6. explain when advanced airway management is needed; 7. assess breathing; 8. explain when to assist breathing; 9. assess fluid status (circulation); 10. provide appropriate fluid resuscitation; 11. describe the critical ABCDE actions; 12. list the elements of a SAMPLE history; 13. perform a relevant SAMPLE history. Essential skills • Assessing ABCDE • Cervical spine immobilization • Full spine immobilization • Head-tilt and chin-lift/jaw thrust • Airway suctioning • Management of choking • Recovery position • Nasopharyngeal and oropharyngeal airway placement • Bag-valve-mask ventilation • Oxygen administration • Skin pinch test • AVPU (alert, voice, pain, unresponsive) assessment • Glucose administration • Needle decompression for tension pneumothorax • Three-sided dressing for chest wound • Intravenous (IV) line placement • IV fluid resuscitation • Direct pressure for haemorrhage control, including deep wound packing • Tourniquet for haemorrhage control • Pelvic binding • Wound management • Fracture immobilization • Snake bite management Module 1: The ABCDE and SAMPLE history approach 12 KEY TERMS Write the definition using the Glossary at the back of the workbook. ABCDE: Accessory muscle use: Altered mental status (AMS): Anaphylaxis: AVPU: Bag-valve-mask (BVM): Capillary refill: Cardiopulmonary resuscitation (CPR): Cervical spine (c-spine): Convulsion: Crackles (crepitations): Crepitus: Deep wound packing: Defibrillator: Diaphoresis: Difficulty in breathing (DIB): Disposition: Foreign body: INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 13 GCS (Glasgow Coma Scale): Hives: Haematoma: Haemorrhage: Haemothorax: Hyperresonance: Hyperthermia: Hypoglycaemia: Hypothermia: Hypotension: Hypoxia: Inhalation injury: Intubation: Large bore IV: Nasal flaring: Nasopharyngeal airway (NPA): Needle decompression: Oedema: Oropharyngeal airway (OPA): Oxygen saturation (O2 sat): Module 1: The ABCDE and SAMPLE history approach 14 Percussion: Perfusion: Pericardial tamponade: Personal protective equipment (PPE): Pleural effusion: Pneumothorax: Pulse oximeter: Retractions: SAMPLE history: Seizure: Shock: Stridor: Sucking chest wound: Tachypnoea: Tension pneumothorax: Wheezing: INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 15 OVERVIEW Approaching every patient in a systematic way ensures that life-threatening conditions are recognized promptly and that the most critical interventions are done first. In a stable patient, the initial ABCDE approach may only take seconds to a few minutes. The ABCDE should be followed by a rapid history using the SAMPLE approach (Signs and Symptoms, Allergies, Medications, Past medical history, Last oral intake and Events). The SAMPLE history categories are described in general below, and essential questions for a specific presentation are listed in the relevant module. Using the standard SAMPLE and ABCDE approach together ensures that different providers can easily communicate about acutely ill patients. The goal of the ABCDE approach is to rapidly identify life-threatening conditions; ensure the airway stays open; and ensure that breathing and circulation are adequate to deliver oxygen to the body. The goal of the SAMPLE approach is to rapidly gather history critical to the management of the acutely ill patient. This module will address: Safety considerations Elements of the ABCDE approach In-depth: acute life-threatening conditions (signs, symptoms and management) Paediatric considerations in the ABCDE approach Elements of the SAMPLE history Disposition considerations SAFETY CONSIDERATIONS A critical part of the approach to any ill or injured patient is keeping providers and others safe. An ill or injured provider will be unable to help anyone, and instead becomes an extra patient for other responders to treat. Safety consideration involves checking for: scene hazards. Is there a fire, electrical wire or chemical spill that could injure providers or bystanders? At a road traffic crash, is the scene closed to oncoming traffic? If a building has collapsed, is it safe to enter? At the scene of an explosion, always consider the possibility of further explosions. Remember that delayed building collapse may follow explosions, fires and earthquakes. violence. Is there a chance that providers may be harmed by the patient or by others? For patients who are aggressive or agitated, request help as needed from security personnel or police before beginning your assessment. infectious disease risk. Is there a possibility for disease exposure (such as flu or haemorrhagic fever)? Module 1: The ABCDE and SAMPLE history approach 16 USE PERSONAL PROTECTIVE EQUIPMENT You may not know the cause of illness or injury when you first approach a patient, and without appropriate personal protective equipment (PPE), may expose yourself to diseases, chemicals or poisons. You must use appropriate PPE every time you approach a patient. Always protect yourself from any exposure to bodily fluids. This will almost always require gloves and eye protection, and may require a gown and mask. Some circumstances, such as suspected or confirmed haemorrhagic fever outbreaks, require specific protective practices. Always be sure that you are up-to-date on current local recommendations. CLEANING AND DECONTAMINATION Infectious disease exposure is a significant risk. Use PPE and wash your hands before and after every patient contact. At the scene, hand washing may not be immediately possible; carry an alcohol gel cleanser if possible. Between patients, clean and disinfect all facility and vehicle surfaces and all reusable equipment. Decontamination may be required after exposure to pesticides or other chemicals (dry or wet) and, depending on the chemical, may include washing or brushing to remove the substance. Not all chemicals can be safely washed away, and some must be removed in specific ways to avoid further injury. You must wear appropriate PPE for this. Refer to local decontamination protocols for people and equipment. ASK FOR MORE HELP IF NEEDED If multiple people are injured or ill, call for help or send someone to call. If advanced care is needed, begin making arrangements as early as possible for consultations or transfers. Know the relevant local agencies to contact for suspected outbreaks or hazardous exposures, such as chemical spills or radiation. There is often support and guidance available for containment and decontamination. Workbook question 1: Safety A person walks into your health post vomiting, bleeding from the mouth, and complaining of abdominal pain. Using the workbook section above, describe what is needed to safely approach this person: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 17 ELEMENTS OF THE ABCDE APPROACH The ABCDE approach The ABCDE approach provides a framework for the systematic and organized evaluation of acutely ill patients in order to rapidly identify and intervene for life-threatening conditions: A – Airway: check for and correct any obstruction to movement of air into the lungs B – Breathing: ensure adequate movement of air into the lungs C – Circulation: evaluate whether there is adequate perfusion to deliver oxygen to the tissues; check for signs of life-threatening bleeding D – Disability: assess and protect brain and spine functions E – Exposure: identify all injuries and any environmental threats and avoid hypothermia This stepwise approach is designed to ensure that life-threatening conditions can be identified and treated early, in order of priority. If a problem is discovered in any of these steps, it must be addressed immediately before moving on to the next step. The ABCDE approach should be performed in the first 5 minutes and repeated whenever a patient’s condition changes or worsens. Module 1: The ABCDE and SAMPLE history approach 18 THE ABCDE ASSESSMENT AND MANAGEMENT REMEMBER... Always check for signs of trauma in each of the ABCDE sections, and reference the trauma module as needed. [see TRAUMA] ASSESSMENT IMMEDIATE MANAGEMENT Airway A Can the patient talk normally? If YES, the airway is open. If the patient cannot talk normally: • look to see if the chest wall is moving and listen to see if there is air movement from the mouth or nose. • listen for abnormal sounds (such as stridor, grunting, or snoring) or a hoarse or raspy voice that indicates a partially obstructed airway. – Stridor plus swelling and/or hives suggest a severe allergic reaction (anaphylaxis). • Look and listen for fluid (such as blood, vomit) in the airway. • Look for foreign body or abnormal swelling around the airway, and altered mental status. • Check if the patient is able to swallow saliva or is drooling. • If the patient is unconscious and not breathing normally and: – NO TRAUMA: open the airway using the head-tilt and chin-lift manoeuvre. [See SKILLS] – CONCERN FOR TRAUMA: maintain cervical spine immobilization and open the airway using the jaw thrust manoeuvre. [See SKILLS] – Place an oropharyngeal or nasopharyngeal airway to maintain the airway. [See SKILLS] • If a foreign body is suspected: – If the object is visible, remove it – be careful not to push the object any deeper. – If the patient is able to cough or make noises, keep the patient calm and encourage coughing. – If the patient is choking (unable to cough, not making sounds) use age-appropriate chest thrusts/ abdominal thrusts/back blows. [See SKILLS] – If the patient becomes unconscious while choking, follow relevant CPR protocols. • If secretions or vomit are present, suction when available, or wipe clean. Consider placing patient in the recovery position if the rest of the ABCDE is normal and no trauma is suspected. [See SKILLS] • If the patient has swelling, hives or stridor, consider severe allergic reaction (anaphylaxis), and give intramuscular adrenaline. [See SKILLS] • Allow the patient to stay in a position of comfort and prepare for rapid handover/transfer to a centre capable of advanced airway management, if needed. If the airway is open, move onto “Breathing”. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 19 ASSESSMENT IMMEDIATE MANAGEMENT Breathing B • Look, listen, and feel to see if the patient is breathing. • Assess if breathing is very fast, very slow, or very shallow. • Look for signs of increased work of breathing (such as accessory muscle use, chest indrawing/ retractions, nasal flaring) or abnormal chest wall movement. • Listen for abnormal breath sounds such as wheezing or crackles. [See DIFFICULTY IN BREATHING] • With severe wheezing, there may be limited/no breath sounds on examination because narrowing of the airways may be so severe that breathing cannot be heard. • Listen to see if breath sounds are equal on both sides. • Check for the absence of breath sounds and dull sounds with percussion on one side (large pleural effusion or haemothorax). [See SKILLS] • If there are no breath sounds on one side, and hypotension, check for distended neck veins or a shifted trachea (tension pneumothorax). • Check oxygen saturation with a pulse oximeter when available. • If unconscious with abnormal breathing, start bag-valve-mask ventilation and follow relevant CPR protocols. • If not breathing adequately (too slow for age or too shallow), begin bag-valve-mask ventilation with oxygen [See SKILLS]. If oxygen not immediately available, DO NOT DELAY ventilation. Start ventilation while oxygen is being prepared. Plan for rapid handover/transfer. • If breathing fast or hypoxic, give oxygen [See SKILLS] • If wheezing, give salbutamol. [See SKILLS] Repeat salbutamol as needed. • If concern for severe allergic reaction (anaphylaxis), give intramuscular adrenaline. [See SKILLS] • If concern for tension pneumothorax, perform needle decompression immediately and give IV fluids and oxygen. [See SKILLS] Plan for rapid handover/ transfer. • If concern for large pleural effusion or haemothorax, give oxygen and plan for rapid handover/transfer. • If cause unknown, remember the possibility of trauma [See TRAUMA] If breathing is adequate, move onto “Circulation”. Circulation C • Look and feel for signs of poor perfusion (cool, moist extremities, delayed capillary refill greater than 3 seconds, low blood pressure, tachypnoea, tachycardia, absent pulses). • Look for both external AND internal bleeding, including bleeding: – into chest; – into abdomen; – from stomach or intestine; – from pelvic or femur fracture; – from wounds. • Look for hypotension, distended neck veins and muffled heart sounds that might indicate pericardial tamponade. • For cardiopulmonary arrest, follow relevant CPR protocols. • If signs of poor perfusion, give IV fluids and oxygen [See SKILLS] and: – For external bleeding, apply direct pressure or use other technique to control. [See SKILLS] – If internal bleeding or pericardial tamponade are suspected, refer rapidly to a centre with surgical capabilities. If cause unknown, remember the possibility of trauma: Bind pelvic fractures and splint femur fractures, or any fracture with compromised blood flow. [See TRAUMA and SKILLS] If circulation is adequate, move onto “Disability”. Module 1: The ABCDE and SAMPLE history approach 20 ASSESSMENT IMMEDIATE MANAGEMENT Disability D • Assess level of consciousness with the AVPU scale (Alert, Voice, Pain, Unresponsive) or in trauma cases, the Glasgow Coma Scale (GCS). [See SKILLS] • Always check glucose level in the confused or unconscious patient. • Check for pupil size, whether the pupils are equal, and if pupils are reactive to light. • Check movement and sensation in all four limbs. • Look for abnormal repetitive movements or shaking on one or both sides of the body (seizure/convulsion). • If altered mental status and no evidence of trauma, place in recovery position. [See SKILLS] • If glucose low (<3.5 mmol/L) or glucose test not available and patient has altered mental status, give glucose. [See SKILLS] • For active seizures, give a benzodiazepine. [See SKILLS] • If pregnant and having seizures, give magnesium sulphate. [See SKILLS] • If pupils are small and breathing slow, consider opioid overdose and give naloxone. [See SKILLS] • If pupils are not equal, consider increased pressure on the brain and raise head of bed 30 degrees if no concern for spinal injury. Plan for rapid transfer to an advanced provider or facility with neurosurgical care. If cause unknown, remember possibility of trauma: Immobilize the cervical spine if concern for trauma. [See TRAUMA and SKILLS] Exposure E • Examine the entire body for hidden injuries, rashes, bites or other lesions. • Rashes, such as hives, can indicate allergic reaction, and other rashes can indicate serious infection. • If snake bite is suspected, immobilize the limb. [See SKILLS] Take a picture of the snake if possible from a distance and send with patient. Do not risk additional bites to catch/kill snake. • Remove constricting clothing and all jewelry. • Cover the patient as soon as possible to prevent hypothermia. Acutely ill patients have difficulty regulating body temperature. • Remove any wet clothes and dry patient thoroughly. • Respect the patient and protect modesty during exposure. If cause unknown, remember the possibility of trauma: Log roll if suspected spinal injury [See TRAUMA and SKILLS] INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 21 ABCDE IN DEPTH: ACUTE, LIFE-THREATENING CONDITIONS This section takes a deeper look at conditions that must be managed during the ABCDE approach. AIRWAY conditions A CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT Obstruction due to foreign body • Visible secretions, vomit or foreign bodies in the airway • Abnormal sounds from the airway (such as stridor, snoring, gurgling) • Mental status changes leading to airway obstruction from the tongue • Poor chest rise The airway can become obstructed by secretions, vomit or foreign bodies. • Remove the foreign body if possible and suction fluid. Be careful not to push a foreign body further into the airway. Do not try to remove a foreign body unless clearly visible. • Use age-appropriate chest thrusts/abdominal thrusts/back blows if the airway is completely obstructed. [See SKILLS] • The tongue may obstruct the airway in patients with a decreased level of consciousness. – Open the airway using a head-tilt and chin- lift manoeuvre, or use jaw thrust (if there is concern for trauma); and place an oral or nasopharyngeal airway as needed. [See SKILLS] – These patients may also not be able to protect their airway and need to be watched for vomiting and aspiration. • Plan for rapid handover/transfer to advanced provider capable of advanced airway management if the obstruction cannot be removed. Obstruction due to burns • Burns to head and neck • Burned nasal hairs or soot around the nose or mouth • Abnormal sounds from the airway (such as stridor) • Change in voice • Poor chest rise Burns can cause airway swelling due to inhalational injuries. • Give oxygen to ALL patients with suspected airway burn even if they do not show signs of hypoxia. [See SKILLS] • Open the airway using appropriate manoeuvre and place an oral or nasopharyngeal airway as needed. [See SKILLS] • Maintain cervical spine immobilization if there is evidence of trauma. [See SKILLS] • The airway can swell and close off very quickly in burn patients. Plan for rapid handover/transfer to a provider capable of advanced airway management. Module 1: The ABCDE and SAMPLE history approach 22 CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT Obstruction due to severe allergic reaction (anaphylaxis) • Mouth, lip, and tongue swelling • Difficulty breathing with stridor and/or wheezing • Rash or hives (patches of pale or red, itchy, warm, swollen skin) • Tachycardia and hypotension • Abnormal sounds from the airway (such as stridor, snoring, gurgling) • Poor chest rise Severe allergic reactions can cause swelling of the airway that can lead to obstruction. • Give intramuscular adrenaline for airway obstruction, severe wheezing or shock. [See SKILLS] – Adrenaline can wear off in minutes so be prepared to give additional doses. • Place an IV and give IV fluids. [See SKILLS] • Reposition airway as needed (sit patient upright if no trauma) and give oxygen. [See SKILLS] • If severe or not improving, prepare for rapid handover/transfer for advanced airway management. Obstruction due to trauma • Neck haematoma or injuries to head and neck • Abnormal sounds from the airway (such as stridor, snoring, gurgling) • Change in voice • Poor chest rise Airway obstruction may result from injuries to the head or neck. Blood, bone or damaged tissue may block the airway. Penetrating wounds to the neck may also cause obstruction due to swelling or expanding haematoma. • Suction to remove any blood that might block the airway. • Open the airway using jaw thrust only (do not use head-tilt/chin-lift); and place an oral airway as needed (do not use nasopharyngeal airways if there is facial trauma). [See SKILLS} • Maintain cervical spine immobilization if there is evidence of trauma. [See SKILLS] • Plan for rapid handover/transfer to advanced provider capable of advanced airway management or surgical intervention. For any abnormal airway sounds, re-assess airway frequently as partial obstruction may worsen rapidly and block airway. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 23 BREATHING conditions B CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT Tension pneumothorax Hypotension WITH difficulty in breathing AND any of the following: • distended neck veins • absent breath sounds on affected side • hyperresonance with percussion on affected side [See SKILLS] • tracheal shift away from affected side Any pneumothorax can become a tension pneumothorax. Air in the cavity between the lungs and the chest wall can collapse the lung (simple pneumothorax). Building pressure (tension) from a large pneumothorax can displace and block flow from the main vessels back to the heart, causing shock (tension pneumothorax). • If tension pneumothorax is suspected, perform emergency needle decompression. [See SKILLS] • Give oxygen. [See SKILLS] • Give IV fluids. [See SKILLS] • Arrange for rapid handover/transfer to an advanced provider capable of placing a chest tube. Suspected opioid overdose • Slow respiratory rate • Hypoxia • Very small pupils Opioid medications (such as morphine, pethidine, and heroin) can decrease the body’s drive to breathe. • Give naloxone to reverse the effects of opioids. [See SKILLS] – Monitor closely as naloxone will wear off and additional doses may be needed. • Give oxygen. [See SKILLS] Asthma/ COPD (chronic obstructive pulmonary disease) • Wheezing • Cough • Accessory muscle use • May have history of asthma/COPD diagnosis, allergies or smoking Asthma and COPD are conditions causing spasm in the lower airways, resulting in narrowing that causes difficulty in breathing and wheezing. • Administer salbutamol as soon as possible. (Salbutamol helps to relieve the spasm in the air passages) [See SKILLS] • Give oxygen if indicated. [See SKILLS] Large pleural effusion/ haemothorax • Decreased breath sounds on affected side • Dull sounds with percussion on affected side [See SKILLS] • If there is a large amount of fluid, may have shock Pleural effusion occurs when fluid builds up in the space between the lung and the chest wall or diaphragm. As the fluid builds up, it limits expansion of the lungs. • Give oxygen. [See SKILLS] • Arrange for handover/transfer immediately (many of these patients will need a procedure to drain fluid). If cause unknown, remember the possibility of trauma [See TRAUMA] Module 1: The ABCDE and SAMPLE history approach 24 CIRCULATION conditions C CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT Pulselessness • No pulse • Unconscious • Not breathing Follow relevant cardiopulmonary resuscitation (CPR) protocols. Shock • Rapid heart rate (tachycardia) • Rapid breathing (tachypnoea) • Pale and cool skin • Capillary refill>3 seconds • Sweating (diaphoresis) • May have dizziness, confusion, altered mental status • May have hypotension Poor perfusion is the failure to deliver enough oxygen-carrying blood to the vital organs. When poor perfusion continues until organ function is affected, this is called shock and can lead rapidly to death. • Initial treatment for shock includes laying the patient flat (if tolerated). • Give oxygen. [See SKILLS] • Control bleeding. [See SKILLS] • Start an IV and give IV fluids. [See SKILLS] • If there are signs of infection, give antibiotics if available. • Prepare for rapid handover/transfer. Severe bleeding (haemorrhage) • Bleeding wounds • Bruising around the umbilicus (belly button) or over the flanks can be a sign of internal bleeding • Bleeding from the rectum or vagina or in vomit • Pelvic fracture • Femur fracture • Decreased breath sounds on one side of the chest (haemothorax) • Signs of poor perfusion (such as hypotension, tachycardia, pale skin, diaphoresis) External bleeding that is not controlled can lead quickly to shock. A large quantity of blood can also be lost into the chest, pelvis, thigh and abdomen before the bleeding is recognized. • Stop the bleeding. Depending on the source, use: – direct pressure [See SKILLS] – deep wound packing [See SKILLS] – a tourniquet [See SKILLS] – pelvic binder or femur splint. [See SKILLS] • Give IV fluids. [See SKILLS] • Refer for blood transfusion and ongoing surgical management if needed. A tourniquet should be used only for life- threatening bleeding. Pericardial tamponade • Signs of poor perfusion (tachycardia, tachypnoea, hypotension, pale and cool skin, cold extremities, capillary refill >3 seconds) • Distended neck veins • Muffled heart sounds • May have dizziness, confusion, altered mental status Pericardial tamponade occurs when fluid builds up in the sac around the heart. The pressure from this fluid can collapse the chambers of the heart and keep them from filling properly, limiting blood flow to the tissues and causing shock. Treatment is drainage by pericardiocentesis. • In order to keep the patient alive until the fluid around the heart can be drained, give IV fluids to ensure that as much volume as possible enters the heart. [See SKILLS] • Refer rapidly for surgical management. If cause unknown, remember the possibility of trauma [See TRAUMA] INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 25 DISABILITY conditions D CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT Hypoglycaemia • Sweating (diaphoresis) • Altered mental status (ranging from confusion to unconsciousness) • Seizures/convulsions • Blood glucose <3.5 mmol/L • History of diabetes, malaria or severe infection • Responds quickly to glucose Patients with hypoglycaemia (low blood sugar) need glucose immediately. [See SKILLS] • If the person can speak and swallow, give oral glucose. • If the person cannot speak or is unconscious, give IV glucose if possible. • If IV glucose is not possible or available, give buccal (inside of the cheek) glucose. [See SKILLS] Increased pressure on the brain • Headache • Seizures/convulsions • Nausea, vomiting • Altered mental status • Unequal pupils • Weakness on one side of the body Increased pressure on the brain can occur from trauma, tumours, increased fluid, bleeding or infections. Because the skull is rigid, any swelling, fluid, or mass increases the pressure around the brain, limiting blood flow and possibly displacing brain tissue, causing death. • Raise the head of the bed to 30 degrees if there is no concern for trauma and there is no hypotension. • Check glucose. [See SKILLS] • If there are seizures/convulsions, give a benzodiazepine. [See SKILLS] • The pressure must be reduced as quickly as possible. Arrange for rapid handover/transfer to a surgical centre. Seizure/ convulsion Signs and symptoms of active seizure: • Repetitive movements, gaze fixed to one side or alternating rhythmically and not responsive. Sign and symptoms of recent seizure: • Bitten tongue • Urinated on self • Known history of seizures/convulsions • Confusion that gradually improves over minutes to hours The goal in managing seizures/convulsions is to prevent hypoxia and injury. • Protect the seizing person from falls and from any hard or sharp objects nearby. • Do not place anything in the mouth of a person with active seizure except to suction airway. [See SKILLS] • Give oxygen. [See SKILLS] • Check blood glucose. Give glucose if <3.5 mmol/L. [See SKILLS] • Treat with a benzodiazepine [See SKILLS] and monitor closely for slowing or difficult breathing. • Place patient in recovery position if there is no trauma suspected. [See SKILLS] • If the patient is pregnant, or recently gave birth, give magnesium sulphate. [See SKILLS] If cause unknown, remember the possibility of trauma [See TRAUMA] Module 1: The ABCDE and SAMPLE history approach 26 EXPOSURE conditions E CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT Snake bite • History of snake bite • Bite marks may be seen • Oedema • Blistering of the skin • Bruising • Hypotension • Paralysis • Seizures • Bleeding from wounds The goal of managing snake bites is to limit the spread of the venom and the effects of venom on the body. • Immobilize the extremity. [See SKILLS] • Take a picture of the snake when possible and send with the patient (for example, with the patient’s mobile phone). • Give IV fluids if evidence of shock. [See SKILLS] • These patients may have delayed shock or airway problems. Monitor closely and plan early for rapid handover/transfer. Vital signs should be checked at the end of the ABCDE A full set of vital signs (blood pressure, heart rate, respiratory rate, and oxygen saturation if available) should be performed after the ABCDE approach. Do not delay ABCDE interventions for vital signs. ABCDE SHOULD BE REPEATED FREQUENTLY The ABCDE approach is designed to quickly identify reversible life-threatening conditions. Ideally, the ABCDE approach should be repeated at least every 15 minutes or with any change in condition. Workbook question 2: ABCDE approach Using the workbook section above, list the management for airway blocked by a foreign body. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 27 PAEDIATRIC ABCDE CONSIDERATIONS While the ABCDE approach is used in both adults and children, there are some aspects of assessing and managing children that are different from adults. The “Paediatric considerations” sections throughout the workbook highlight these differences. Paediatric considerations Pediatric airway conditions A Excessive drooling, stridor, airway swelling and unwillingness to move the neck are all high-risk signs in children. Look carefully in the airway for foreign bodies, burns or obstruction. Allow the child to remain in a position of comfort. Position airway as needed below. Compared to adults, children have: So you must do this: Bigger tongues. • Place the child in the “sniffing” position (modified head-tilt, chin-lift – like the slight upward and forward tilt of the head when sniffing a flower). Shorter necks with airways that are softer and more easily blocked. • Avoid over-extending or flexing the neck. A larger head compared to the rest of the body. • Watch closely for airway obstruction. • Use the jaw thrust if airway is not open. [See SKILLS] • Position head (using padding under shoulders for very small children) to open airway if no trauma. [See SKILLS] Neutral position in infants page 2 For choking, use age-appropriate chest thrusts/abdominal thrusts/back blows. [See SKILLS] Module 1: The ABCDE and SAMPLE history approach 28 Pediatric breathing conditions B • Nasal flaring, head bobbing, grunting and chest indrawing OR retractions, are signs of respiratory distress in children. • CYANOSIS – a blue/grey discoloration around the lips, mouth or fingertips – is the result of a lack of oxygen and is a danger sign. • CHEST INDRAWING is a common presentation of paediatric accessory muscle use. – Look at the lower chest wall (lower ribs). The child has chest indrawing if the lower chest wall goes IN when the child breathes IN. – In normal breathing, the whole chest wall (upper and lower) and the abdomen move OUT when the child breathes IN. • A SILENT CHEST (no breath sounds when you listen to the chest) is a sign of severe respiratory distress in a child. With severe spasm and narrowing of the airways, there may be limited air movement and few breath sounds on exam. Give salbutamol and oxygen and re-assess frequently. [See SKILLS] • STRIDOR signals severe airway compromise, and there are many possible causes. Children with stridor should be allowed to stay in a position of comfort and transferred immediately to an advanced provider. Further treatment will often include nebulized adrenaline. If immediate transfer is not possible, consider intramuscular adrenaline as per severe allergic reaction treatment. [See SKILLS] Pediatric circulation conditions C • MANAGEMENT OF POOR PERFUSION IN CHILDREN MAY CHANGE based on the cause and on the condition of the child. [See SHOCK and SKILLS modules] • LOW BLOOD PRESSURE IN A CHILD IS A SIGN OF SEVERE SHOCK. Children are able to maintain normal blood pressure for longer than adults when in shock. Closely monitor other signs of poor perfusion, such as decreased urine output and altered mental status. • THE AMOUNT OF INTRAVENOUS FLUID GIVEN TO CHILDREN IS DIFFERENT FROM ADULTS. [See SKILLS] • IN MALNOURISHED CHILDREN, both the rate of fluid administration and the type of fluid are different. [See SKILLS] • SEVERE SIGNS: Sunken fontanelle, poor skin pinch [See SKILLS], lethargy, altered mental status. Chest indrawing page 33 Chest indrawing INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 29 Pediatric disability conditions D • LOW BLOOD GLUCOSE is a very common cause of altered mental status in sick children. – If possible, check blood glucose in children with altered mental status. – When it is not possible to check the blood glucose level, administer glucose. • Always check for seizure/convulsions. • It is sometimes difficult to determine if infants are acting normally. Always ask the person caring for the child. Pediatric exposure conditions E • INFANTS AND CHILDREN HAVE DIFFICULTY MAINTAINING TEMPERATURE and can very quickly become hypothermic (low body temperature) or hyperthermic (high body temperature). – Remove wet clothing and dry skin thoroughly. Place infants skin-to-skin when possible. – For hypothermia, be sure to cover infants’ heads (but do not obstruct face). – For hyperthermia, unbundle tightly wrapped infants. PAEDIATRIC DANGER SIGNS IN ABCDE In addition to performing a thorough ABCDE approach, all paediatric patients should be evaluated for the presence of danger signs. Children with danger signs need URGENT attention and referral/ handover to a provider able to provide advanced paediatric care. Paediatric danger signs include: • Signs of airway obstruction (stridor or drooling/unable to swallow saliva) • Increased breathing effort (fast breathing, nasal flaring, grunting, chest indrawing or retractions) • Cyanosis (blue colour of the skin, especially at the lips and fingertips) • Altered mental status (including lethargy or unusual sleepiness, confusion, disorientation) • Moves only when stimulated or no movement at all (AVPU other than “A”) • Not feeding well or cannot drink or breastfeed • Vomiting everything • Seizures/convulsions • Low body temperature (hypothermia) Module 1: The ABCDE and SAMPLE history approach 30 Workbook question 3: ABCDE approach Using the workbook section above, list one of each of the following: a paediatric airway consideration ______________________________________________________________________ a paediatric breathing consideration ______________________________________________________________________ a paediatric circulation consideration ______________________________________________________________________ a paediatric disability consideration ______________________________________________________________________ a paediatric exposure consideration ______________________________________________________________________ Elements of the SAMPLE history The SAMPLE approach is a standard way of gathering the key history related to an illness or injury. Sources of information include: the ill/injured person, family members, friends, bystanders, or prior providers. SAMPLE stands for: S: Signs and symptoms The patient/family’s report of signs and symptoms is essential to assessment and management. A: Allergies It is important to be aware of medication allergies so that treatments do not cause harm. Allergies may also suggest anaphylaxis as the cause of acute symptoms. M: Medications Obtain a full list of medications that the person currently takes and ask about recent medication or dose changes. These may affect treatment decisions and are important to understanding the person’s chronic conditions. P: Past medical history Knowing prior medical conditions may help in understanding the current illness and may change management choices. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 31 L: Last oral intake Record the time of last oral intake and whether solid or liquid. A full stomach increases the risk of vomiting and subsequent choking, especially with sedation or intubation that might be required for surgical procedures. E: Events surrounding the injury or illness Knowing the circumstances around the injury or illness may be helpful in understanding the cause, progression and severity. Workbook question 4: SAMPLE history Using the workbook section above, list what the letters in SAMPLE stand for: S: ______________________________________________________________________ A: _____________________________________________________________________ M: _____________________________________________________________________ P: ______________________________________________________________________ L: ______________________________________________________________________ E: ______________________________________________________________________ DISPOSITION CONSIDERATIONS If you have to intervene in any of the ABCDE categories, immediately plan for handover/ transfer to a higher level of care. Once you have completed the ABCDE approach, take a SAMPLE history and complete a physical examination based on the specific condition (secondary examination). A good handover summary [See SKILLS] to the next provider requires: – brief identification of the patient; – relevant elements of the SAMPLE history; – physical examination findings; – record of interventions given; – plans for care needed next and other concerns you may have. Module 1: The ABCDE and SAMPLE history approach 32 FOR REFERENCE: NORMAL VITAL SIGNS NORMAL ADULT VITAL SIGNS Pulse rate: 60–100 beats per minute Respiratory rate: 10–20 breaths per minute – A respiratory rate of less than eight breaths per minute is a danger sign and may require intervention. Systolic blood pressure >90 mmHg Oxygen saturation >92% If you cannot take a blood pressure reading, you can use the pulse to estimate systolic blood pressure. Feeling for a pulse at the locations below can provide an estimate of systolic blood pressure in an adult (although this method may not work well in the elderly): • Carotid (neck) pulse ≥ 60 mmHg • Femoral (groin) pulse ≥ 70 mmHg • Radial (wrist) pulse ≥ 80 mmHg NORMAL PAEDIATRIC VITAL SIGNS Vital signs are age-dependent in children. Normal heart rate and respiratory rate are higher in younger children, and normal blood pressures are lower. The brachial (middle of the upper arm) artery should be used to check the pulse in infants and small children. Normal paediatric vital signs AGE (in years) NORMAL HEART RATE (beats per minute) ≤1 100–160 1–3 90–150 4–5 80–140 AGE RESPIRATORY RATE (breaths per minute) ≤2 months 40–60 2–12 months 25–50 1–5 years 20–40 * To estimate a child’s (1–10 years old) weight in kilograms use the formula: [age in years + 4] x 2 or use weight-estimation tools such as PAWPER, Mercy TAPE, or Broselow tape. Children are able to maintain normal blood pressure for longer than adults when they are in shock. You must check closely for signs of poor perfusion. The amount of IV fluid appropriate for children is different from that for adults. [See SKILLS] Location of brachial pulse in a child page 35 Location of brachial pulse in a child INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 33 FACILITATOR-LED CASE SCENARIOS These case scenarios will be discussed in small groups. These cases in this module will NOT be assessed and are for practice only. It is important that you practise with these scenarios since you will be assessed on how you lead a case in later modules. To complete a case scenario, the group must identify the critical findings and management needed and formulate a 1–2 line handover summary that includes assessment findings and interventions. You should use the Quick Cards to manage these scenarios. CASE #1: ADULT ABCDE A 70-year-old man is brought in by taxi. The driver states the patient lost consciousness while talking with his daughter. There was no trauma, but the daughter poured water on him to try to wake him up. Initially he was confused and vomiting. Now he is unconscious with a respiratory rate of 3 breaths per minute. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate 1–2 sentences to summarize this patient for handover. Module 1: The ABCDE and SAMPLE history approach 34 CASE #2: PAEDIATRIC ABCDE A mother brings in her 2-year-old son for difficulty in breathing. She reports that he has had a fever for 3 days and has had worsening difficulty in breathing. He has been coughing a lot and today will not eat or drink. 1. What is your initial approach to this patient? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator for specific findings when you look, listen and feel; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate a 1–2 sentence summary of this patient for handover. MULTIPLE CHOICE QUESTIONS Answer the questions below. Questions and answers will be discussed within the session. 1. A mother brings in her 3-year-old child because of difficulty in breathing. On assessment, you hear loud, high-pitched sounds when the child breathes in. What is the most immediate concern? A. Severe infection B. Shock C. Asthma attack D. Upper airway obstruction 2. An elderly woman fell at home. She had normal vital signs, but complained of neck and knee pain prior to transport. During transport, she starts snoring and gurgling when taking a breath. What is the most appropriate method to immediately manage this problem? A. Placing her in the recovery position B. Administering salbutamol C. Jaw thrust D. Head-tilt/chin-lift INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 35 3. A 50-year-old man has collapsed in a store and you are called to assist him. He is unconscious, has a respiratory rate of four breaths per minute and a pulse of 100 beats per minute. The collapse was witnessed and there is no trauma. What is the best next step? A. Begin chest compressions B. Open the airway C. Begin bag-valve-mask ventilations D. Check pupils 4. A 2-year-old boy is brought to you for being more sleepy than normal. He is unconscious. You open his airway, and insert an oropharyngeal airway. What is your next step? A. Check blood pressure B. Check AVPU scale C. Check glucose D. Check breathing 5. You are listening to the lungs of a 26-year-old man who has sudden onset chest pain and he is taking 30 breaths a minute. Which lung-sound finding is most suggestive of pneumothorax? A. Crackles on both sides B. Absent lung sounds on one side C. Stridor D. 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INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS 37 PARTICIPANT WORKBOOK Module 2: Approach to trauma Objectives On completing this module you should be able to: 1. recognize key history findings suggestive of high-risk injuries; 2. recognize physical examination findings suggestive of high-risk injuries; 3. perform Trauma Primary Survey (the ABCDE approach to trauma patients); 4. perform Trauma Secondary Survey (the head-to-toe trauma exam); 5. recognize life-threatening injuries; 6. perform critical interventions for high-risk conditions. Essential skills • Cervical spine immobilization • Spine immobilization and log-roll manoeuvre • Jaw-thrust manoeuvre • Airway suctioning • Insertion of oropharyngeal and nasopharyngeal airway • Recovery Position • Oxygen delivery • Bag-valve-mask ventilation • Needle decompression for tension pneumothorax • Three-sided dressing for a sucking chest wound • Direct pressure for haemorrhage control, including deep wound packing • Tourniquet for haemorrhage control • IV line insertion • IV flluid resuscitation • AVPU and GCS assessment • Pelvic binding • Basic fracture immobilization • Trauma secondary survey • Basic wound management, including irrigation (washing) • Burn management KEY TERMS Write the definition using the Glossary at the back of the workbook. AVPU: Bradycardia: Circumferential burn: Crepitus: Compartment syndrome: Module 2: Approach to trauma 38 Cyanosis: Decontamination: Deep wound packing: Diaphoresis: Direct pressure: Disposition: Escharotomy: Flail chest: Fracture: Glasgow Coma Scale: Guarding: Haemorrhage: Haemorrhagic shock: Haematoma: Haemothorax: Hyperresonance: Hypothermia: Hypovolaemic shock: Hypoxia: Laceration: Large bore IV: INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 39 Log-roll manoeuvre: Needle decompression: Parkland Formula: Percussion: Pericardial tamponade: Pneumothorax: Priapism: Rebound tenderness: SAMPLE history: Shock: Sprain: Sucking chest wound: Tension pneumothorax: Trauma primary survey: Trauma secondary survey: Module 2: Approach to trauma 40 Overview GENERAL PRINCIPLES OF TRAUMA CARE Early priorities for an injured person include managing airway and breathing emergencies, controlling bleeding, treating shock and immobilizing the spine if needed. The goal of INITIAL ASSESSMENT is to identify life-threatening injuries. The goal of ACUTE MANAGEMENT is to ensure oxygenation and perfusion, to control pain and to plan ongoing care. This module will guide you through the: Approach to trauma ABCDE: Trauma primary survey DO: Important conditions to recognize and manage in the primary survey (signs, symptoms and management) ASK: Key history findings (SAMPLE history) CHECK: Trauma secondary survey DO: Important conditions to recognize and manage based on the history and secondary survey (Signs, symptoms and management) Special populations – Trauma in pregnancy – Special considerations in children Disposition considerations APPROACH TO TRAUMA Approach to the trauma patient consists of three phases: Trauma primary survey: The ABCDE approach for injured patients SAMPLE history: Signs and Symptoms, Allergies, Medications, Past medical history, Last oral intake, and Events surrounding the injury Trauma secondary survey: A complete head-to-toe examination to look for injuries not identified by the primary survey During primary and secondary surveys, if life-threatening problems are identified, STOP AND MANAGE them. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 41 ABCDE: TRAUMA PRIMARY SURVEY The ABCDE approach in injured patients is often also called the trauma primary survey. As for all patients this should be conducted within the first 5 minutes and repeated whenever the patient’s condition worsens. This trauma-specific ABCDE approach includes the initial assessment and management for all immediately life-threatening injuries. Always suspect head and spine injury in a trauma patient with altered mental status. ASSESSMENT IMMEDIATE MANAGEMENT Airway with cervical spine immobilization A Look for: • blood, vomit, tongue or objects obstructing the airway • burned nasal hairs or soot around the nose or mouth • head or neck trauma • neck haematoma (bleeding under the skin) • altered mental status, as this can affect the ability to protect the airway Listen for abnormal airway sounds (such as gurgling, snoring, stridor, noisy breathing). • Stabilize the cervical spine. [See SKILLS] • Open airway using jaw thrust, NOT head-tilt chin-lift if suspected spine injury. [See SKILLS] • Suction airway secretions, blood and/ or vomit. Remove any visible foreign objects from the airway. [See SKILLS] • Place oral airway (avoid nasal airway if facial trauma). [See SKILLS] • If the patient has an expanding neck haematoma or evidence of airway burns or trauma, plan for rapid handover/transfer to a provider capable of advanced airway management. If the airway is open, move onto “Breathing”. Breathing B Look for: • increased work of breathing • abnormal chest wall movement which may indicate flail chest • tracheal shift • sucking chest wound • cyanosis (blue-grey color of the skin) around the lips and fingertips • abrasion, bruising or other signs of injury to chest • circumferential burns (burns that go all the way around a body part) to chest or abdomen • absent or decreased breath sounds Listen for dull sounds or hyperresonance with percussion. Feel for crepitus (cracking and popping when pressing on the skin). • Give oxygen. [See SKILLS] • Perform needle decompression immediately and give oxygen and IV fluids for tension pneumothorax. [See SKILLS] • Place three-sided dressing for sucking chest wound. [See SKILLS] • If breathing not adequate or patient remains hypoxic on oxygen, assist breathing with bag-valve-mask ventilation. [See SKILLS] • For chest or abdominal burns that restrict breathing, handover for escharotomy (a surgical procedure to cut and release burned tissue that may restrict breathing or blood supply to a limb). If breathing is adequate, move onto “Circulation”. Module 2: Approach to trauma 42 ASSESSMENT IMMEDIATE MANAGEMENT Circulation C Look for: • capillary refill longer than 3 seconds • pale extremities • distended neck veins • external AND internal bleeding Common sources of serious bleeding are: • chest injuries • abdominal injuries • pelvic fractures • femur fractures • amputations or large external wounds • burns, noting size and depth Feel for: • cold extremities • weak pulse or tachycardia • Apply direct pressure to control active bleeding, or deep wound packing if large or gaping. [See SKILLS] • If amputated limbs or any other source of uncontrolled bleeding are present, apply tourniquet (document time of application), start IV fluids and plan for urgent transfer to a surgical unit. [See SKILLS] • If ongoing blood loss or evidence of poor perfusion, place two large bore IVs, give IV fluids and re-assess. [See SKILLS] • If burn injury, start IV fluids according to burn size. • Splint suspected femur fracture. [See SKILLS] • Bind pelvic fracture. [See SKILLS] • Leave any penetrating objects in place and stabilize object for transfer to a surgical team. • Position pregnant patients on their left side while maintaining spinal immobilization. If circulation is adequate, move onto “Disability”. Disability D Look for: • confusion, lethargy or agitation • seizures/convulsions • unequal or poorly reactive pupils • deformities of skull • blood or fluid from ear or nose Check: • AVPU or GCS • movement and sensation in all extremities • blood glucose level if confused or unconscious • If GCS <9 (or for children, AVPU score of P or U), plan for rapid handover/ transfer to a provider capable of advanced airway management. • If patient is lethargic or unconscious, re-assess the airway frequently as above. • Suspect spine injury or closed head injury with any trauma and altered mental status. • Give oxygen if concern for hypoxia as a cause of altered mental status. [See SKILLS] • Give glucose if altered mental status and: measured low blood glucose, unable to check blood glucose, or history of diabetes. [See SKILLS] • If seizing, give a benzodiazepine. [See SKILLS] INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 43 ASSESSMENT IMMEDIATE MANAGEMENT Exposure E Remove all clothing. Examine entire body for evidence of injury (including the back, spine, groin and underarms) using the log-roll manoeuvre. • If spinal injury is suspected, perform log-roll manoeuvre to examine the back. [See SKILLS] • Remove restrictive clothing and all jewellery. • Remove any wet clothes and dry patient thoroughly. • Cover the patient as soon as possible to prevent hypothermia. Acutely injured patients have difficulty regulating body temperature. • Respect the patient and protect modesty during exposure. Workbook question 1: Approach to trauma A middle-aged man is brought in after being hit by a car. Using the workbook section above, list the immediate management for the assessment findings below. PRIMARY SURVEY FINDINGS IMMEDIATE MANAGEMENT On airway assessment: • Gurgling airway sounds • Obvious head trauma 1. ������������������������������������������������ 2. ������������������������������������������������ 3. ������������������������������������������������ 4. ������������������������������������������������ On circulation assessment: • Weak pulses • Capillary refill of <3 seconds • Unstable pelvis on exam 1. ������������������������������������������������ 2. ������������������������������������������������ 3. ������������������������������������������������ Module 2: Approach to trauma 44 DO: IMPORTANT CONDITIONS TO RECOGNIZE AND MANAGE IN THE PRIMARY SURVEY A Airway conditions CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Airway obstruction • Visible blood, secretions, vomit, tongue or foreign bodies in the airway • Changes in voice • Abnormal sounds from the airway (such as stridor, snoring, gurgling) • Neck haematoma or burns to head and neck • Mental status changes leading to airway obstruction • Poor chest rise • Injury causing swelling of the airway (such as anaphylaxis or airway burn) Head and neck injuries may result in obstruction of the airway by blood, secretions, vomit, foreign bodies, or swelling. Penetrating wounds to the neck can cause expanding haematomas. Inhalational injuries due to burns can cause swelling. • Patients with a decreased level of consciousness may not be able to protect their airways and need to be watched for vomiting and aspiration. – Suction the airway and remove foreign bodies. – Open the airway using a jaw thrust manoeuvre (NOT head-tilt/chin-lift) and place an oral airway as needed. [See: SKILLS] • Maintain cervical spine immobilization throughout, if needed. • Plan for rapid handover/transfer to a provider capable of advanced airway management. B Breathing conditions CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Tension pneumothorax • Hypotension WITH: – difficulty breathing – distended neck veins – absent breath sounds on affected side – hyperresonance with percussion on affected side – may have tracheal shift away from affected side Any pneumothorax can become a tension pneumothorax. Air in the cavity between the lungs and the chest wall can collapse the lung (simple pneumothorax). Building pressure (tension) from a large pneumothorax can displace and block flow from the great vessels to the heart, causing shock as the heart cannot receive and pump enough blood to the rest of the body (tension pneumothorax). In tension pneumothorax, perfusion is compromised. • Treat tension pneumothorax immediately with needle depression. [See: SKILLS] • Give oxygen and IV fluids. [See: SKILLS] • Plan for rapid handover/transfer to an advanced provider capable of placing a chest tube. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 45 CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Sucking chest wound (open pneumothorax) • Open wound in the chest wall with air passing through causing bubbling or “sucking” noises • Difficulty in breathing • Chest pain Sucking chest wounds are important to recognize because they can rapidly cause a tension pneumothorax. Air enters the chest cavity (into the space between the chest wall and the lungs) through the wound in the chest wall when the patient takes a breath. Pressure on the lung builds if the air cannot escape. • Give oxygen. [See SKILLS] • Place a three-sided dressing that allows air to leave with exhalation but prevents air from entering when the person inhales. [See SKILLS] – There is a danger of the dressing becoming stuck to the chest wall with clotted blood and causing a tension pneumothorax. – After applying a three-sided dressing the patient should be observed continuously. – Remove the dressing if worsening respiratory status or evidence of worsening perfusion. Plan for rapid handover/transfer to an advanced provider capable of placing a chest tube. Flail chest • Difficulty in breathing • Chest pain • Part of chest wall moving in the opposite direction of the rest of the chest when breathing Flail chest segments occur when ribs are broken in multiple places, freeing an entire section of ribs from the chest wall. Without the connection to the chest wall, this section will move abnormally with breathing and prevent part of the lung from expanding. Flail chest is also usually associated with damage to underlying lung tissue. • Give oxygen and pain control. [See SKILLS] • There is a very high risk of developing difficulty in breathing and hypoxia. • Plan for rapid handover/transfer to a provider capable of chest tube placement, advanced airway placement and ventilation. Haemothorax • Difficulty in breathing • Decreased breath sounds on affected side • Dull sounds with percussion on affected side • Large haemothorax may cause shock Haemothorax (blood in the space between the lungs and the chest wall) can present with decreased or absent breath sounds and dull sounds with percussion on the affected side. • Give oxygen and IV fluids. • Plan for rapid handover/transfer to a centre with surgical capacity. Module 2: Approach to trauma 46 C Circulation conditions CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Hypovolaemic shock • Tachycardia, tachypnoea, pale skin, cold extremities, slow capillary refill • May have dizziness, confusion or altered mental status • May have hypotension • External bleeding or internal bleeding (chest, abdomen, pelvis, femur, blood vessels) Hypovolaemic shock can result from rapid loss of blood (haemorrhagic shock) or from the fluid loss associated with burns. An adult patient in shock may have only tachycardia (elevated heart rate) and/or tachypnoea (high respiratory rate) and may not have low blood pressure until the condition is immediately life-threatening. Even with a systolic blood pressure greater than 90 mmHg, suspect hypovolaemic shock if there is severe bleeding or any sign of poor perfusion (such as cool, moist, or pale skin, slow capillary refill, fast breathing, confusion, restlessness, anxiety). • Stop bleeding with direct pressure, deep wound packing if wound is gaping, a tourniquet, splinting of fractures and binding the pelvis as needed. [See SKILLS] • Start two large-bore IV lines and give IV fluids. [See SKILLS] • Patients with suspected large haemothorax or other internal haemorrhage will need rapid handover/transfer to a unit with surgical care and blood transfusion capabilities. REMEMBER... Children and young people are able to maintain a normal blood pressure until they have lost up to a quarter of their blood. Always check for other signs of shock. [See “Special considerations in children” section] Pericardial tamponade • Signs of poor perfusion (such as tachycardia, tachypnoea, hypotension, pale skin, cold extremities, capillary refill greater than 3 seconds) • Distended neck veins • Muffled heart sounds • May have dizziness, confusion, altered mental status Pericardial tamponade occurs when fluid builds up in the sac around the heart. The pressure from this fluid can collapse the chambers of the heart and prevent them from filling, limiting the amount of blood the heart can pump. • Give IV fluid to improve heart filling. [See SKILLS] • Patients need immediate handover/transfer to an advanced provider for drainage of the fluid. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 47 D Disability conditions CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Severe head injury • Visual changes, loss of memory, seizures/ convulsions, vomiting, headache • Altered mental status or other neurologic deficit • Scalp wound and/or skull deformity • Bruising to head (particularly around eyes or behind ears) • Blood or fluid from the ears or nose • Unequal pupils • Weakness on one side of the body Brain injuries can range from mild bruising to severe bleeding in or around the brain. Because the skull is rigid, the bleeding cannot expand and causes increased pressure on the brain. If the pressure becomes too high, it will prevent blood from entering into the skull and perfusing the brain, and can squeeze part of the brain through the base of the skull, causing death. Any trauma to the brain can cause significant impact on function. • Always remember that head injuries can be associated with spinal injuries. Immobilize the spine and use the log-roll technique to examine the back of the body. • Use the Glasgow Coma Scale (or AVPU in children) to assess and monitor patients with head injury. • Be sure to frequently re-assess ABCDE. • If concern for open skull fracture, give IV antibiotics as per local protocol. • Always check glucose and administer as needed. • Do not give food or drink by mouth. • Plan for early handover/transfer to a facility with specialist care. REMEMBER… People who initially appear well may have hidden life-threatening injuries, such as internal bleeding. It is very important to re-assess trauma patients frequently using the primary survey. Once you find a primary survey problem and manage it, go back and repeat the primary survey to identify any new problems and make sure that the management worked. Ideally, the ABCDE approach should be rechecked every 15 minutes and with any change in condition. Vital signs should be checked at the end of the primary survey A full set of vital signs (blood pressure, heart rate, respiratory rate and oxygen saturation if available) should be performed after the primary survey. Do not delay primary survey interventions for vital signs. Module 2: Approach to trauma 48 Workbook question 2: Approach to trauma Using the workbook section above, list five important conditions to recognize in the primary survey 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ ASK: KEY HISTORY FINDINGS FOR TRAUMA PATIENTS Information about an injured person and the injury event can be critical to planning management. Children, older adults and people with chronic disease have an increased risk of complications from trauma. They may need to be watched for several hours even when they appear well. Certain mechanisms are often associated with multiple injuries, some of which may not be obvious right away. High-risk mechanisms include: pedestrian being hit by a vehicle; motorcycle crashes or any vehicle crash with unrestrained occupants; falls from heights greater than 3 metres (or in children, twice the child’s height); gunshot or stab wounds; and explosion or fire in an enclosed space. Use the SAMPLE approach to obtain a history. Remember that you may be able to obtain information from bystanders, family, police, fire service or other health-care workers. If the history identifies a primary survey condition, STOP AND RETURN IMMEDIATELY TO PRIMARY SURVEY to manage it. S: SIGNS AND SYMPTOMS Is there a history of hoarse or raspy voice, or other voice changes? Changes in voice in the setting of injury to the head, neck or with burns may suggest that the airway is swelling and that it may obstruct. Is there any difficulty in breathing? Problems with breathing may develop over time and might not be present in the initial primary survey. Difficulty in breathing may suggest that the person has an injury to the lungs, ribs, muscles, chest wall or spine. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 49 Is there reported bleeding? It is usually quite difficult for patients to estimate the volume of blood loss, but it may be helpful to know how long there has been bleeding, how many bandages have been soaked and if the bleeding is getting lighter or heavier. Is there confusion or unusual sleepiness? Confusion after injury may be a sign of head injury, lack of oxygen or shock (with decreased blood flow to the brain). A head injury can cause bleeding or increased pressure on the brain leading to confusion, lethargy (increased sleepiness) and coma. Is there pain? Where is the pain, what does it feel like and how severe is it? Pain is a sign of underlying injury. Headache may suggest that the person has an injury to the skull or the brain. Pain along the spine can suggest an injury that may progress to cause damage to the spinal cord. Pain in the chest or abdomen may suggest damage to the heart, lungs or other organs. Pain in the pelvis or hips may suggest a fracture in the pelvis which can cause serious bleeding and shock. Pain may be the first sign of an internal injury in the chest, abdomen or pelvis. Is there nausea or vomiting? This may indicate an abdominal or head injury. Is there reported numbness or weakness? This may indicate a spinal injury. Are there reported vision changes? Direct trauma to the eye, fractures of bones around the eye, and head injuries can all cause vision changes. A: ALLERGIES Any allergies to medications? M: MEDICATIONS Currently taking any medications? Medications that affect blood clotting (e.g. aspirin, warfarin, clopidigrel) can make bleeding more difficult to control and increase the risk of delayed bleeding. Blood pressure medications can make it hard to manage shock. Obtain a full list of medications if possible or ask family members to bring in medications. Module 2: Approach to trauma 50 P: PAST MEDICAL HISTORY Is the person pregnant? Pregnancy causes some of the organs to be moved out of their usual position and causes changes in the body that need to be considered when managing trauma. Always ask women of childbearing age about the date of last menstrual period. Tetanus status? A person who has not had a tetanus vaccination within the past 5 years and who has an injury that damages the skin needs a tetanus vaccination. Are other conditions present that put the person at higher risk for serious injury? RISK FACTORS FOR POOR OUTCOMES FROM INJURY: – Age less than 5 years or greater than 55 years – Heart or lung disease – Diabetes – Liver failure (cirrhosis) – Severely overweight – Pregnancy – Immunosuppression (including HIV) – Bleeding disorder or taking blood-thinning medications (medications that prevent clotting) L: LAST ORAL INTAKE When did the person last eat or drink? E: EVENTS SURROUNDING INJURY Certain mechanisms of injury are so high risk that patients should be observed closely, even if they do not appear to be significantly injured. Was there a fall from 3 metres or more (or twice the height in children)? Falls are a common cause of injury for both adults and children. A greater distance fallen increases the chance of serious injury. Falls in adults are often associated with older age, alcohol intoxication, or the failure of workplace equipment, including scaffolding and ladders. Children often fall from trees, windows or balconies. Was a pedestrian or a cyclist hit by a vehicle? Adults and children who are hit by a vehicle while walking or using non-motorized forms of transport (such as bicycles) are always at high risk of serious injury. Young children may be less able than adults to report events, even major events like being hit by a vehicle. Always consider the possibility of unwitnessed trauma in young children. Children and adults can sustain multiple injuries when hit by a vehicle – both from direct impact to the body, especially the lower extremities, and from secondary impact if they are thrown against the windscreen or road, which may cause injuries anywhere in the body, including to head, neck, chest or limbs. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 51 In a motorcycle (or powered 3-wheeler) crash, was the rider thrown? Motorcycles collisions often result in a rider being thrown. Ask if the motorcyclist was wearing a helmet and how far away from the vehicle the rider was found. Common injury sites include head (especially when no helmet was worn), spine, chest, abdomen and pelvis (as the rider hits the handlebars), as well as limbs and skin (as the rider hits the road). Was there a road traffic crash at high speed? Was the person thrown from or trapped inside a vehicle? Did any vehicle occupants die in this crash? With higher-speed crashes, greater force is transmitted to vehicle occupants increasing the risk of serious injury. Vehicle occupants may be injured by impact with the windscreen or steering wheel, or by the forces that result from the sudden stopping of the vehicle. A person thrown from a vehicle is at very high risk of serious injury. If a person was trapped within a vehicle it is important to find out what part of the body was trapped (arm/leg, etc.) and for how long. Consider crush injury in a person who has been trapped. A death at the scene of a road traffic crash suggests that there was significant force exerted on the vehicle and its passengers. All passengers involved in the crash, even if they appear unhurt, are at high risk for serious injury. In a motor vehicle crash, was the patient wearing a seatbelt? Some types of injuries are more common in patients who were not wearing a seat-belt (being thrown from the vehicle, head strike on the windscreen, chest strike on the steering column). However, in very high-speed crashes, seat belts can also cause certain types of injuries (cervical spine injury, abdominal injury). Was a weapon used? Any time there is a history of a stab or gunshot wound, there may be multiple wounds. Always check the full body for wounds. After a bullet enters the body it may not follow a direct path and can twist throughout the body. Many internal organs can be injured by a single bullet. A stab wound creates a direct path (it is important to know the length of the blade that was used). Remember that blunt injuries from objects such as sticks and bats can cause damage to internal organs in addition to obvious injuries such as fractures, bruises and lacerations. Was there a burn? If so, what type of burn was it? Burns from fires (flame burns) are the most common. A history of flame burn in an enclosed space can also suggest an inhalation or airway injury. Scald burns (due to hot liquids) are common in children. Electrical injuries often come from high-voltage sources such as overhead electrical wires coming in contact with the body. On the surface, these electrical injuries may look small but they can cause extensive tissue and muscle damage. The electrical current often crosses the body, taking the shortest path from the point of contact with the skin to the ground, often leaving entry and exit burn marks. In the case of chemical burns, information about the specific chemical may be needed to remove it properly. For burns, was first aid provided at the scene? It is important to know if the burning process was stopped, and in the event of a chemical exposure, if decontamination was performed. If the burn is less than 3 hours old and no first aid was provided, the wound will need to be washed with clean water to stop the burning process. If there is a history of chemical exposure, protect yourself from the chemical and ensure that it is properly removed from the skin. Module 2: Approach to trauma 52 Did the person sustain a crush injury? Is there severe pain or numbness? Is there dark urine? Crush injuries may damage skin, muscle, blood vessels and bone. Damaged muscle can release a muscle by-product (called myoglobin) that can build up and damage the kidneys. It is important to know how long a body part was crushed. Even a small crushed area can cause the release of a dangerous amount of myoglobin (for example when a limb is caught under falling debris for an extended time). If a person with a crush injury has dark urine, this may be a sign of build-up of myoglobin in the kidneys. Tissue damage and swelling from crush injury can also cause a build-up of pressure (particularly in limb-crush injuries) that can limit blood flow to the muscles and nerves (compartment syndrome). Did the person sustain a blast injury? Blast injuries (from explosions) can involve all systems of the body, especially the hollow organs. Common blast injuries include damage to the lungs, intestines and ears. Patients involved in explosions need to be checked carefully and repeatedly because these injuries are easily missed. Blasts may also be associated with foreign bodies in the skin and eyes, burns or chemical injury, and toxin or radiation exposure. Workbook question 3: Approach to trauma Using the workbook section above, list five questions you would ask when taking a SAMPLE history from a person injured in a road traffic crash: 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ CHECK: TRAUMA SECONDARY SURVEY Following the primary survey and SAMPLE history, the secondary survey is a detailed head-to- toe examination designed to identify any additional injuries or issues requiring intervention. The secondary survey gives the provider an organized way to assess the entire body for signs of trauma that may not have been obvious on the primary survey. Remember that very painful or frightening injuries may distract both patients and providers from recognising other injuries. Always examine the entire body. If the secondary survey identifies a primary survey condition, STOP AND RETURN IMMEDIATELY TO THE PRIMARY SURVEY to manage it. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 53 Head, ears, eyes, nose, and throat (HEENT) Look for: • Scalp wounds or bruising • Skull deformities • Blood in mouth or throat • Unequal or unresponsive pupils indicating head injury • Vision loss or changes and eye injuries • Any problems with eye movements • Blood or fluid from ear or nose, which can indicate tissue injury or skull fracture • Tooth injury or poor alignment of teeth • Signs of airway burns: ash, singed nasal hairs, new or worsening lip/ mouth swelling Listen for: • Stridor which could indicate that the airway will obstruct soon • Gurgling indicating fluid in the airway • Changes in voice, which can indicate airway or vocal cord injury Feel for: • Tenderness or abnormal movement of facial bones, suggesting fracture • Loose teeth that may accidentally be inhaled • Defects or crepitus in the skull or facial bones concerning for fracture Neck Look for: • Reduced ability to move neck or pain on movement • Bruising, bleeding or swelling • Haematoma (bruising/bleeding under the skin) – this may eventually cause airway obstruction • Penetrating neck wounds • Distended neck veins (which may indicate tension pneumothorax or tamponade) Feel for: • Air in the skin or soft tissue – concerning for airway injury or pneumothorax • Tenderness or deformity along the spine – concerning for fracture Chest Look for: • Bruising, deformity, wounds • Uneven chest wall movement–concerning for pneumothorax or flail chest • Burns around the entire chest (circumferential) which can cause difficulty in breathing Listen for: • Breath sounds (decreased, unequal or absent, wheeze, crepitations) • Muffled heart sounds – concerning for pericardial tamponade Feel for: • Tenderness • Crepitus – concerning for fracture or pneumothorax Module 2: Approach to trauma 54 Abdomen Look for: • Abdominal distension • Visible abdominal wounds, bruising or abrasions • Bruising on back or abdomen, which may indicate internal bleeding • Circumferential burns to the abdomen (may cause severe problems with breathing) Feel for: • Abdominal rebound tenderness (pain when releasing pressure on the abdomen) or guarding (sudden contraction of the abdominal wall muscles when the abdomen is pressed), suggesting serious injury • Abdominal tenderness, which can indicate organ or blood vessel injury Pelvis and genitals (always protect patient privacy during exam) Look for: • Bruising/lacerations to pelvis • Blood at the opening of the penis or rectum. May be a sign of sexual assault. • Vaginal lacerations or bleeding – these could indicate open pelvic fracture, injury to the uterus, or may be a source of significant blood loss. May be a sign of sexual assault. • Penile lacerations • Priapism (prolonged erection) can indicate spinal injury • Urine colour changes (dark urine or obvious blood) that might indicate muscle breakdown or kidney injury Feel for: • Tenderness or abnormal movement in pelvis Extremities Look for: • Swelling or bruising • Deformity, which could indicate fracture • Open fractures • Amputation • Circumferential burns • Pale skin that could indicate limited blood flow Feel for: • Absent or weak pulses • Cold skin that could indicate limited blood flow • Tenderness • Abnormally firm, painful muscular compartments in the extremities can indicate compartment syndrome INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 55 Spine/back Log roll the person with assistance, then: Look for: • Bruising • Deformity Feel for: • Tenderness, crepitus and alignment along the entire spine (upper neck to lower back) • Tenderness, crepitus or misalignment over any other areas with visible evidence of trauma Skin Look for: • Bruising • Abrasions • Lacerations • Feel for peripheral pulses in all extremities • Burns – Look for circumferential burns: depending on the location, these can cause difficulty in breathing (if on the chest) or compartment syndrome (if on the extremities) Neurologic Check for: • Decreased level of consciousness (using AVPU or GCS) and seizures/ convulsions, which may be signs of serious head injury • Movement and strength in each limb • Sensation on face, chest, abdomen, limbs; if there is a sensory deficit, identify where it begins • Priapism (persistent penile erection) • Decreased sensation, decreased strength or priapism can indicate spinal cord injury Module 2: Approach to trauma 56 Workbook question 4: Approach to trauma Using the workbook section above, list one way that you would ASSESS the following systems. Head, ears, eyes, nose, throat: Listen for: _______________________________________________________________ Look for: ________________________________________________________________ Feel for: _________________________________________________________________ Chest: Look for: ________________________________________________________________ Listen for: _______________________________________________________________ Feel for: _________________________________________________________________ Pelvis and genitals: Look for: ________________________________________________________________ Feel for: _________________________________________________________________ INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 57 DO: IMPORTANT CONDITIONS TO RECOGNIZE AND MANAGE BASED ON HISTORY AND SECONDARY SURVEY Management of specific injuries found during secondary survey CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Head injury • Headache • Altered mental status • Abnormal pupils • Scalp lacerations and/or skull fractures • Bruising to head (particularly around eyes or behind ears) • Blood or clear fluid coming from nose or ears • Weakness on one side of the body • Seizures/convulsions • Visual change • Loss of memory • Vomiting Because the brain is encased in the rigid skull, any swelling or bleeding caused by brain injury can rapidly become life-threatening. • Monitor level of consciousness (a marker of brain function) using the Glasgow Coma Scale (GCS) or AVPU scale in children. [See SKILLS] • Any patient who has significant head injuries is at risk of having spine injuries as well. [See SKILLS] • Always monitor immobilized patients for vomiting to avoid choking. • If there is concern for an open skull fracture, give IV antibiotics. • Check blood glucose and give glucose if less than 3.5 mmol/L or unable to measure. • Any patient with GCS less than 9 should be transferred for a CT scan within 2 hours of injury, if possible. Facial fractures • Deformities or unusual movement in the facial bones • Patient reports jaw not closing normally or teeth not aligned • Problems with eye movements • Give antibiotics for open facial fractures (laceration over a broken bone). • Update tetanus vaccination. • Suspect cervical spine injury and immobilize the cervical spine if needed. [See SKILLS] • Remember to position patient to keep blood from flowing into airway. • Avoid nasopharyngeal airways and nasogastric tubes when facial fracture is suspected. Penetrating eye injury • Any visible object in the eye • Painful red eye or a reported feeling of something in the eye; it may be difficult to see small objects that have penetrated the eye • Problems with vision • An abnormally shaped pupil or clear liquid draining from the eye may indicate a puncture wound • Evidence of facial trauma • Avoid any pressure on the injured eye – this could worsen the injury • Do not remove objects penetrating the eye. • Give antibiotics. • Update tetanus vaccination if needed. • Keep the head elevated and place a loose patch over both eyes (do NOT put pressure on the eye). • Plan for handover/transfer to an advanced provider. Module 2: Approach to trauma 58 Management of specific injuries found during secondary survey CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Penetrating neck wound • Small lacerations or puncture wounds may be the only sign of serious injury • Swelling (suggesting haematoma) • Look carefully for penetrating objects Patients with penetrating neck wounds are at risk of airway obstruction, so monitor the airway closely. Neck wounds may also have significant haemorrhage. • Maintain cervical spine precautions. [See SKILLS] • Stabilize, but do not remove penetrating objects. • Apply firm pressure to bleeding site, being careful not to block the airway. • Do not insert anything into wound to check the depth – this can cause further damage. • Initiate rapid handover/transfer to a unit with surgical care and advanced airway management capabilities. Chest injury • Difficulty in breathing • Crepitus or tenderness to palpation over the ribs • Uneven chest wall movement or unequal breath sounds Monitor closely for difficulty in breathing due to lung injury which can develop over time. Tension pneumothorax is treated in the primary survey; however, chest injury may also be associated with simple pneumothorax which can progress to a tension pneumothorax. • Any patient with a pneumothorax should be placed on oxygen and monitored closely for development of a tension pneumothorax. • Crepitus or tenderness may be signs of rib fractures which are often associated with underlying chest or abdominal injury. • Plan for handover/transfer for chest tube (pneumothorax) or advanced airway and breathing management. Abdominal injury • Abdominal pain or vomiting • Tender, firm or distended abdomen on examination • Sudden abdominal wall muscle contractions when the abdomen is touched (guarding) • Very few or no bowel sounds on examination • Rectal bleeding • Visible wound in the abdominal wall • Bruising around the umbilicus or over the flanks can be a sign of internal bleeding Severe pain or bruising to the abdomen is concerning for organ injury or internal bleeding. • If you suspect abdominal injuries, give IV fluids. • Do not give the patient anything to eat or drink. • If bowel is visible: – leave it outside the body; – cover it with sterile gauze soaked in sterile saline; – give antibiotics. • If there is any concern for abdominal injury, plan for rapid handover/transfer to a unit with surgical capabilities. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 59 Management of specific injuries found during secondary survey CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Spinal cord injury • Midline spinal pain/tenderness • Movement problems: paralysis, weakness, abnormal reflexes • Sensation problems: tingling (“pins and needles” sensation), loss of sensation • Loss of control of urine or stool • Priapism • May have hypotension, bradycardia • Crepitus when you touch the spinal bones • Spinal bones that are not properly aligned • Difficulty in breathing (upper cervical spine injury) • Provide spinal immobilization to any person with a history of trauma who is unconscious; or who is conscious and has neck pain, cervical spine tenderness, numbness or weakness. – Use a rolled sheet or neck collar to immobilize the cervical spine. [See SKILLS] Keep the patient lying flat in bed to immobilize the rest of the spine. [See SKILLS] When examining or moving the trauma patient, the spine should be protected by using the log-roll manoeuvre. [See SKILLS] • Give IV fluids. [See SKILLS] • Any patient with possible spinal trauma needs handover/transfer to a specialist unit. NOTES: • Spinal trauma is not always obvious. Fractured spinal bones can injure the spinal cord, causing paralysis. If the spinal cord injury is in the cervical spine, paralysis could involve the muscles that control respiration and could lead to death. Examination findings should be carefully documented so that future providers can evaluate if the patient’s condition has changed. • Spinal injuries can also cause shock. This can occur when nerves that control the contraction of the blood vessels in the body are damaged. When the walls of a blood vessel relax, the vessel dilates and pressure drops, leading to poor perfusion and shock. Risk is higher if there is also blood loss, so patients must be monitored closely. Always consider spinal injury in a patient with shock that does not improve with treatment. • Spine boards should only be used to move patients. Leaving patients on spine boards for long periods of time can cause pressure sores. Remove patients from boards as soon as they arrive at the facility and can be laid flat. Internal bleeding (not seen on primary survey) • Bruising around the umbilicus or over the flanks can be a sign of internal bleeding • Pelvic fracture • Femur fracture • Decreased breath sounds on one side in the chest (haemothorax) • Signs of poor perfusion (hypotension, tachycardia, pale skin, diaphoresis) A large quantity of blood can be lost into the chest, pelvis, thigh, and into the abdomen before bleeding is recognized. • Stop the bleeding if possible – bind pelvis or splint femur. [See SKILLS] • Give IV fluid. [See SKILLS] • Refer for blood transfusion and ongoing surgical management if needed. Module 2: Approach to trauma 60 Management of specific injuries found during secondary survey CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Pelvic fracture • Pain with palpation of the pelvis • Instability or abnormal movement of the pelvic bones • Blood at opening of the penis or rectum • Give IV fluids and pain control. [See SKILLS] • Compress pelvis gently to check for stability. • Do not open and rock pelvis or perform repeat exams as this can worsen internal bleeding. • Stabilize the pelvis with a sheet or pelvic binder. [See SKILLS] • Plan for early handover/transfer to a unit with blood transfusion capabilities. Extremity fracture with poor perfusion • Deformity or crepitus of the bone • Absent pulses beyond the fracture • Capillary refill time of greater than 3 seconds beyond the fracture • Cold extremities beyond the fracture with blue or grey skin colour Fractures can displace blood vessels and limit blood supply to the limb beyond the fracture. • Look for signs of poor perfusion beyond the fracture. Feel the pulse. Check capillary refill. Look for pale skin. [See SKILLS] If a fracture is found with weak pulses or poor perfusion, re-establish perfusion by reducing (manually re-aligning bone ends to put limb back to its normal position) and splinting the fracture. [See SKILLS] Always check and document pulses, capillary refill and sensation before and after any reduction. • Plan for urgent handover/transfer to a specialist unit. Open fracture • Deformity or crepitus of the bone with overlying laceration Consider any patient to have an open fracture if there is a wound (more than just a skin abrasion) near a fracture site. Open fractures are emergencies because they can lead to severe bone infections. • Control haemorrhage with direct pressure. [See SKILLS] • Reduce the fracture immediately if there is poor perfusion. [See SKILLS] • Irrigate the wound well. [See SKILLS] • Dress wound. • Give antibiotics and tetanus vaccination. • Splint the wound. • Plan for handover/transfer to a specialist unit. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 61 Management of specific injuries found during secondary survey CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Open wound • Laceration • Abrasion • Wounds in the underarm area, genital area, buttocks or back are easily missed • Pumping or squirting blood can indicate arterial bleeding The goal of wound care is to stop bleeding, prevent infection, assess damage to underlying structures and promote healing. • Stop bleeding. [See SKILLS] • Clean wounds thoroughly with soap and clean water or antiseptic to remove any dirt, foreign bodies or dead/dying tissue. (Give local anaesthetic before cleaning the wound if available.) • Dress wounds with sterile gauze, if available. • Check perfusion beyond the wound (capillary refill and/or distal pulses) before and after dressing wounds. • Splint extremities with large lacerations to help with wound healing and pain control. [See SKILLS] • Stabilize but do not remove penetrating objects. • For snake bite, immobilize the extremity. [See WOUND MANAGEMENT in SKILLS] • For animal bites, consult advanced provider to assess for risk of infection and rabies exposure. Depending on vaccination status, management can be extremely time-sensitive. • Give tetanus vaccination if needed. REMEMBER… Always assess, treat and monitor pain. Applying direct pressure to a wound Applying direct pressure to a wound page 15 Module 2: Approach to trauma 62 SPECIAL CONSIDERATIONS Management by injury mechanism CONDITION CONCERNING SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Crush injury • Fractures, bruising, soft tissue damage • Evidence of compartment syndrome (pain, firm muscle compartments, numbness, decreased pulses or pale skin) • Small amounts of red-brown urine Crush injuries can have serious complications. Look for compartment syndrome (a build-up of pressure within the muscle compartments that can limit blood supply to muscles and nerves) and kidney damage due to by-products of muscle injury. • It is important to monitor urine output and look for red- brown urine (a concern for possible kidney damage). • Give IV fluids to help the kidneys maintain urine output. • Splint fractures to keep bone ends from causing further damage. • Plan for early surgical referral to release the pressure if compartment syndrome develops. • Patients may have many systemic problems related to muscle damage and should always be handed over to an advanced provider. Blast injury • Injury to air-filled organs (such as lung, stomach and bowel) • Delayed symptoms of tachypnoea, hypoxia, chest pain, cough with or without blood • Abdominal pain, nausea, vomiting with or without blood • Tympanic membrane (ear drum) rupture: hearing loss, ringing in the ears, pain, ear bleeding • Other injuries, burns, exposure to chemicals or toxins An explosive blast can cause injuries in three ways: 1. Visible injuries from shrapnel (fragments of metal released by an explosive device) or burns from heat or chemicals released; 2. Internal (often hidden) injuries from the change in pressure caused by the blast. The stomach and bowel, lungs, and ears are commonly injured; and 3. Additional blunt injuries that result when the body is thrown by the blast. • Examine carefully for pneumothorax. • Give oxygen if there is difficulty in breathing. [See SKILLS] • Update tetanus. • Burns should be dressed and fluid needs calculated based on burn area. [See SKILLS] • If the patient has abdominal pain, consider bowel perforation, give IV fluids [See SKILLS] • Prepare for rapid surgical referral. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 63 Management by injury mechanism CONDITION CONCERNING SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Burn injury • Skin colour can range from pink, red, pale, or black, depending on the burn depth. The burn may or may not have blisters. • The following may suggest inhalation or airway injury. – Soot (ash) around nose or mouth, or singed (burned) nasal hairs – Swelling to lips or mouth – Voice changes Burns can affect the whole body and cause soft tissue injury, swelling and shock resulting from fluid loss due to the burn. The goal of burn management is to stop the burning process, watch for swelling and compensate for fluid loss. In significant burn injury, fluid leaks into the skin and surrounding tissue causing swelling and shock. • Burns involving the airway can rapidly cause airway obstruction. • It is crucial to replace fluid loss and anticipate ongoing losses. – In order to calculate the IV fluid requirements, it is important to determine the depth of the burn and the percentage of body surface area (BSA) that is burned. [See SKILLS] • Do not forget to give tetanus vaccination and pain relief for burn injuries. • Remove all jewelry and elevate the burned limb if possible. • Burns are at high risk for infection, even with good care. Clean and dress the wound carefully. [See SKILLS] BURNS REQUIRING RAPID HANDOVER/TRANSFER: • Serious burns to >15% of body [See SKILLS] • Burns involving the hands, face, groin area, joints, or circumferential burns • Inhalation injury • Burns with other associated trauma • Any burn in very young or elderly people • Significant pre-burn illness (such as diabetes) Module 2: Approach to trauma 64 Workbook question 5: Approach to Trauma Using the workbook section above, list what you would DO to manage the following injuries. INJURY MANAGEMENT Pelvic fracture 1. ______________________________________________________ 2. ______________________________________________________ 3. ______________________________________________________ 4. ______________________________________________________ Burn injury in an adult 1. ______________________________________________________ 2. ______________________________________________________ 3. ______________________________________________________ 4. ______________________________________________________ Abdominal injury 1. ______________________________________________________ 2. ______________________________________________________ 3. ______________________________________________________ 4. ______________________________________________________ INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 65 SPECIAL POPULATIONS TRAUMA IN PREGNANCY Any female patient aged 10–50 years should have a pregnancy test. Pregnancy causes many changes in physiology and there are added considerations for fetal well-being. Even minor trauma may cause harm to the mother and fetus. Women suffering trauma in the third trimester are at risk for placental abruption (where the placenta can separate from the uterus wall, resulting in bleeding), uterine rupture, and premature labour. Remember resuscitation of the mother resuscitates the fetus. KEY ELEMENTS OF PATIENT HISTORY Gestational age (age of the fetus or number of weeks since last menstrual period). Any pregnancy complications. PRIMARY SURVEY Airway: swelling in pregnancy can make airway obstruction more likely, so monitor closely. Breathing: the diaphragm is pushed up by the pregnant uterus, leaving less lung space for breathing. Circulation: check for vaginal bleeding; a pregnant uterus can also compress large blood vessels, causing hypotension. Place on left side with cervical spine precautions. [See SKILLS] Disability: always consider eclampsia if seizures/convulsions occur. Exposure: keep patient warm. COMMON CONDITIONS CAUSED BY TRAUMA Preterm (early) labour with or without premature rupture of membranes (loss of the fluid surrounding the baby). Placental abruption or uterine rupture: causing blood loss and shock. Seizures/convulsions. SPECIAL MANAGEMENT CONSIDERATIONS Plan early for handover/transfer to a specialist unit with obstetric care. If the uterus can be felt at the level of the umbilicus (belly button), this generally indicates that the patient is at least 20 weeks pregnant. If the woman is more than 20 weeks (5 months) pregnant, the pregnant uterus can compress the inferior vena cava, the large vessel that brings blood back to her heart, and can cause shock. When lying the pregnant patient flat, always place on the left side (on a spine board if immobilization necessary). [See SKILLS] Trauma in late pregnancy may trigger early labour. Prepare for neonatal resuscitation as well when trauma occurs in late pregnancy. Module 2: Approach to trauma 66 Workbook question 6: Approach to Trauma Using the workbook section above, list the common conditions in a pregnant woman that can be caused by trauma. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 67 SPECIAL CONSIDERATIONS IN CHILDREN Children can appear well after an injury, and yet deteriorate quickly. They have different injury patterns, and serious internal organ injuries may occur without overlying skull or rib fractures (paediatric bones are more flexible). Common management problems include over- or under-resuscitation, medication errors and failure to recognize hypothermia and hypoglycaemia. Below are special considerations for injured children. Refer also to the ABCDE module for normal paediatric vital signs and additional details. AIRWAY • When neck trauma or cervical spine injury is suspected, use jaw thrust to manually open airway while maintaining cervical spine immobilization. Children have big heads and large tongues that may easily obstruct their airways. Young children and infants may require a pad under the shoulders to align the airway. [See SKILLS] BREATHING • If the child is not breathing adequately after opening the airway, assist breathing with a bag-valve-mask, ideally with oxygen. • Give a breath every 4 seconds (15 breaths per minute) for older children and a breath every 3 seconds (20 breaths per minute) for infants. [See SKILLS] Neutral position in infants page 2 Module 2: Approach to trauma 68 CIRCULATION • For ongoing blood loss or evidence of poor perfusion in children with normal nutritional status (see also SKILLS): – place IV; – give IV fluids and re-assess. [See SKILLS] • For malnourished children, fluids MUST be adjusted. [See SKILLS] • For severe burn injury, initial bolus is with dextrose- containing fluids. [See SKILLS] • If significant haemorrhage, arrange for blood transfusion or rapid handover/transfer to a centre capable of blood transfusion. DISABILITY • Monitor child’s level of consciousness with the AVPU scale (Alert, responsive to Verbal stimuli, responsive to Painful stimuli, Unresponsive). AVPU is preferred to GCS in young children. • Assess for and manage seizures/convulsions. • Assess for and manage hypoglycaemia. EXPOSURE • Expose the entire body but watch for hypothermia. • Protect the child’s modesty at all times. • Use log-roll to assess remainder of child’s back and head. Estimate weight in children based on age Weight in kilograms = [age in years + 4] × 2 or use weight-estimation tools such as PAWPER tape, Mercy TAPE, or Broselow tape, etc. GENERAL Young children may be less able than adults to report events, even major events like being hit by a vehicle. Always consider the possibility of unwitnessed trauma in young children. Location of brachial pulse in a child page 35 Location of brachial pulse in a child INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 69 HEAD INJURIES Head injuries are a common cause of death in children, and children frequently suffer from acute brain swelling after a severe head injury. If a paediatric patient has signs of traumatic brain injury, transport urgently to a facility with critical care and/or surgical capacity. CHEST INJURIES Chest injuries can be life-threatening, and children require less force for more serious internal injuries. The ribs are more flexible than in adults, and there may be extensive chest injuries without rib fractures. ABDOMINAL INJURIES Children’s abdomens are relatively larger than adults, and the abdomen is a common site of injury in children. Injuries to the spleen and liver are especially common. Abdominal injuries should be considered in all paediatric trauma patients as they can be life- threatening and can cause severe internal bleeding. BURN INJURIES Burns in children can be difficult to manage. They require careful fluid resuscitation, close observation for airway swelling, and pain medications for dressing changes. In children who are burned, plan for rapid handover/transfer to a burn unit. Workbook question 7: Approach to Trauma Using the workbook section above, list the circulation considerations in children who suffer trauma. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ List the disability considerations in children who suffer trauma. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ Module 2: Approach to trauma 70 DISPOSITION CONSIDERATIONS Trauma patients can have complex injuries that may be hidden, and can worsen and die very quickly. Always refer seriously injured patients to a higher level of care for specialized treatment. The following high-risk conditions always require handover/transfer to a specialist unit for ongoing care: Airway problem requiring intervention. Signs of shock: – Tension pneumothorax: perform needle decompression prior to transfer (will need urgent chest tube placement). – Pericardial tamponade: ensure IV fluids started and continued on transfer. Altered mental status (drowsy, lethargic, confused or unconscious). Trauma in pregnancy: place on left side for transport (needs specialist obstetric care). Child with ABCDE problem, burn, or any head, chest or abdominal injury. Any serious burn injury: assess the burn depth and total burn surface area, commence fluid resuscitation (transfer preferably to a specialist burns unit). [See SKILLS] Other considerations for transfer: If a patient has required oxygen, arrange to continue it during transport and after handover. If an injured person is displaying signs of shock, ensure IV fluid started and continued during transfer. Ensure any external bleeding is controlled and monitored during transport. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 71 FACILITATOR-LED CASE SCENARIOS These case scenarios will be presented in small groups. The following cases WILL NOT be assessed and are for practice only. It is important that you practise these scenarios as you will be assessed on how you lead a case in the following modules. For each case scenario the group must identify the critical findings and management needed and formulate a one- line summary for handover, including assessment findings and interventions. You should use the Quick Cards for these scenarios. CASE #1: ADULT TRAUMA A taxi driver brings in a man that was severely injured. You come outside to find a 30-year-old male lying in the back seat of the taxi in severe pain. He was in a car crash a few kilometers away. His jeans are soaked with blood, with bone sticking out of the right thigh. 1. What do you need to do in your initial approach? 2. Use the primary survey to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate a short summary of this patient for handover. CASE #2: PAEDIATRIC TRAUMA A 5-year-old boy pulled a pan of boiling water off the stove at 8pm tonight. The boiling water spilled on him, burning his right side. His mother used a container of cool water to wash him down and then brought him in for evaluation. The child is crying and tells you he is in pain. He has burns to his right palm, and right inner arm up to the elbow, and the front of his chest and abdomen and the front of his right thigh. The mother does not know how much the child weighs. Module 2: Approach to trauma 72 1. What do you need to do in your initial approach? 2. Use the primary survey to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. Use the table below for your notes. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO A. Calculate the total burn surface area in this child. Try to shade in the children’s burn diagram for burn area estimation. B. Explain how you will decide if this child needs IV fluids? C. Calculate how much fluid is needed, explaining your method. D. What fluid would you use? 3. Formulate a short summary of this patient for handover. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 73 MULTIPLE CHOICE QUESTIONS Answer the questions below. Questions and answers will be discussed in the session. 1. Which of the following is a component of the trauma primary survey? A. Examine the arms for any fractures B. Check the skin color and temperature C. Examine the ears for any drainage of blood or clear liquid D. Check skin pinch 2. You are assessing a man who was in a car crash. He is very confused, but the remainder of his primary survey is normal. How do you perform a SAMPLE history if the patient is too confused to answer your questions? A. You do not need to do a SAMPLE history in a trauma patient B. Ask the patient repeatedly until he is able to answer C. Ask bystanders or family member for the information D. Assume that there is no important information 3. A 23-year-old man is carried in after diving head first into a river. He is speaking and his airway is open but he cannot walk or move his arms or legs. What is the first thing you must do? A. Place an IV line B. Examine him for other injuries C. Immobilize the cervical spine D. Give him a tetanus vaccination 4. You are evaluating a 21-year-old male who was in a motorcycle crash. He was thrown from the motorcycle and suffered injuries to his face, chest and legs. When you compress his pelvis, he screams in pain. His vital signs are: blood pressure 90/40 mmHg, heart rate 120 bpm, respiratory rate 25/min. What should be your next step? A. Place in a pelvic binder B. Administer tetanus vaccine C. Provide antibiotics D. Clean the abrasions with soap and water 5. A young woman has been brought in after an explosion. She has an open airway, a respiratory rate of 30/min, heart rate 125 bpm, blood pressure of 85/50 mmHg, has moist pale skin and she complains of abdominal pain. She has small wounds to her skin but there is no obvious bleeding. What would you do to manage this patient? A. Place two large-bore cannulae and give 1 litre of fluid B. Offer her a drink of water C. Check her temperature D. Provide antibiotics 74 Notes ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS 75 PARTICIPANT WORKBOOK Module 3: Approach to difficulty in breathing Objectives On completing this module you should be able to: 1. recognize signs of difficulty in breathing (DIB); 2. list the high-risk causes of difficulty in breathing; 3. perform critical actions for high-risk causes of difficulty in breathing. Essential skills Basic airway manoeuvres Basic airway device insertion Management of choking Oxygen administration Bag-valve-mask ventilation Needle decompression for tension pneumothorax Three-sided dressing for sucking chest wound KEY TERMS Write the definition using the Glossary at the back of the workbook. Accessory muscle use: Anaemia: Asthma: Chronic obstructive pulmonary disease (COPD): Circumferential burns: Crepitus: Module 3: Approach to difficulty in breathing 76 Cyanosis: Diabetic ketoacidosis (DKA): Diaphoresis: Difficulty in breathing (DIB): Disposition: Drowning: Haemothorax: Heart attack: Heart failure: Hives: Hyperventilation: Inflammation: Ischaemia: Large-bore IV: Needle decompression: Pericardial effusion: Pleural effusion: Pleuritic: Pneumonia: Pulmonary embolism: TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 77 Stridor: Tachycardia: Tachypnoea: Tracheal shift: Tripod position: Wheezing: Overview Difficulty in breathing (DIB) is a term used to describe a range of conditions from a feeling of shortness of breath to abnormal breathing movements, or any increased effort required to breathe. DIB can result from problems in the upper or lower airways, the lungs, the heart or the muscles used for breathing; or from conditions that may cause faster breathing (such as anaemia or chemical imbalance). DIB can be caused by: upper or lower airway obstruction (blockage by an object; by spasm of the airways, such as with asthma; by swelling due to allergy; infection or injury); fluid in the airspaces of the lung (such as from pneumonia or pulmonary oedema); air or fluid outside the lung causing lung collapse or compression (such as pneumothorax or effusion); blood clots in the vessels supplying the lungs; any other cause of decreased oxygen carried in the blood (such as anaemia); conditions that increase respiratory rate such as toxic ingestion, chemical imbalance (for example in diabetic ketoacidosis) or anxiety. The goal of INITIAL ASSESSMENT is to identify reversible causes of difficulty in breathing, and to recognize conditions that require urgent intervention or rapid transfer. The goal of ACUTE MANAGEMENT is to ensure the airway stays open and breathing is adequate to deliver oxygen to the organs. Module 3: Approach to difficulty in breathing 78 This module will guide you through: ABCDE key elements ASK: key history findings (SAMPLE history) CHECK: secondary exam findings Possible causes DO: management Special considerations in children Disposition considerations REMEMBER... • ALWAYS START WITH THE ABCDE APPROACH, intervening as needed. • Then do a SAMPLE history. • Then do a secondary exam. ABCDE: KEY ELEMENTS FOR PATIENTS WITH DIFFICULTY IN BREATHING For the patient with difficulty in breathing, the following are key elements that should be considered in the ABCDE approach. AIRWAY A person with difficulty in breathing may have airway swelling caused by a severe allergic reaction (anaphylaxis) or choking (obstruction from a foreign body). Stridor suggests serious airway narrowing. BREATHING Hypotension with absent breath sounds on one side – especially with distended (swollen or enlarged) neck veins or tracheal shift – may indicate tension pneumothorax. Wheezing may indicate asthma or severe allergic reaction. CIRCULATION Shock, heart attack, heart failure and severe infection can all present with poor perfusion and difficulty in breathing. Poor perfusion sends signals to the brain to increase the rate of breathing, which can feel and look like difficulty in breathing. Check for signs of shock by checking capillary refill, heart rate and blood pressure. Swelling in the legs or crackles in the lungs can indicate heart failure and fluid overload as a cause of difficulty in breathing. A B C TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 79 DISABILITY Patients with decreased level of consciousness may not be able to protect their airways. Drugs, infection or injury can directly affect the part of the brain that controls breathing. Assess for paralyzing conditions affecting the breathing muscles. Check level of consciousness with the AVPU scale: A: Alert V: Responds to Voice P: Responds to Pain U: Unresponsive EXPOSURE Expose the patient fully to assess for abnormal chest wall movement and any signs of trauma. Penetrating trauma to the back, chest, underarms or abdomen may cause lung injury and is often missed. ASK: KEY HISTORY FINDINGS FOR PATIENTS WITH DIFFICULTY IN BREATHING Use the SAMPLE approach to obtain a history from the patient and/or family. If the history identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it. S: SIGNS AND SYMPTOMS When did the symptoms start and was onset sudden? Do they come and go and how long do they last? Have they changed over time and has there been a similar episode previously? Sudden difficulty in breathing can suggest airway obstruction such as by a foreign body; swelling of the airway from allergic reaction or infection; trauma to the airway, lungs, heart or chest wall; or inhalation of hot gases or smoke. Acute heart problems such as heart attack, abnormal heart rhythm or valve problems can cause rapid onset DIB. A history of rapid or deep breathing may suggest poisoning, high acid levels in the blood (infection or diabetic ketoacidosis) or anxiety. DIB that starts slowly is more common with infection and chronic conditions such as a gradual build-up of fluid around the lungs (as occurs in TB and heart failure), fluid around the heart (from TB or kidney disease), lung cancer or diseases affecting the function of the chest wall. Recurrent difficulty in breathing associated with wheeze may suggest asthma or COPD. Did anything trigger the difficulty in breathing and what makes it better or worse? A history of allergies may suggest that the airway is blocked by swelling due to a severe allergic reaction. Inhaling smoke or hot gas (such as in fires) or some chemicals may cause E D Module 3: Approach to difficulty in breathing 80 DIB through upper airway injury and swelling. Exposure to some chemicals (such as certain pesticides) can cause fluid to build up in the airways and can cause weakness in the muscles involved in breathing. Difficulty in breathing that gets worse when the person lies flat can be due to fluid in the lungs. Is there any tongue or lip swelling, or voice changes? Swelling to the mouth, lips, tongue or upper throat, or a change in voice can suggest a severe allergic reaction or other inflammation of the airway. Are there abnormal sounds with breathing? High-pitched or ‘squeaking’ sounds when breathing IN may be stridor, which is caused by narrowing of the upper airway and may suggest severe allergic reaction or other airway obstruction. Wheezing – a high-pitched sound with breathing OUT – is caused by narrowing or spasm of the lower airways in the lungs and can suggest asthma, COPD, heart failure or allergic reactions. Gurgling sounds with breathing suggest that there is mucus, blood or other fluid in the airway. Is there pain associated with the difficulty in breathing? Difficulty in breathing with chest pain can suggest heart attack, pneumothorax, pneumonia or trauma to the lungs, ribs or ribcage muscles. In particular, pain that is worse with deep breaths (pleuritic pain) may suggest infection or blood clot in the lung (pulmonary embolism). Is there fever or cough? Fever suggests infection. Lung infection and any severe infection may cause fluid in the lungs. A cough may indicate fluid in the lungs from pneumonia or oedema. Cough and wheezing may suggest asthma or COPD. Is there foot or leg swelling or recent pregnancy? Difficulty in breathing with oedema of both feet or legs can suggest heart failure with fluid back-up to the lungs and body. Difficulty in breathing with swelling and pain in one leg may suggest a clot in a leg vein that has travelled to the lung (pulmonary embolism). Pregnancy is a risk factor for both pulmonary embolism and heart failure. A: ALLERGIES Any allergies to medications or other substances? Any recent insect bites or stings? Severe allergic reactions may cause difficulty in breathing due to airway swelling. People can have severe allergic reactions to almost anything, but food, plants, medications and insect bites/stings are the most common. M: MEDICATIONS Currently taking any medications? Ask about new medications and changes in doses. New medications can cause allergies with associated difficulty in breathing. Accidental overdose of some medications can stop or slow breathing. TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 81 P: PAST MEDICAL HISTORY Is there a history of asthma or chronic obstructive pulmonary disease (COPD)? Asthma and COPD often cause episodes of difficulty in breathing. A history of prior hospitalization or intubation for these conditions suggests a high-risk patient. Is there a history of heart disease or kidney disease? People with a history of heart or kidney failure may have fluid in the lungs. Heart attack may present with difficulty in breathing. Is there a history of tuberculosis (TB) or cancer? Conditions such as tuberculosis and cancer can cause build up of fluid in the sac around the heart (pericardial effusion) or build-up of fluid outside the lung (pleural effusion), both of which can cause a feeling of difficulty in breathing. Is there a history of diabetes? Diabetes can cause diabetic crisis (diabetic ketoacidosis or DKA). DKA causes fast breathing that may be reported as difficulty in breathing. Is there a history of smoking? Smoking increases the risk of asthma, COPD, lung cancer and heart attack. Is there a history of HIV? HIV infection increases the risk of other infections. L: LAST ORAL INTAKE When did the person last eat or drink? A full stomach puts the patient at risk of vomiting and possible choking. E: EVENTS SURROUNDING ILLNESS What was the person doing when the difficulty in breathing started? Always consider choking if DIB started while eating or drinking. DIB with exercise might be due to heart attack, especially when there is also chest pain. Was the patient found in or near water? Always consider drowning (inhalation of water) in a person found in or near water. Even a small amount of inhaled water can cause serious lung damage, which can worsen over time. Has there been exposure to pesticides or other chemicals? Inhaled chemicals can cause DIB by irritating the airways and lungs. Some pesticides used in farming can be absorbed through the skin, causing fluid buildup in the airways and lungs. Exposure to gases from a fire is often associated with chemical inhalation. Has there been any recent trauma? DIB with trauma is concerning for rib fractures, pneumothorax, haemothorax, and heart or lung bruising. Module 3: Approach to difficulty in breathing 82 Workbook question 1: Difficulty in breathing Using the workbook section above, list five questions about past medical history you would ask when taking a SAMPLE history. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ CHECK: SECONDARY EXAMINATION FINDINGS FOR PATIENTS WITH DIFFICULTY IN BREATHING DIB may present with changes in respiratory rate, respiratory effort, or low oxygen saturation. Always assess ABCDE first. The initial ABCDE approach identifies and manages life-threatening conditions. The secondary exam looks for changes in the patient’s condition or less obvious causes which may have been missed during ABCDE. If the secondary examination identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it. LOOK Look for signs of respiratory failure: Accessory muscle use and increased work of breathing. Difficulty speaking in full sentences. Inability to lie down or lean back. Diaphoresis (excessive sweating) and mottled skin. Confusion, irritability, agitation. Poor chest wall movement. Cyanosis (blue skin colour, especially lips and fingertips). Look at the pupils for size and reactivity: Very small pupils suggest possible opioid overdose or exposure to chemicals (including pesticides). Unequal or abnormally shaped pupils suggest head injury which can cause abnormal breathing. TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 83 Look at the face, nose and mouth: Cyanosis around the lips or nose suggests low oxygen levels in the blood. Pale inner surface of lower eyelids suggests severe anaemia. Swelling of the lips, tongue and mouth suggests an allergic reaction. Soot around the mouth or nose, burned facial hair or facial burns suggest smoke inhalation and airway burns. Bleeding or swelling of the airway may be due to trauma. Look at the neck and chest: Distended neck veins can be due to a back-up of blood due to heart failure, tension pneumothorax or pericardial tamponade. Excessive muscle use in the neck and chest (between the ribs) suggests significant respiratory difficulty. If the trachea is shifted to one side, think about tension pneumothorax or tumour. Swelling or redness of the neck suggests infection or trauma. Examine the entire neck and chest carefully for bruising, wounds or other signs of trauma. Look at the rate and pattern of breathing: People with wheeze may take longer to breathe out because of narrowing of the lower airways in the lung. Fast breathing can be due to dehydration, severe infection, chemical imbalance in the blood, poisoning or anxiety. Slow and shallow breathing might be due to opioid overdose. Look for very small pupils and altered mental status. Chest wall injury is often associated with pain that limits the ability to take deep breaths. A flail chest occurs when multiple rib fractures cause a segment of the rib cage to be separated from the rest of the chest wall. The segment may appear to be moving in the opposite direction from the rest of chest wall during breathing. Look at the legs: Swelling to the both lower legs suggests heart failure as a cause of difficulty in breathing. Swelling to one leg may be due to a blood clot in the leg. If there is also difficulty in breathing, this may mean that part of the clot has traveled to the lung. Look at the skin: Bites can be a source of allergic reaction. Rashes, such as hives, can indicate allergic reaction. When associated with difficulty in breathing, rashes can indicate widespread (systemic) infection. Pallor (pale skin) can indicate anaemia as a cause of DIB. Circumferential burns (a burn that goes entirely around a body part) to the chest can restrict chest wall expansion and limit breathing. Module 3: Approach to difficulty in breathing 84 LISTEN Listen to the breath sounds: Stridor suggests partial upper airway obstruction, which may be due to a foreign object, mass, or swelling from trauma or infection. Decreased or absent breath sounds suggest abnormal air movement in the lungs. This can be due to air or fluid around the lung (pneumothorax, haemothorax, effusion), narrowing or foreign body blockage of the airways, and infection or tumour in or around the lung. Wheezing, in particular, suggests lower airway obstruction such as from asthma, COPD, allergic reaction, foreign body or tumour. Crackles or crepitations suggest fluid in the airspaces of the lung. Listen to the heart sounds: Abnormal heart rhythms can cause the heart to pump blood abnormally, leading to poor perfusion and a feeling of difficulty in breathing. Difficulty in breathing accompanied by heart murmurs can suggest damage to the heart valves. Muffled or distant heart sounds accompanying low blood pressure, fast heart rate and distended neck veins suggest pericardial tamponade. FEEL Feel the ribs and chest wall: Deformities and abnormal movement when pressing on the chest wall suggest rib fracture. Crepitus (crackling or popping when pressing on the skin of the chest wall) may suggest underlying fracture or air under the skin (associated with pneumothorax). Unequal expansion of the chest wall suggests pneumothorax, haemothorax, or flail chest. Percuss the chest wall [See SKILLS]: Hollow sounds (hyperresonance) on one side when tapping the chest wall suggest pneumothorax. Dull sounds when tapping the chest wall may indicate fluid or blood either inside the airspaces of the lungs or between the lungs and the chest wall. TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 85 Workbook question 2: Difficulty in breathing Using the workbook section above, list three signs you should LOOK for in a patient with difficulty in breathing. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ List four things you should LISTEN for in a patient with difficulty in breathing. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ List three things you should FEEL the chest wall for in a patient with difficulty in breathing. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ POSSIBLE CAUSES OF DIFFICULTY IN BREATHING The causes of difficulty in breathing can be organized by body area: airway, lung, heart, or whole body. Key airway causes CONDITION SIGNS AND SYMPTOMS Foreign body in the airway • Acute difficulty in breathing • Visible secretions, vomit or foreign body in the airway • Abnormal sounds from the airway (such as stridor, snoring, gurgling) • Coughing • Drooling Severe allergic reaction • Swelling of lips, tongue and mouth • Stridor and/or wheezing • Rash or hives • May have tachycardia and hypotension • Exposure to known allergen Module 3: Approach to difficulty in breathing 86 CONDITION SIGNS AND SYMPTOMS Airway swelling (due to inflammation/ infection) • Stridor • Hoarse voice • Drooling or difficulty swallowing (indicates severe swelling) • Unable to lie down • May have fever (with infection) Airway burns • History of exposure to chemical or fire • Burns to head and neck (or singed facial hair or soot around nose or mouth) • Stridor • Change in voice Key lung causes CONDITION SIGNS AND SYMPTOMS Pneumonia • Fever and cough • Gradually more laboured breathing • Pain worse with breathing (pleuritic) • Abnormal lung examination (crackles) Asthma/COPD • Wheezing • Cough • Accessory muscle use • Tripod position (see figure) • May have history of smoking or allergies Pneumothorax • Decreased breath sounds on one side • Sudden onset • Hollow sounds (hyperresonance) to percussion on affected side [See SKILLS] • May have pain that worsens with breathing • May have history of trauma or evidence of rib fracture • Hypotension with distended neck veins and decreased breath sounds on one side indicate tension pneumothorax. Haemothorax • Decreased breath sounds on affected side • Dull sounds with percussion [See SKILLS] • May have a history of trauma, cancer or tuberculosis Shock (if large haemothorax) Pleural effusion • Decreased breath sounds on one or both sides • Dull sounds with percussion [See SKILLS] • May have history of cancer, tuberculosis, heart disease or kidney disease • Acute or chronic difficulty in breathing Acute chest syndrome in a patient with sickle dell disease • History of sickle cell disease • Chest pain • Fever • Hypoxia TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 87 Tripod position page 32 Key heart causes CONDITION SIGNS AND SYMPTOMS Heart attack • Pressure, tightness or crushing feeling in the chest • Diaphoresis and mottled skin • Nausea or vomiting • Signs of heart failure • History of smoking, heart disease, hypertension, diabetes, high cholesterol, family history of heart problems Heart failure • Worse with exertion • Worse when lying flat • Swelling to both legs • Distended neck veins • Crackles may be heard in the lungs • May have chest pain Pericardial tamponade • Signs of poor perfusion (tachycardia, tachypnoea, hypotension, pale skin, cold extremities, capillary refill greater than 3 seconds) • Distended neck veins • Muffled heart sounds • May have dizziness, confusion, altered mental status • History of tuberculosis, trauma, malignancy, kidney failure Tripod position Module 3: Approach to difficulty in breathing 88 Key systemic causes CONDITION SIGNS AND SYMPTOMS Anaemia • Pale skin and inner lower eyelids • Tachycardia • Tachypnoea • History of haemorrhage, malnourishment, cancer, pregnancy, malaria, sickle cell disease, renal failure Opioid overdose • Clinical or recreational opioid use • Altered mental status • Very small pupils • Slow, shallow breathing Diabetic ketoacidosis • May have known history of diabetes • Deep or rapid breathing • Frequent urination • Sweet smelling breath • High glucose in blood or urine • Dehydrated Workbook question 3: Difficulty in breathing Using the workbook section above, list the possible cause of difficulty in breathing next to the history and physical findings below. HISTORY AND PHYSICAL FINDINGS LIKELY CAUSE A 20-year-old man presents with difficulty in breathing, wheezing and: • swelling of lips, tongue and mouth • rash or hives (patches of pale or red, itchy, warm, swollen skin) • tachycardia and hypotension • history of allergies • exposure to known allergen A 50-year-old woman presents with difficulty in breathing, signs of poor perfusion (tachycardia, tachypnoea, hypotension, pale skin, cold extremities, capillary refill >3 seconds) and: • distended neck veins • muffled heart sounds • history of tuberculosis TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 89 DO: MANAGEMENT FIRST PERFORM ABCDE ASSESSMENT AND INTERVENE FOR LIFE-THREATENING CONDITIONS. Assess and manage airway and provide bag-mask-ventilation (BVM) for any patient who is not breathing or not breathing adequately (too slow for age or too shallow); any unconscious patient with abnormal (slow, shallow, gasping or noisy) breathing; or any patient with a pulse who is not breathing. For patients without a pulse, follow relevant CPR protocols. CONDITION MANAGEMENT CONSIDERATIONS Airway inflammation or burns Keep patients calm. Give oxygen if you can do this without upsetting the patient. [See SKILLS] If the patient is fully alert and no spinal injury suspected, the seated position may be more comfortable. Patients with airway burns may require early intubation as the airway can swell and block quickly; delays may make intubation more difficult. A person with airway inflammation or burns requires urgent handover/ transfer. Choking Use age-appropriate chest thrusts/abdominal thrusts/back blows. [See SKILLS] Allergic reaction Remove the allergen, if possible. For severe allergic reaction with difficulty breathing give intramuscular adrenaline as soon as possible. Give oxygen for severe cases. [See SKILLS] Asthma/COPD Administer salbutamol as soon as possible. Give oxygen if indicated. [See SKILLS] Fever Give antibiotics as soon as possible if infection might be the cause of difficulty in breathing. If the patient has signs of poor perfusion, give IV fluids with caution to avoid fluid overload. [See SKILLS] Heart attack Give aspirin. While oxygen is no longer recommended in all patients with heart attack, it should initially be given to patients with shock or difficulty in breathing. [See SKILLS] For those patients who already have nitroglycerin, you can assist them in taking it if perfusion is adequate. Chronic, severe anaemia Give IV fluids more slowly and check the lungs for crackles (fluid overload) frequently. [See SKILLS] These patients may need handover/transfer for blood transfusion. Diabetic ketoacidosis Give IV fluids. [See SKILLS] A person with diabetic ketoacidosis is extremely ill and requires urgent transfer to an advanced provider. Opioid overdose Support breathing with a bag-valve-mask as needed. Give naloxone. [See SKILLS] Pleural effusion or haemothorax Give oxygen. [See SKILLS] Arrange for handover/transfer immediately. Many of these patients will need a chest tube or other drainage. Trauma All trauma patients with difficulty in breathing should be given oxygen. IV fluid should be given to help fill the heart if either pericardial tamponade or tension pneumothorax is suspected. Needle decompression should be performed if tension pneumothorax is suspected. Treat sucking chest wounds with a 3-sided dressing. [See SKILLS] The patient will need urgent handover/transfer for a chest tube if needle decompression is performed or a 3-sided dressing is applied. Acute chest syndrome Give oxygen, IV fluids, antibiotics. May need transfer for advanced management. Module 3: Approach to difficulty in breathing 90 Workbook question 4: Difficulty in breathing Using the workbook section above, list what you would DO to manage a person who presents with: DIB, coughing. You suspect choking. 1. ���������������������������������������� 2. ���������������������������������������� DIB, high fever, cough. You suspect serious infection. 1. ���������������������������������������� 2. ���������������������������������������� DIB, hoarse voice and stridor on breathing in. You to suspect airway inflammation. 1. ���������������������������������������� 2. ���������������������������������������� 3. ���������������������������������������� SPECIAL CONSIDERATIONS IN CHILDREN The following are danger signs in children: • Signs of airway obstruction (unable to swallow saliva/drooling or stridor). • Increased breathing effort (fast breathing, nasal flaring, grunting, chest indrawing or retractions). • Cyanosis (blue colour of the skin, especially at the lips and fingertips). • Altered mental status (lethargy or unusual sleepiness, agitation). • Poor feeding or drinking. • Vomiting everything. • Seizures/convulsions. • Low temperature (hypothermia). REMEMBER... • Wheezing in children can be caused by viral infection, asthma or an inhaled object blocking the airway. • Stridor in children can be caused by an object stuck in the upper airway OR airway swelling. • Children may present with rapid breathing as the only sign of pneumonia. • Rapid breathing can also indicate diabetic crisis (DKA), which may be the first sign of diabetes in a child. TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 91 Workbook question 5: difficulty in breathing Using the workbook section above, list the paediatric danger signs. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ 6. ______________________________________________________________________ 7. ______________________________________________________________________ 8. ______________________________________________________________________ DISPOSITION CONSIDERATIONS Keep in mind that the effects of inhaled medications such as salbutamol last for only approximately 3 hours. Patients need to be monitored closely. If a patient with a severe allergic reaction is given adrenaline, the reaction can return when the adrenaline wears off. Patients need to be monitored closely. Naloxone only lasts about 1 hour. Most opioid medications last longer than this, so patients may need repeat naloxone doses. Following immersion in water (drowning), a person may develop late signs of breathing problems after several hours and should be observed closely. Never leave patients who might need definitive airway placement unmonitored during handover/transfer. Ensure that a new provider is monitoring the patient before leaving. Make transfer arrangements as early as possible for any patient who may require assisted ventilation. Module 3: Approach to difficulty in breathing 92 FACILITATOR-LED CASE SCENARIOS These case scenarios will be presented in small groups. One participant will be identified as the lead and will be assessed while the rest of the group writes the responses in the workbook. To complete a case scenario, the group must identify the critical findings and management needed and formulate a one-line summary for handover, which includes assessment findings and interventions. You should use the Quick Cards for these scenarios while being assessed. CASE #1: ADULT WITH DIFFICULTY IN BREATHING A 22-year-old man arrives by taxi. He was robbed on the street, and was stabbed in the left chest with a knife. He is now having severe difficulty in breathing. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Cards for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate one sentence to summarize this patient for handover. TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 93 CASE #2: PAEDIATRIC PATIENT WITH DIFFICULTY IN BREATHING A mother brings in her 6-year-old son for difficulty in breathing. The mother states that her son has been having difficulty breathing for the past 3 days. She says he makes funny noises when he breathes. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate one sentence to summarize this patient for handover. Module 3: Approach to difficulty in breathing 94 MULTIPLE CHOICE QUESTIONS Answer the questions below. Questions and answers will be discussed in the session 1. You are evaluating a 34-year-old female complaining of difficulty in breathing, coughing, and fever for 3 days. Which of the following actions should you do first? A. Check blood pressure B. Administer antibiotics C. Start an IV D. Check the lung sounds 2. A 67-year-old man with a history of a heart attack is complaining of difficulty in breathing that is worse whenever he lies flat. His legs are both swollen, which has become worse in the past 2 weeks. What is the most likely cause of his difficulty in breathing? A. Heart failure B. Asthma C. Pneumothorax D. Pneumonia 3. There was a fire in a nearby house and a patient is brought to you with burned nasal hairs and shortness of breath. What should you do first? A. Give oxygen B. Give intramuscular adrenaline C. Start an IV line D. Perform needle decompression 4. A 30-year-old woman was stung by a bee and now has difficulty in breathing, facial swelling, and a rash. She has a history of severe allergic reactions to bee stings. What medication should you give her? A. Naloxone B. Benzodiazepine C. Adrenaline D. Aspirin 5. You are assessing a 10-year-old boy for difficulty in breathing. You notice that the skin on his fingertips and around his mouth has a blue color. What is this finding called? A. Retractions B. Nasal flaring C. Crepitus D. Cyanosis BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 95 Module 4: Approach to shock Objectives On completing this module you should be able to: 1. recognize signs of shock/poor perfusion; 2. perform critical actions for patients with shock; 3. assess fluid status; 4. select appropriate fluid administration based on patient age, weight and condition; 5. recognize malnourishment, anaemia and burns and adjust fluid resuscitation. Essential skills Oxygen administration IV line placement Fluid status assessment IV fluid resuscitation Burn management Needle decompression Three-sided dressing Direct pressure for bleeding control Uterine massage for bleeding control Trauma secondary survey KEY TERMS Write the definition using the Glossary at the back of the workbook. Bolus: Bradycardia: Capillary refill: Cholera: Module 4: Approach to shock 96 Diaphoresis: Dehydration: Diabetic ketoacidosis (DKA): Dilation (of blood vessels): Disposition: Ectopic pregnancy: Fluid status: Fontanelle: Gastroenteritis: Large-bore IV: Lethargy: Oral rehydration solution (ORS): Perfusion: Pericardial tamponade: Resuscitation: Shock: Skin pinch testing: BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 97 Overview Poor perfusion is when the body is not able to get enough oxygen-carrying blood to vital organs. When organ function is affected, this is called shock and can lead rapidly to death. Infants, children and older adults are more likely to be affected by shock. Causes of poor perfusion which may lead to shock include: loss of blood (haemorrhage); loss of fluid due to diarrhoea, vomiting, extensive burns or excess urination (such as caused by high blood sugar); poor fluid intake. Small children, the elderly and the very ill may be unable to drink enough fluids without assistance and are at risk of dehydration; abnormal relaxation and enlargement (dilation) of the blood vessels (with the same amount of blood inside the vessel) can lower blood pressure. This can occur in severe infection, spinal cord injury and severe allergic reaction; poor filling of the heart can result from blood or other fluid in the sac around the heart (pericardial tamponade), or increased pressure in the chest that can shift and block the vessels returning blood to the heart (tension pneumothorax); failure of the heart muscle to pump effectively can be due to a heart attack (vessel blockage that causes acute heart muscle damage); inflammation or other disease of the heart muscle itself; an abnormal rhythm or valve problems. (Shock due to failure of the heart to pump effectively is sometimes called cardiogenic shock.) The goal of INITIAL ASSESSMENT is to identify shock and any reversible causes of shock. The goal of ACUTE MANAGEMENT is to restore perfusion (oxygen delivery to the organs) and address ongoing fluid loss where possible. This module will guide you through: ABCDE key elements ASK: key history findings (SAMPLE history) CHECK: secondary examination findings Possible causes DO: management Special considerations in children Disposition considerations REMEMBER... ALWAYS START WITH THE ABCDE APPROACH, intervening as needed. Then do a SAMPLE history. Then do a secondary examination. Module 4: Approach to shock 98 ABCDE: KEY ELEMENTS IN SHOCK For the person in shock, the following are key elements that should be considered in the ABCDE approach. AIRWAY Face/mouth swelling or voice changes can indicate an allergic reaction. A severe allergic reaction can cause shock. BREATHING Wheezing can indicate a severe allergic reaction which can cause shock. Shock, difficulty in breathing and absent breath sounds on one side can indicate a tension pneumothorax. Poor perfusion itself can sometimes cause rapid breathing when vital organs do not receive enough oxygen. Severe heart failure can cause poor perfusion with difficulty in breathing when fluid backs up into the lungs. Any infection severe enough to cause shock may be associated with lung inflammation that causes difficulty in breathing. CIRCULATION Shock can be caused by many types of bleeding (from the stomach or intestines, pregnancy-related, and internal and external haemorrhage from trauma). Shock can also result from the fluid loss associated with diarrhoea, vomiting, extensive burns, or excess urination (such as caused by high blood sugar). DISABILITY Confusion in a person with poor perfusion suggests severe shock. Paralysis may indicate a spinal cord injury causing shock. EXPOSURE Look for signs of bleeding, trauma, and excessive sweating (diaphoresis). Hives can indicate allergic reaction, and other rashes can indicate systemic infection. ASK: KEY HISTORY FINDINGS IN SHOCK Use the SAMPLE approach to obtain a history from the patient and/or family. If the history identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it. A B C D E BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 99 S: SIGNS AND SYMPTOMS Has there been vomiting and/or diarrhoea? For how long? Fluid losses through vomiting and diarrhoea can be severe and can lead to shock. The amount of vomiting or diarrhoea can help give a rough estimate of the risk for shock, so always ask about frequency of episodes. Has the person had blood in stool or vomit? Bleeding in the stomach and/or intestines can be severe before it is recognized. A person can lose a significant portion of his or her blood volume in the intestines. Blood may appear black in both vomit and stools. Has there been any vaginal bleeding? Vaginal bleeding may be related to pregnancy in women of childbearing years. Always ask about pregnancy status, last menstrual period, any missed periods, or known recent pregnancy. Blood loss from normal delivery or miscarriage can cause shock. A pregnancy developing outside the uterus (ectopic pregnancy) can also be life-threatening if it ruptures. Ectopic pregnancy rupture can occur before a woman even knows she is pregnant. Other causes of vaginal bleeding are masses in the cervix or uterus. Has the person had any chest pain? Chest pain may suggest the person has had a heart attack. The muscle damage to the heart from a heart attack can reduce its ability to pump blood around the body, which can cause shock. Has there been fever? Fever may suggest infection as the cause of shock. Severe infection causes both dilation of the blood vessels (which lowers blood pressure) and fluid leakage from the blood vessels (with fluid loss into the tissues). Has there been any exposure to toxins, medications, insect stings or other substances? Severe allergic reactions can lead to shock. Additionally, many medications, including blood pressure and seizure/convulsion medications, can cause shock. Has there been altered mental status or unusual sleepiness? The brain is one of the last organs to be affected by poor perfusion, so altered mental status may be a sign of severe shock. A: ALLERGIES Does the person have any known allergies? Allergic reactions can lead to shock by causing abnormal relaxation of the blood vessels. Module 4: Approach to shock 100 M: MEDICATIONS Currently taking any medications? Obtain a full medication list from the person or the family. Knowing the patient’s medication list can help understand why the patient is in shock (such as heart medications). Overdose of blood pressure or seizure/convulsion medications can cause shock, and it may be more difficult to treat shock from any cause in patients taking these medications. Medications that thin the blood can worsen bleeding. Always ask about new medications in particular and recent dose changes to evaluate for allergic reaction or unexpected side effects. P: PAST MEDICAL HISTORY History of pregnancy or recent miscarriage or delivery? Blood loss following delivery can be severe if the uterus does not contract well. Hidden blood loss leading to shock can occur with ruptured ectopic pregnancy, even in women who do not know they are pregnant. Any woman of childbearing age with shock should be evaluated for pregnancy. History of recent surgery or induced abortion? Internal bleeding or infection after surgery can lead to shock. History of heart disease (heart attack or heart valve problems)? Patients with heart disease are at risk for worsening heart function that may lead to shock or worsen shock from other causes. Is there a history of HIV? HIV increases the risk of infection. L: LAST ORAL INTAKE When did the person last eat or drink? A person who is not eating or drinking well can develop severe dehydration, leading to shock. E: EVENTS SURROUNDING ILLNESS Has there been any recent trauma? Trauma can cause hidden internal bleeding, tension pneumothorax, and bruising or bleeding around the heart, all of which may reduce blood flow and cause shock. In addition, trauma to the neck or back causing spinal cord injury can interfere with the blood vessels’ ability to maintain blood pressure. Has there been any recent illness? Any infection can cause a blood infection that can spread throughout the body and lead to shock. BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 101 Workbook question 1: Shock Using the workbook section above, list six questions about signs and symptoms you would ask when taking a SAMPLE history. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ 6. ______________________________________________________________________ CHECK: SECONDARY EXAMINATION FINDINGS IN SHOCK A person with shock will have signs of poor perfusion, which may include a fast heart rate, a low systolic blood pressure, fast breathing, pale and cool skin, slow capillary refill, dizziness, confusion, altered mental status, decreased urine output or excessive sweating. REMEMBER: Perfusion can be limited even before blood pressure falls, especially in the young. Low blood pressure with poor perfusion is a very serious sign. Always assess ABCDE first. The initial ABCDE approach identifies and manages life-threatening conditions. The secondary exam looks for changes in the patient’s condition or less obvious causes that may have been missed during ABCDE. If the secondary examination identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it. REMEMBER: Children have different normal vital signs ranges, and children with shock may not have changes in vital signs until they are very ill. Always do a careful exam for any signs of shock. Check breath sounds and respiratory rate: – Abnormal or noisy breathing can indicate pneumonia as a source for system-wide infection causing shock. – High sugar levels can result in chemical imbalance (diabetic ketoacidosis) that the body tries to address by faster or deeper breathing. This condition may also result in sweet or ‘fruity’ smelling breath. Since elevated blood glucose levels cause increased urination, severe dehydration and shock can result. Check for bleeding: – All external bleeding should be controlled with direct pressure. [See SKILLS] Arterial bleeding may appear as pulsing or high pressure bleeding, and significant blood volume can be lost in minutes. Module 4: Approach to shock 102 – Vaginal bleeding may be an important source of blood loss from pregnancy-related bleeding (even in those who think they are not pregnant) or from masses in the cervix or uterus. Check fluid status: In dehydration states, the patient may feel thirsty or may have dry lips and mouth, abnormal skin pinch, lethargy, and delayed capillary refill. Patients with heart failure can be in shock with fluid overload, and may have lower body swelling (usually in both legs), crackles on lung examination, and distended neck veins. Check for pale conjunctiva (the inside of the lower eyelid): No matter the person’s skin color, the inside of the eyelid should appear pink and moist. If the inner portion of the eyelid (conjunctiva) is pale, it may indicate significant blood loss. You can compare the patient’s conjunctiva to another healthy person or look at your own in a mirror. Check mental status: Confusion in a patient with other signs of poor perfusion suggests severe shock. Check for fever: Fever in a patient with shock suggests severe infection. Check blood sugar: Low blood glucose can sometimes look like shock. If you cannot check blood glucose, but the person has altered mental status, a history of diabetes or another reason to have low sugar (for example, is taking quinine for malaria, is very ill, or is very malnourished), give glucose. [See SKILLS] Check for severe abdominal pain or a very firm abdomen: If the person has severe abdominal pain, this can be a sign of bleeding or infection in the abdomen. In a patient who might be pregnant, this can be a sign of an ectopic pregnancy. Check urine: Check the urine colour and volume. Small amounts of darker urine may indicate substantial dehydration. Check stool: Any significant diarrhoea can cause dehydration. A large amount of watery, “rice-water” stool suggests cholera, which can rapidly cause severe dehydration and shock. Black, dark, or reddish colored stool can suggest stomach or intestinal bleeding. BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 103 Check for malnourishment [see SKILLS]: If the person appears malnourished, fluid must be adjusted [see SKILLS]. Be sure to ask about recent changes in weight. Check for swelling, rash or excessive sweating: Swelling of mouth or body can indicate an allergic reaction. Rashes can indicate allergic reaction (hives) or systemic infection. Swelling of both legs can indicate heart failure. Sweating may occur with moderate to severe shock. Workbook question 2: Shock Using the workbook section above, list what you need to check for in a person with shock. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ 6. ______________________________________________________________________ 7. ______________________________________________________________________ 8. ______________________________________________________________________ 9. ______________________________________________________________________ 10. _____________________________________________________________________ Visible severe wasting in a child page 23 Visible severe wasting in a child Assessing for pitting edema in children with malnutrition page 22 Assessing for pitt ng edema in children with malnutri ion page 2 Asse ing for pitting ed ma in children with malnutrition page 22 Assessing for pitting edema in children with malnutrition Module 4: Approach to shock 104 POSSIBLE CAUSES OF SHOCK POOR PERFUSION DUE TO DILATED BLOOD VESSELS CONDITION SIGNS AND SYMPTOMS Severe infection • Fever • Tachycardia • Tachypnoea • May have hypotension • May or may not have obvious infectious source: visible skin infection, cough and crackles in one area of the lungs (often with tachypnoea), burning with urination, urine that is cloudy or foul smelling, or any focal pain in association with fever Spinal cord injury • History or signs of trauma • May have spinal pain/tenderness, vertebrae not in line, or crepitus (crunching) when you touch the spinal bones • Movement problems: paralysis, weakness, abnormal reflexes • Sensation problems: tingling (“pins and needles” sensation), loss of sensation • Unable to control urine and stools • Priapism • May have hypotension or bradycardia • Difficulty in breathing with an upper cervical spine injury Severe allergic reaction • Swelling of the mouth • Difficulty breathing with stridor and/or wheezing • Skin rash • Tachycardia • Hypotension POOR PERFUSION DUE TO FLUID LOSS CONDITION SIGNS AND SYMPTOMS Diabetic ketoacidosis (DKA) • May have known history of diabetes • Rapid or deep breathing • Frequent urination • Sweet-smelling breath • High glucose in blood or urine • Dehydration Severe dehydration • Abnormal skin pinch • Decreased fluid consumption or increased fluid loss (vomiting, diarrhoea, excessive urination) • Dry mucous membranes • Tachycardia Burn injury • Red, white or black areas of skin depending on depth of burn • May have blistering • May have signs of inhalational injury BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 105 POOR PERFUSION DUE TO BLOOD LOSS CONDITION SIGNS AND SYMPTOMS External bleeding • History of trauma • Visible bleeding • Use of blood-thinning medications Large bone fracture • History of trauma • Pain or abnormal movement of the pelvis, blood at opening of penis or rectum (pelvic fracture) • Deformity or crepitus of the femur, shortening of the leg with the injury (femur fracture) Abdominal bleeding • Bruising around the umbilicus or over the flanks can be a sign of internal bleeding • Abdominal pain • Very firm abdomen Bleeding in the stomach or intestines • Blood in vomit or stool • Black vomit or stool • History of alcohol use Haemothorax • Difficulty in breathing • Decreased breath sounds on affected side • Dull sounds with percussion on affected side • Shock (if large amount of blood) Ectopic pregnancy • History of pregnancy, missed menstrual cycle or any woman of childbearing age • Abdominal pain • Vaginal bleeding Postpartum haemorrhage • Recent delivery • Heavy vaginal bleeding: – Pad or cloth soaked in <5 minutes – Constant trickling blood – Bleeding >250 ml – Soft uterus/lower abdomen Module 4: Approach to shock 106 POOR PERFUSION DUE TO PROBLEMS WITH THE HEART CONDITION SIGNS AND SYMPTOMS Heart failure • Difficulty breathing with exertion or when lying flat • Swelling to both legs • Distended neck veins • Crackles may be heard in the lungs • May have chest pain Heart attack • Pressure, tightness, pain or crushing feeling in the chest • Diaphoresis and mottled skin • Difficulty in breathing • Nausea or vomiting • Pain moving to jaw or arms • Signs of heart failure • History of smoking, heart disease, hypertension, diabetes, high cholesterol, family history of heart problems Abnormal heart rhythm • Very fast or very slow pulse • Irregular pulse Heart valve problem • History of rheumatic fever or heart disease • Murmur Pericardial tamponade • Signs of poor perfusion (tachycardia, tachypnoea, hypotension, pale skin, cold extremities, capillary refill greater than 3 seconds) • Distended neck veins • Muffled heart sounds • May have dizziness, confusion, altered mental status • History of tuberculosis, trauma, cancer, kidney failure Tension pneumothorax • Hypotension WITH the following: – Difficulty breathing – Absent breath sounds on affected side – Hyperresonance with percussion on affected side – Distended neck veins – May have tracheal shift away from affected side REMEMBER... hypoglycaemia can look like shock. Signs and symptoms include: • Sweating (diaphoresis) • Seizure/convulsion • Blood glucose <3.5 mmol/L • Altered mental status (ranging from confusion to unconsciousness) • History of diabetes, malaria, or a severe illness, especially in children BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 107 Workbook Question 3: Shock Using the workbook section above, list the possible cause of shock next to the history and physical findings below. HISTORY AND PHYSICAL FINDINGS LIKELY CAUSE A 35-year-old woman presents with shock, fever and: • burning with urination • cloudy urine A 20-year-old woman presents with shock, abdominal pain and: • missed menstrual cycle • vaginal bleeding A 17-year-old man presents after a motor vehicle crash with shock, bruising to the pelvis and: • a femur fracture DO: MANAGEMENT FIRST PERFORM ABCDE ASSESSMENT AND INTERVENE FOR LIFE- THREATENING CONDITIONS. Start by giving IV fluid (normal saline or Ringer’s Lactate in adults and children with normal nutritional status). Then work to address underlying causes. Place IV access rapidly (two large-bore IVs) and start IV fluids. Place IV access rapidly (two large-bore IVs), start IV fluids and assess response. Repeat with additional boluses if needed. [See SKILLS] If you cannot place an IV, immediately call for a provider who can place a nasogastric tube (a tube that goes from the nose into the stomach) or intraosseous line (a needle that is placed directly into the bone). See if the patient can safely take oral fluids in the meantime. CAUTION! For severely malnourished or severely anaemic people, or anyone with signs of volume overload, do NOT follow the fluid protocol below. Use adjusted protocol. [See SKILLS] Module 4: Approach to shock 108 Uterine massage for postpartum hemorrhage page 17 If vaginal bleeding after delivery (postpartum haemorrhage) is suspected as a cause of shock: ALL patients need rapid handover/transfer to an advanced obstetric provider. While arranging for transport and during transport, it is important to try to stop the bleeding. Give BOTH intramuscular and IV oxytocin. This is a loading dose. After these doses, continue oxytocin IV until one hour after the bleeding stops. [See SKILLS] Bleeding frequently happens if the uterus is not fully contracted (does not feel hard on palpation). Perform uterine massage [See SKILLS] until the uterus is hard. You should use BOTH oxytocin and uterine massage to stop the bleeding. If the placenta delivers, collect it in a leak-proof container and keep with the patient to allow the advanced obstetric provider to examine it. Visually check externally for a perineal or vaginal tear. If found, apply direct pressure with sterile gauze and put legs together. Even if the bleeding stops, these patients still need rapid handover/transfer to an advanced obstetric provider (see figure). IV FLUID IMMEDIATELY AVAILABLE? IV FLUID AVAILABLE NEARBY? START ORS via NG NASOGASTRIC TUBE REASSESS IMMEDIATELY AFTER BOLUS DID PERFUSION IMPROVE? TRANSFER IMMEDIATELY CONTINUE ORS VIA NG YES YES YES YES No No No No DID PERFUSION IMPROVE? IV FLUIDS REASSESS IMMEDIATELY AFTER BOLUS CONTINUE E <30 MINUTES <30 MINUTES START IV FLUIDS RE-BOLUS GIVING FLUID IN SHOCK NO malnutrition, overload or severe anaemia Uterine massage for postpartum hemorrhage BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 109 REMEMBER... fluid only addresses the immediate problem of perfusion. Patients with shock need rapid handover/transfer to a unit capable of addressing the causes of shock and providing advanced management, including transfusion. REMEMBER... fluid status assessment is critical. Patients who have signs of poor perfusion but overall volume overload can be particularly difficult to manage. Patients with malnutrition, severe anaemia, and excess fluid in the lungs due to heart, liver, or kidney failure can present this way. These patients still need fluids, but the fluids must be given cautiously and, especially in malnourished children, according to a specific protocol. [See SKILLS] Postpartum Haemorrhage 1. Arrange immediate transfer to qualifi ed obstetric provider! 2. Attempt to control bleeding while arranging and during transfer. 3. Check: 4. Transfer immediately Heavy bleeding after delivery? Has the placenta delivered? Still bleeding? Is there a perineal or lower vaginal tear? Massage uterus until it is hard. Give oxytocin IM. Give IV uids and IV oxytocin. Empty bladder. Continue uterine massage. When uterus is hard, the placenta will likely deliver. Collect placenta and keep with patient. Continue oxytocin. Continue oxytocin for at least 1 hour after bleeding stops. Apply pressure with sterile gauze, put legs together. Continue to massage uterus until hard. Continue oxytocin. Continue IV uids with oxytocin. Insert second IV line. YES YES NO NO YES Module 4: Approach to shock 110 DO: MANAGEMENT OF SPECIFIC CONDITIONS • Always perform ABCDE first. Patients in shock need oxygen. • In all forms of shock, the primary management is administration of IV fluids appropriate for age and condition. • The specific conditions below require additional considerations. CONDITION MANAGEMENT CONSIDERATIONS Burns • Burns disrupt the skin barrier and can cause significant fluid losses that can lead to shock. These patients have different fluid replacement needs. [See SKILLS] Hyperglycaemia • If concern for diabetic ketoacidosis, treat with IV fluids. [See SKILLS] A person with diabetic ketoacidosis is extremely ill and requires rapid transfer to a unit where IV infusion and close monitoring are available. Fever • Give fluids and start antibiotics. [See SKILLS] If infectious diarrhoea (like cholera) is suspected, use gloves, aprons and relevant isolation precautions and report it to the local public health agency. If signs of poor perfusion do not improve with fluids, consider rapid handover/transfer. Spinal cause • Give IV fluids and refer for ongoing management at a unit that can provide spinal care. [See SKILLS] Stomach or intestinal bleeding • Start IV fluids and refer for blood transfusion. [See SKILLS] Ectopic pregnancy • Give IV fluids and refer for blood transfusion and obstetric care. [See SKILLS] Postpartum haemorrhage • Give oxytocin and IV fluids and plan for rapid transfer to facility with blood transfusion and obstetric care capabilities. • Give IV fluids and massage uterus until it is hard. [See SKILLS] • Give oxytocin. [See SKILLS] • If the placenta has delivered, collect it in a leak-proof container and keep with patient for inspection by advanced provider. • Check for perineal and vaginal tears and apply direct pressure. Tension pneumothorax • Perform needle decompression immediately to relieve the pressure, give oxygen and IV fluids. [See SKILLS] Any patient who has had a needle decompression will need rapid handover/ transfer to a unit that can place a chest tube. Pericardial tamponade • Give IV fluids to help fill the heart against the building pressure in the heart sac. [See SKILLS] Plan for rapid handover/transfer to a provider who can drain the pericardial fluid. BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 111 CONDITION MANAGEMENT CONSIDERATIONS Suspected heart attack • Give aspirin if indicated. Place an IV and give fluids, re-assessing the patient frequently. [See SKILLS] • While oxygen is no longer recommended in all patients with heart attack, it should initially be given in patients with shock or difficulty in breathing, even when heart attack is the suspected cause. • Plan for rapid handover/transfer to advanced provider. Heart failure • Give IV fluids more slowly, checking the lungs for crackles (fluid overload) frequently. Stop IV fluids if fluid overload develops (difficulty in breathing, crackles in the lungs, increased respiratory rate, increased heart rate). [See SKILLS] • Plan for rapid handover/transfer to an advanced provider. Severe allergic reaction • Give intramuscular adrenaline [See SKILLS]. These patients will also need IV access and fluids as their condition can rapidly worsen once the adrenaline wears off. You may give a second dose if the effects wear off. [See SKILLS] If the airway is swollen or there is difficulty in breathing, patients may need rapid transfer. Traumatic injury or rapid blood loss suspected • Stop the bleeding, give IV fluids, and conduct a thorough trauma assessment. [See SKILLS] Refer for blood transfusion and ongoing surgical management. Workbook question 4: Shock Using the workbook section above, list what you would do to manage this patient. A 6-year-old boy is brought in with fever. He is in shock and does not appear malnourished. Your facility has supplies to put in an IV. 1. ________________________________________ 2. ________________________________________ 3. ________________________________________ A young man is brought in after a motorcycle crash. He has a large cut to his arm that is bleeding and there is a large pool of blood under him. He is in shock when you examine him. 1. ________________________________________ 2. ________________________________________ 3. ________________________________________ A 30-year-old woman is brought in after accidentally eating prawns. She has a known shellfish allergy, her body is covered in a red, itchy rash and she is in shock. 1. ________________________________________ 2. ________________________________________ 3. ________________________________________ Module 4: Approach to shock 112 SPECIAL CONSIDERATIONS IN CHILDREN Shock can occur quite rapidly in children and is life-threatening. Children have a relatively larger surface area (compared to their body volume) and are thus likely to become dehydrated more rapidly. Infants and young children are particularly at risk as they are unable to say when they are thirsty and cannot drink more on their own. Assessing shock in children: The clinical definition of shock in children varies. The 2016 WHO guidelines for the care of critically ill children use the presence of three clinical features: cold extremities, capillary refill greater than 3 seconds, and weak and fast pulse. There are also other important signs of poor perfusion, including low blood pressure, fast breathing, altered mental status, and decreased urination (always ask parents how much urine the child is passing). [See SKILLS] Signs of dehydration in children • Very dry mouth and lips • Lethargy (excessive drowsiness and slowness to respond), child not interactive • Sunken eyes • Small amounts of dark urine (ask about number of nappies for infants) • Sunken fontanelles in infants under 1 year • Delayed capillary refill (normal capillary refill is less than 3 seconds) • Abnormal skin pinch [See SKILLS] • Pallor (anaemia makes dehydration even more difficult to treat [See SKILLS]) Abnormal skin pinch in a child page 34 Abnormal skin pinch in a child Common causes of shock and dehydration in children include: • Vomiting and diarrhoea: Gastroenteritis causes sudden onset of vomiting and diarrhoea with some abdominal pain and fever. Large amount of watery diarrhoea may suggest cholera, and needs to be reported to public health authorities. • Vomiting without diarrhoea: Vomiting without diarrhoea or fever may suggest raised pressure on the brain (trauma, tumour, brain swelling), or intestinal blockage. It is important to examine the child for signs of trauma. Vomiting associated with fever may suggest infection. • Overwhelming infection: Fever can cause children to become dehydrated quickly. In addition, overwhelming infection can cause blood vessels to dilate, worsening shock. BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 113 Special management considerations: • Malnourishment: Malnourished children are at high risk for hypoglycaemia and will need sugar in addition to fluids. Give specialized fluids if available. [See SKILLS] Give less IV fluid more slowly, and check the lungs for crackles (fluid overload) every 5 minutes. Stop IV fluids if fluid overload develops (crackles in the lungs, increased respiratory rate, increased heart rate). Switch to oral fluids as soon as signs of poor perfusion improve. These patients need rapid handover/transfer over to an advanced provider at a centre with blood transfusion capabilities. Workbook question 5: Shock Using the workbook section above, list signs of severe dehydration in children. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ 6. ______________________________________________________________________ 7. ______________________________________________________________________ 8. ______________________________________________________________________ DISPOSITION CONSIDERATIONS People with shock can worsen and die quickly. They must be monitored very closely. Additionally, the same illnesses that cause shock interfere with the body’s ability to manage fluids, so these patients must be monitored very closely for signs of difficulty in breathing. Patients with shock may be confused and anxious. Ensure they are safe and contained during transfer. Patients with shock are often transferred for transfusion or general or obstetric surgery. Always communicate directly with the receiving facility to make sure that these resources are actually available at the time of transfer. Module 4: Approach to shock 114 FACILITATOR-LED CASE SCENARIOS These case scenarios will be presented in small groups. One participant will be identified as the lead and will be assessed while the rest of the group writes the responses in the workbook. To complete a case scenario, participants must identify the critical findings and management needed, and formulate a one-line summary for handover, including assessment findings and interventions. You should use the Quick Card for these scenarios while being assessed. CASE #1: ADULT SHOCK A 48-year-old male with a history of alcohol abuse is brought in by his wife to be evaluated for weakness. His wife states that he has been having very dark stools for the past 2 days and now cannot stand up. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 115 3. Formulate one sentence to summarize this patient for handover. CASE #2: PAEDIATRIC SHOCK The patient is a 4-year-old girl brought in by her mother. She has been having almost constant diarrhoea for the past 3 days and vomiting every time she tries to drink anything. The mother thinks she may have had a fever as well. She has no signs of malnutrition. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate one sentence to summarize this patient for handover. Module 4: Approach to shock 116 MULTIPLE CHOICE QUESTIONS Answer the questions below. Questions and answers will be discussed in the session. 1. A 7-year-old boy has had lethargy, vomiting and diarrhoea for the past 4 days. His vital signs are: blood pressure 80/40 mmHg, heart rate 140 beats per minute, respiratory rate 18 breaths per minute. The patient vomits when you try to give anything by mouth. What is your most immediate management? A. Start an IV line and give fluids B. Continue to attempt oral rehydration C. Place a nasogastric (NG) tube and hydrate through it D. Rapidly transfer to a referral hospital 2. You are taking care of a 28-year-old man who was shot in the abdomen. He is lethargic and the vital signs are as follows: blood pressure 80/40 mmHg, heart rate 130 beats per minute, respiratory rate 20 breaths per minute. There is heavy bleeding from the gunshot wound and the abdomen is rigid and tender. What is the first intervention you should give this patient? A. IV fluids B. Intraosseous line C. Surgery D. Adrenaline 3. A child that presents with sunken eyes, small amounts of dark urine, dry mucous membranes and abnormal skin pinch testing is most likely suffering from: A. Pneumonia B. Head injury C. Dehydration D. Hypoglycaemia 4. A 60-year-old man states he has been weak and dizzy for the past week. His vital signs are: blood pressure 90/50 mmHg, heart rate 125 beats per minute, respiratory rate 16 breaths per minute. His skin is cool and pale. He states that his stools have been black for the past 2 days. What is the most likely cause of his shock? A. Stomach bleeding B. Abdominal trauma C. Dehydration D. Severe infection BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 117 5. You are assessing a 23-year-old man who was stabbed in the chest. You expose the chest to find one stab wound in the right chest with minor bleeding. He is complaining of severe difficulty in breathing and there are no lung sounds on the right side. His neck veins are distended and his skin is cool and sweaty. His vital signs are: blood pressure 86/56 mmHg, heart rate 136 beats per minute, respiratory rate 28 breaths per minute. What is your next step? A. Chest tube placement B. Needle decompression C. Blood transfusion D. Start IV fluids 118 Notes ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS 119 PARTICIPANT WORKBOOK Module 5: Approach to altered mental status Objectives On completing this module you should be able to: 1. recognize key history findings suggestive of different causes of altered mental status; 2. recognize key physical findings suggestive of different causes of altered mental status; 3. list high-risk causes of altered mental status in adults and children; 4. perform critical actions for high-risk causes of altered mental status. Essential skills Glasgow Coma Scale AVPU assessment Recovery position Oxygen administration IV cannula insertion IV fluid resuscitation Snake-bite management Spinal immobilization KEY TERMS Write the definition using the Glossary at the back of the workbook. Altered mental status: Coma: Confusion: Convulsion: Cyanosis: Module 5: Approach to altered mental status 120 Delirium: Dementia: Diabetic ketoacidosis (DKA): Eclampsia: Envenomation: Human Immunodeficiency Virus (HIV): Hypoglycaemia: Hypoxia: Ingestion: Kangaroo care: Large-bore IV: Level of consciousness: Orientation: Psychosis: Rabies: Seizure: Stroke: SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 121 Overview Altered mental status (AMS) is a term used for a range of presentations, from sudden or gradual changes in behaviour to disorientation, confusion and coma. Changes in mental status and/or level of consciousness may be due to conditions that affect the brain (such as lack of oxygen or glucose; or shock causing lack of perfusion) or problems with the brain itself (such as infection, inflammation or injury). While chronic psychiatric problems and dementia can cause changes in mental status, altered mental status is often an indication of severe disease, and other life- threatening causes must always be considered. The presence of delirium – a rapidly changing state of confusion with agitation, loss of focus and inability to interact appropriately – always requires a full assessment. Always ask family/friends about baseline mental status when possible. The goal of INITIAL ASSESSMENT is to identify rapidly reversible causes of altered mental status, and to recognize dangerous conditions requiring transfer. The goal of ACUTE MANAGEMENT is to ensure that blood, oxygen and glucose reach the brain; and to protect the brain from additional injury. This module will guide you through: ABCDE key elements ASK: key history findings (SAMPLE history) CHECK: secondary exam findings Possible causes DO: Management Special considerations in children Disposition considerations REMEMBER... ALWAYS START WITH THE ABCDE APPROACH, intervening as needed. Then do a SAMPLE history. Then do a secondary exam. Module 5: Approach to altered mental status 122 ABCDE: KEY ELEMENTS FOR ALTERED MENTAL STATUS For the person with altered mental status, the following are key elements that should be considered in the ABCDE approach. AIRWAY People with altered mental status may not be able to protect their airways and may be at risk of choking on vomit. BREATHING Hypoxia (lack of oxygen) can be a cause of altered mental status. Search for any signs of difficulty breathing, or cyanosis (blue colouring of the skin). Abnormal breathing can reflect diabetic ketoacidosis or poisoning. CIRCULATION Lack of perfusion to the brain can cause altered mental status. Look for and manage signs of shock (low blood pressure, elevated heart rate, delayed capillary refill). DISABILITY Check AVPU or GCS (in trauma). Look for abnormal glucose (hypoglycaemia or hyperglycaemia can cause altered mental status). Very small pupils suggest opioid overdose or poisoning (consider pesticides). Very dilated pupils suggest stimulant drug use. Unequal pupils suggest an increased pressure on the brain. If the patient can follow commands, test for strength and sensation in face, arms and legs. Weakness or loss of sensation on one side suggests a mass, bleeding, or blocked blood vessels in the brain (stroke), though hypoglycemia can also present this way. Altered mental status with general muscle weakness may suggest salt (electrolyte) imbalance in the blood. Look for abnormal repetitive movements or shaking on one or both sides of the body (seizure/ convulsion) – this may be due to a tumour, bleeding, brain infection, hypoglycaemia, or salt (electrolyte) imbalance. EXPOSURE Remember that patients with altered mental status may not report their history accurately. Examine the entire body for infections, rashes, and any evidence of trauma, bites or stings. Needle marks on the arms may suggest drugs as a cause. ASK: KEY HISTORY FINDINGS FOR PATIENTS WITH ALTERED MENTAL STATUS Use the SAMPLE approach to obtain a history from the patient and/or family. It is important to obtain a history from bystanders, friends or family as it may be difficult to obtain accurate history from a confused patient. For example, a person with hypoglycaemia may be too confused to relate a history of diabetes. If the history identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it. A B C D E SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 123 S: SIGNS AND SYMPTOMS How does the current condition compare to baseline mental status? Always ask family/friends about baseline mental status when possible. Is there difficulty breathing? Altered mental status associated with difficulty in breathing may indicate lack of oxygen to the brain. Is there headache? Headache with altered mental status can indicate infection, tumour or bleeding. Is there vomiting/diarrhoea? Vomiting without diarrhoea can be a sign of increased pressure in the brain. Any source of dehydration, including vomiting and diarrhoea, may cause altered mental status from poor perfusion. Vomiting and diarrhoea can also cause hypoglycaemia leading to altered mental status. Has there been any dizziness or fainting? These may be signs of poor perfusion (lack of oxygenated blood) to the brain. When did the symptoms start? Do they come and go? How long do they last? Have they changed over time? Rapid onset of altered mental status may suggest infection, inflamation, bleeding or drugs/ toxic exposures. A more gradual onset (over weeks or months) may indicate a space- occupying lesion in the brain, such as a tumour or slow bleeding in the brain. Altered mental status that comes and goes with normal intervals between episodes may suggest other causes, such as seizures/convulsions or psychiatric disease. Has there been any recent fever? Any person with altered mental status and fever may have an infection. Brain infections often present with altered mental status and fever. In small children and the elderly, any serious infection, such as urine, lung, or blood infection can cause altered mental status. Also consider prolonged outdoor exposure, poisonings, medications and drugs as these may present with fever as well. Very high fever itself from any source may cause altered mental status. Is there any weakness, clumsiness or difficulty walking? Change in mental status with weakness or sensory loss in one area of the body, or problems with walking and balance, suggest that the altered mental status comes from a cause in the brain itself, such as a stroke or tumour. Is there neck pain or stiffness? Fluid that circulates around the brain also circulates around the spinal cord, meaning any bleeding, inflammation or infection in the brain (meningitis, encephalitis) can also cause neck pain and stiffness. Module 5: Approach to altered mental status 124 Is there a recent history of trauma or falls? Bleeding in or around the brain can cause altered mental status some days after an injury. Remember that chronic alcohol drinkers and the elderly are more prone to brain bleeding and may not remember falls. Always consider slow bleeding around the brain as a cause, even several days after a fall, and consider unwitnessed trauma in a patient who is found altered with no known cause. Has there been any recent depression or changes in behaviour? Drug and alcohol use or psychiatric problems can present as altered mental status. Always consider the possibility of a suicide attempt by poisoning. Does anyone else from the same family or location have symptoms? Gaseous poisoning, like carbon monoxide poisoning, can cause altered mental status in multiple people. Carbon monoxide poisoning is usually seen in cold climates when people use indoor heating. A: ALLERGIES Any allergies or recent exposure to a known allergen? Severe allergic reactions (anaphylaxis) may present with altered mental status due to low blood oxygen levels or poor blood circulation to the brain as a result of shock. M: MEDICATIONS Currently taking any medications? Many common medications can cause altered mental status as a side effect, including those for seizures/convulsions, pain and sleeping. Ask about new medications and changed doses, and consider medication interactions. A medication list should be collected and can provide clues for underlying disease (such as convulsions, liver disease, diabetes) if the person cannot communicate. Opioid medications (such as morphine, pethidine and heroin) can cause altered mental status. P: PAST MEDICAL HISTORY History of diabetes? In any patient with diabetes and altered mental status, suspect diabetic crisis, or low blood sugar caused by medications. Recent increase in urine output, increased thirst, and fast or deep breathing suggest diabetic crisis (diabetic ketoacidosis). History of heart disease? Heart attack can cause decreased blood flow and oxygen to the brain leading to confusion. Those with heart disease are also at an increased risk of stroke. SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 125 History of stroke? Altered mental status in a patient with a history of stroke may suggest an additional stroke or bleeding in the brain. Be sure to ask people who know the patient about his or her usual mental and neurological status. Symptoms of old stroke may return with severe illness of any kind. History of high blood pressure? High blood pressure increases the risk for bleeding in and around the brain (such as stroke). History of seizure/convulsion? Altered mental status in a patient with a history of seizures/convulsions may suggest that the patient is having or recovering from a convulsion. If there is a history of epilepsy (primary seizure/convulsion disorder), ask about regular medication and any recent dose changes or missed doses. With a witnessed convulsion, ask about fall or head trauma. Always ask if the convulsion was the same or different compared to prior. Remember that recovery of normal mental status after convulsions usually takes only a half hour to several hours at most, though patients may feel tired for longer. Longer altered mental status suggests another cause. History of HIV infection? Altered mental status in a person with HIV may suggest infection in or around the brain (meningitis, encephalitis). History of tuberculosis? Tuberculosis can infect the brain and cause altered mental status. History of liver or kidney failure? Liver or kidney failure can cause problems with the clearing of toxins and waste from the blood, which can lead to altered mental status. History of heavy alcohol use? Alcohol intoxication and alcohol withdrawal can present with altered mental status. People with a history of heavy alcohol use also have a high risk for head injury (and may not remember falls) and hypoglycaemia, both of which can cause altered mental status. Use of drugs of abuse? Several drugs of abuse cause altered mental status, including stimulants, sedatives and opioids. History of pregnancy? High blood pressure during pregnancy can lead to eclampsia (or seizures/convulsions and high blood pressure) during pregnancy. L: LAST ORAL INTAKE When did the person last eat or drink? Low blood glucose levels and dehydration can cause altered mental status. Module 5: Approach to altered mental status 126 E: EVENTS SURROUNDING ILLNESS Recent trauma? Both head injury and poor perfusion resulting from blood loss can cause altered mental status. Recent travel to areas where certain types of infections might be more common? Specific infections that can cause altered mental status may be more common in certain areas. Malaria is a key consideration in many areas. Recent exposures: contact with a sick person, recent bites, chemical exposures, hot or cold environments etc.? Sick contacts may suggest infectious cause. Chemical exposures (such as pesticides) or bites may suggest intoxication or envenomation. Altered mental status can be caused by both very low and very high body temperatures. Recent alcohol or drug use? Both alcohol intoxication and alcohol withdrawal can cause altered mental status. Methamphetamines and cocaine may cause severe agitation, while heroin (and other opioids) may cause lethargy and coma. See also “Past medical history” section above. Workbook question 1: Altered mental status Using the workbook section above, list seven questions about signs and symptoms you would ask about when taking a SAMPLE history. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ 6. ______________________________________________________________________ 7. ______________________________________________________________________ CHECK: SECONDARY EXAMINATION FINDINGS IN ALTERED MENTAL STATUS A person with altered mental status may be unable to answer questions, and clues to the cause may only be found during the physical examination. Always assess ABCDE first. The initial ABCDE approach identifies and manages life-threatening conditions. The secondary SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 127 examination looks for changes in the patient’s condition or less obvious causes that may have been missed during ABCDE. If the secondary examination identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it. Check for safety: Agitated and violent behaviour is a common presentation. It is very important to identify and treat the underlying cause if possible, while prioritizing the safety of the patient and providers. Keep calm and work as a team. Ensure that the space is safe from possible weapons and make sure that the patient is not between you and the door. Avoid making the patient feel threatened. Do not sit too close and speak with a calm, soft and sympathetic voice. Continually explain what is happening. Many aggressive patients will cooperate when faced with a team, so call for help and approach a patient as a group if necessary. Check vital signs, including temperature and glucose, and treat abnormalities. Call for help early and arrange handover/transfer to an advanced provider. Check and monitor level of consciousness with the AVPU scale: – A: Alert – V: Responds to Voice – P: Responds to Pain – U: Unresponsive AVPU tests the person’s ability to respond to stimuli. A person who is not intoxicated and who has no illness or injury affecting the brain will usually be alert without being prompted. Patients who only respond when prompted by voice or pain require further assessment of the neurological system. [See SKILLS] In trauma, check Glasgow Coma Scale: Check and monitor the Glasgow Coma Scale. [See SKILLS] Check the blood glucose level: Hypoglycaemia can cause altered mental status. Diabetic ketoacidosis can present with hyperglycaemia and altered mental status. Check the pupils: Very small pupils and slow breathing suggests opioid overdose. Very large (dilated) pupils suggest stimulant drug use. Unequal pupils suggest increased pressure on the brain. Check for orientation: If the patient is alert and responds to voice, ask simple questions (for example: What is your name? Where are you? What time is it? What day of the week is it?). Check for trauma: Any patient with altered mental status and history or evidence of trauma should be considered to have a possible head injury – even if the trauma occurred several days before. Bruising around the eyes, behind the ears, or leaking of clear fluid from the nose or ears suggests head injury with skull fracture. Check temperature: Fever should raise concerns about an infectious cause, and fever with stiff neck suggests an infection in or around the brain. Poisonings, medication overdoses, alcohol withdrawal Module 5: Approach to altered mental status 128 and changes in body hormones can also present with fever. Hypothermia may indicate infection, low body hormone levels (e.g., thyroid) or exposure to wet or cold environments. Check for stiff neck (Remember, if you suspect trauma, do not move the neck): Stiff neck is suggestive of infection (meningitis) or bleeding around the brain. If you suspect infection, anyone who comes in contact with the patient should wear a mask. Check strength and sensation: If the patient can follow commands, test for strength and sensation in face, arms and legs. Weakness or loss of sensation on one side suggests a mass, bleeding or blocked blood vessels in the brain (stroke), though hypoglycaemia can also present this way. Altered mental status with general muscle weakness may suggest salt (electrolyte) imbalance in the blood. Check for signs of dehydration: Dehydration can cause altered mental status. Check for dry mouth and abnormal skin pinch. Dehydration may also suggest diabetic ketoacidosis. Check the abdomen: Feel if the liver is enlarged or tender. A palpable or tender liver suggests liver disease. Check the skin: Cool, pale, and moist skin suggests shock or hypoglycaemia. Yellow skin (jaundice) suggests liver disease. Bruising suggests trauma. Rashes can indicate systemic infection. Check for bites and stings. Monitor for changes in mental status: People who are initially confused and rapidly return to normal without treatment may have had a seizure/convulsion or head trauma. People with altered mental status require close monitoring to make sure they do not worsen again. (This can happen in patients who have low blood sugar or head trauma). Workbook question 2: Altered mental status Using the workbook section above, list five secondary examination findings you would check for in a patient with altered mental status. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 129 POSSIBLE CAUSES OF ALTERED MENTAL STATUS RAPIDLY REVERSIBLE CAUSES CONDITION SIGNS AND SYMPTOMS Hypoglycaemia • Sweating (diaphoresis) • Seizures/convulsions • Blood glucose <3.5 mmol/L • History of diabetes, malaria, or severe illness, especially in children • Mental status improves quickly with glucose Severe dehydration • Signs of poor perfusion • Abnormal skin pinch • Decreased ability to drink fluids, or fluid loss • Dry mucous membranes Heat stroke • Prolonged exposure to heat and sun • High body temperature, very warm skin • May or may not be sweating (diaphoretic) Hypoxia • Shortness of breath • Low blood oxygen levels • Cyanosis INFECTION CONDITION SIGNS AND SYMPTOMS Cerebral malaria • Fever • Rapid malaria test or smear positive • In or from an area with malaria Inflammation/infection around the brain (meningitis, encephalitis, brain abscess, bleeding) • Fever • Neck stiffness • Rash • Eye pain with looking at light/sensitivity to light • Headache • Known infectious epidemic or exposure • History of HIV or TB infection Severe infection • Fever • Tachycardia • Tachypnoea • May have hypotension • Signs of infection: visible infection in the skin, cough and crackles in one area of the lungs (often with tachypnoea), burning with urination or urine that is cloudy (not clear), or any focal pain in association with fever CONDITION SIGNS AND SYMPTOMS Rabies • Agitation • Fear of drinking (hydrophobia) • Drooling • Weakness • History of animal bite Module 5: Approach to altered mental status 130 METABOLIC CONDITION SIGNS AND SYMPTOMS Diabetic ketoacidosis (DKA) • History of diabetes • Rapid or deep breathing • Frequent urination • Sweet smelling breath • High glucose in blood or urine • Dehydration TOXIC CONDITION SIGNS AND SYMPTOMS Alcohol or drug intoxication or withdrawal • Known alcohol or drug use • Injection marks, drugs found on patients • Alcohol – breath smells of alcohol, reddened face – Acutely intoxicated (drunk) – Withdrawal (convulsions, confusion, tachycardia) – Chronic use (balance problems, confusion) • Opioids: – Acutely intoxicated (lethargy, very small pupils and slow breathing) – Withdrawal (agitation, sweating, diarrhoea, vomiting) • Other drugs may cause large pupils, agitation, sweating, fever Pesticide poisoning • History of exposure • Very small pupils • Diarrhoea • Vomiting • Diaphoresis Snake bite • Snake bite history • Bite marks in a setting with venomous snakes • Oedema • Blistering of the skin • Bruising • Hypotension • Paralysis • Seizures • Bleeding from wounds Medication reaction or dosing issue • New medications or recent change in dose Gaseous poisoning • History consistent with possible exposure • Multiple people with symptoms • Headache SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 131 OTHER CAUSES CONDITION SIGNS AND SYMPTOMS Seizures/convulsions • Known history of seizures/convulsions • Bitten tongue • Urinated on self • Gradual improvement over minutes or hours • If pregnant, consider eclampsia Increased pressure on the brain (trauma, tumour, bleeding or brain swelling) • Headache • Seizures/convulsions • Nausea, vomiting • Unequal pupils • Weakness on one side of the body or speech problems Liver disease • History of alcohol abuse or liver disease • Enlarged abdomen with thin arms, yellow coloring to the skin and eyes (jaundice), or hypoglycaemia Kidney disease • High blood pressure • Oedema or swelling in the legs • Decreased or no urine if severe Head trauma • Visual changes, loss of memory, vomiting, headache • History of recent trauma • Scalp lacerations and/or skull deformity • Bruising to head (particularly around eyes or behind ears) • Blood or clear fluid coming from nose or ears • Unequal pupils or weakness on one side of the body • Seizures/convulsions ADDITIONAL CONSIDERATIONS IN CHILDREN CONDITION SIGNS AND SYMPTOMS Ingestions of chemicals or toxins • Common in younger children • History of medications or substances found around child Module 5: Approach to altered mental status 132 Workbook question 3: Altered mental status Using the workbook section above, list the possible cause of altered mental status from the history and physical findings below. HISTORY AND PHYSICAL FINDINGS LIKELY CAUSE A 15-year-old girl presents with altered mental status, fever and: • neck stiffness • eye pain when looking at light • headache A 45-year-old man presents with altered mental status, and deep, rapid breathing and: • frequent urination • sweet-smelling breath • high glucose in blood or urine • dehydration DO: MANAGEMENT FIRST PERFORM ABCDE ASSESSMENT AND INTERVENE FOR LIFE-THREATENING CONDITIONS. NOTE: If the airway is clear, and there is no evidence of trauma, place the patient in the recovery position to avoid getting fluid or vomit in the lungs. [See SKILLS] CONDITION MANAGEMENT CONSIDERATIONS Hypoxia Give oxygen. Look for underlying cause. [See SKILLS] Hypoglycaemia Treat with glucose. [See SKILLS] Hyperglycaemia If concern for diabetic ketoacidosis, treat with IV fluids. [See SKILLS] A person with diabetic ketoacidosis is extremely ill and requires rapid transfer to a unit where IV infusion and close monitoring are available. Fever (hyperthermia) with altered mental status Start antibiotics. Severe infections may require treatment by an advanced provider. Include malaria testing and treatment in endemic areas. Also consider poisoning and envenomation. Treat high fever with paracetamol. [See SKILLS] For severe temperature elevation, spray with cool water mist, fan and give IV fluids. Avoid shivering. Hypothermia Move to warm environment, remove wet clothing, warm with blankets and warm IV fluid. SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 133 CONDITION MANAGEMENT CONSIDERATIONS Bleeding or other cause of increased pressure on the brain If no trauma, raise the head of the bed to 30 degrees. If trauma is suspected ensure spinal immobilization. [See SKILLS] Opioid overdose Administer naloxone. [See SKILLS] Naloxone effects last approximately 1 hour. Most opioids last longer and patients may need repeat naloxone dosing. Consider this when planning ongoing care and re-assess the person frequently. Active seizure/convulsion Treat with benzodiazepine and monitor the person closely to check for slow breathing. Check glucose or give glucose if you are unable to check. Place patient in recovery position if no trauma suspected. [See SKILLS] If the patient continues to seize or does not wake up between seizures, arrange for rapid transfer to an advanced provider and monitor the airway. Pregnant with active seizure/convulsion This could be eclampsia. Arrange rapid handover/transfer to a specialist unit and give magnesium sulphate. Monitor the patient closely for signs of toxicity. [See SKILLS] If any of these occur, do not give additional doses of magnesium. Alcohol withdrawal Always check glucose and give as needed. Treat withdrawal with a benzodiazepine. [See SKILLS] Monitor the airway closely. Poisoning or envenomation Try to identify the poison and refer to an advanced provider for specific treatments. If pesticide poisoning, make sure the patient has been decontaminated, and monitor the airway closely as the secretions can cause obstruction. Snake bites should be treated as described in the “Wound Management” section [see SKILLS] and referred as soon as possible for antivenom. Rabies There is no specific treatment for rabies. Symptomatic rabies is almost always fatal. See TRAUMA for management of suspected exposure from animal bite. Violent or very agitated patient Protect the patient from harming self or others. Ensure that staff have a clear exit path (do not place the patient between staff and the door). Remove potential weapons and unsafe objects. Call for help from colleagues, family members, and security if needed. Speak in a calm, soft, non-threatening tone. Explain what is happening at each stage of care. Do not confront or judge. Consider other causes: check glucose and vital signs including temperature and oxygen saturation. Treat abnormalities. Arrange for safe handover/transport to advanced provider. Trauma Assess GCS, immobilize the spine and evaluate for signs of increased pressure on the brain. [See SKILLS] Module 5: Approach to altered mental status 134 SPECIAL CONSIDERATIONS MANAGEMENT OF ACTIVE CONVULSIONS • Check ABCDE. • Maintain the airway – do not put anything in the mouth. • Give oxygen if concern for hypoxia or prolonged seizure/convulsion. • Place patient on his/her side, if possible. • Protect the patient from harm or further injury. • Check glucose or give glucose (if unable to check). • Give a benzodiazepine. • If pregnant and seizing, give magnesium sulphate. • If no response, give another dose of benzodiazepine (repeat three times if needed) and monitor for low blood pressure and slow breathing. • If the patient does not wake between seizure/convulsions, consider this a life-threatening condition. Arrange for rapid handover/transfer to an advanced provider. • If the seizures/convulsions stop, place patient in recovery position and monitor closely. Workbook question 4: Altered mental status Using the workbook section above, list what you would do to manage these patients. CONDITION MANAGEMENT A 3-year-old child presents with altered mental status and a blood glucose of 2 mmol/L. 1. ____________________________________________ A 25-year-old woman is brought in with jerky movements and you suspect an active seizure/ convulsion. 1. ____________________________________________ 2. ____________________________________________ 3. ____________________________________________ A 50-year-old man is brought in following a fall from a roof. He has a headache and altered mental status. 1. ____________________________________________ 2. ____________________________________________ SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 135 SPECIAL CONSIDERATIONS IN CHILDREN Children with altered mental status may have seemingly mild signs such as sleeping more than usual or being less interactive. Manage ABCDE first, and then look for and manage causes of altered mental status. Remember that very ill or injured children may have normal vital signs until they rapidly deteriorate. Hypoglycaemia occurs frequently in severely ill children and is a common cause of altered mental status in children. Check blood glucose (or give glucose if you are unable to check) in any child with altered mental status. Hypoxia can occur as a result of many conditions, including respiratory infections and shock; birth hypoxia is a consideration in newborns. Hyperthermia with altered mental status suggests infection, but can also be seen with excessive heat exposure, exercise, seizure/convulsion, hormonal imbalance and some medications and poisons. Hypothermia with altered mental status can also suggest infection, particularly in infants, but can be due to drug intoxication, exposure to cold or hormonal imbalance. Young infants are more affected by variation in temperature. Keep the child warm by using blankets and a hat to prevent heat loss and using skin-to-skin contact (also called “kangaroo care”) with a family member 24-hours per day while ill. Seizures/convulsions can be due to fever alone but (as in adults) can also suggest infection, hypoglycaemia or hyponatremia (low sodium). Do not delay antibiotics in patients with suspected serious bacterial infection. Always consider trauma. Infection in or around the brain can cause altered mental status. Look for a bulging or swollen fontanelle (in a child under 1 year) and/or rash to the legs and lower abdomen, which can indicate infection or increased pressure on the brain. Do not delay antibiotics in children with suspected serious bacterial infection. Flat fontanelle Bulging fontanelle page 31 Flat fontanelle Bulging fontanelle Poor perfusion can cause altered mental status. Children can become dehydrated very quickly. Check for signs of dehydration: abnormal skin pinch, dry mucous membranes (the inner, pink part of the mouth), irritability, sunken or depressed fontanelle (in a child under 1 year), slow capillary refill (greater than 3 seconds), cold extremities, tachycardia, and hypotension. Give IV fluids and re-assess frequently. [See SKILLS] Module 5: Approach to altered mental status 136 Malaria may be more severe in children than adults. Children with severe malaria may present with severe anaemia, seizure/convulsions, coma, and hypoglycaemia. Ingestion of chemicals or drugs is common in children. Try to identify the poison (talk to parents) and try to get a photograph of the package. Consult advanced provider immediately for management. Consider unwitnessed ingestions in children aged under 6 years (especially aged 1–3): • Ask about signs and symptoms depending on the substance ingested. • Take a thorough history from the family. • Examine the bottles of the ingested substance or medicine. • Determine what time it took place. • Ensure that no other children were involved. • Check for signs of burns in or around the mouth • Check for stridor (high-pitched noises) suggesting ingestion of chemicals that burned or damaged the airway and are causing swelling. • Children with ingestion of drugs or chemicals need to be monitored closely and may require handover/transfer to a referral unit for further management. Workbook question 5: Altered mental status Using the workbook section above, answer the following questions about altered mental status in children: How would you assess for brain infection in a child? ________________________________________________________________________ ________________________________________________________________________ Why does hypoglycaemia occur frequently in severely ill children? ________________________________________________________________________ Seizures/convulsions in young children can be a sign of what? ________________________________________________________________________ SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 137 DISPOSITION CONSIDERATIONS Disposition depends on the cause of altered mental status. Causes of altered mental status that cannot be rapidly corrected or which might return after medications wear off need management in a hospital setting. Any patient with altered mental status must be closely monitored for airway problems. Consider handover/transfer to a provider with advanced airway capabilities. If the underlying cause of the low blood glucose is not identified and treated, patients with hypoglycaemia who improved with glucose may develop low blood glucose again and may require repeat treatments. These patients need to be monitored closely. Naloxone (opioid reversal agent) effects only last approximately 1 hour. Many opioid medications are longer-acting and may need more doses of naloxone to reverse the opioid effects. Any patient treated with naloxone must be monitored closely. Make sure the new provider knows the patient has been given naloxone and may need additional doses. FACILITATOR-LED CASE SCENARIOS These case scenarios will be presented in small groups. One participant will be identified as the lead and will be assessed, while the rest of the group writes the responses in the workbook. To complete a case scenario, the group must identify the critical findings and management needed, and formulate a one-line summary for handover, including assessment findings and interventions. You should use the Quick Card for these scenarios while being assessed. CASE #1: ADULT WITH ALTERED MENTAL STATUS A 42-year-old man is brought in after he was found slumped over at a bus stop. When the bystanders went to him he was awake but very confused. They do not know him, but because he is so confused they brought him to you for care. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTION TO PERFORM: AIRWAY YES NO BREATHING YES NO Module 5: Approach to altered mental status 138 ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTION TO PERFORM: CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate one sentence to summarize this patient for handover. CASE #2: PAEDIATRIC PATIENT WITH ALTERED MENTAL STATUS A mother brings her 3-year-old child to you for evaluation after she had two seizures/ convulsions today. The child is wrapped in multiple blankets. The mother states that the child has been increasingly confused over the past 2 days and has had high fevers. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTION TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate one sentence to summarize this patient for handover. SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 139 MULTIPLE CHOICE QUESTIONS Answer the questions below. Questions and answers will be discussed in the session. 1. You are evaluating ABCDE on a 4-year-old boy who has a fever and a cough. He is not responding to you calling his name, but if you pinch the sole of his foot, he moans. What is his level on the AVPU scale? A. Alert B. Verbal C. Pain D. Unresponsive 2. A 37-year-old male is brought in by his wife with fever and confusion. She says since the fever began 3 days ago he has become increasingly confused. There has been no trauma. On examination you notice that his neck is stiff. What is the most likely cause of his altered mental status? A. Pneumonia B. Infection around the brain C. Stroke D. Drug use 3. A 46-year-old man comes in to check his blood pressure. His vital signs are: blood pressure 160/90, heart rate 120, respiratory rate 18, and blood glucose is 5 mmol/L. While you are examining him he has a seizure/convulsion. What treatment should you give? A. Benzodiazepine B. Glucose C. Antibiotics D. Naloxone 4. A 36-week pregnant woman is having a seizure/convulsion. She has a recent history of high blood pressure as well. What treatment should you give? A. Magnesium sulphate B. Glucose C. Nitroglycerin D. Nothing, the seizure/convulsion will stop on its own 5. You are assessing a 6-month-old infant and find a depressed fontanelle. What does this physical examination finding suggest? A. Infection in the brain B. Dehydration C. Pneumonia D. Hypoglycaemia 140 Notes ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS 141 PARTICIPANT WORKBOOK WHO BASIC EMERGENCY CARE [SKILLS]
AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 143 TABLE OF CONTENTS: SKILLS 1. AIRWAY SKILL STATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 BASIC AIRWAY MANOEUVRES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 • Adult head-tilt and chin-lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 • Paediatric head-tilt and chin-lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 • Adult and paediatric jaw thrust . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 MANAGEMENT OF CHOKING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 AIRWAY SUCTIONING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 BASIC AIRWAY DEVICE INSERTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Airway skill station assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 2. BREATHING SKILL STATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 BREATHING EXAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 GIVING SUPPLEMENTAL OXYGEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 BAG-VALVE-MASK VENTILATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 EMERGENCY NEEDLE DECOMPRESSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 MANAGEMENT OF OPEN PNEUMOTHORAX (SUCKING CHEST WOUND) . . . . . . . . . . . . . . . . . 157 HOW TO MAKE A SPACER FROM A PLASTIC BOTTLE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 Breathing skill station assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 3. CIRCULATION SKILL STATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 CIRCULATION EXAM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 EXTERNAL BLEEDING CONTROL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 • Direct pressure for external bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 • Deep wound packing for external bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 • Tourniquet technique for uncontrolled external bleeding . . . . . . . . . . . . . . . . . . . . . . . . 162 UTERINE MASSAGE FOR POSTPARTUM HAEMORRHAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 IV CANNULATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 • ADJUSTING FLUID VOLUME FOR SPECIAL CONDITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . 167 • IV FLUID ADMINISTRATION FOR SHOCK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 Circulation skill station assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 TABLE OF CONTENTS: SKILLS 144 4. EXTENDED PHYSICAL EXAMINATION SKILL STATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . 176 NEUROLOGIC EXAM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 • Glasgow Coma Scale (GCS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 • AVPU Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 SECONDARY SURVEY TRAUMA ASSESSMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 Extended physical examination skill station assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . 177 5. IMMOBILIZATION SKILL STATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 CERVICAL SPINE IMMOBILIZATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 LOG ROLL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 FULL SPINAL IMMOBILIZATION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 POSITIONING OF THE PREGNANT PATIENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 RECOVERY POSITION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 FRACTURE IMMOBILIZATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 • FRACTURE IMMOBILIZATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 • FRACTURE IMMOBILIZATION: OPEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 APPLYING A PELVIC BINDER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 Immobilization skill station assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 6. WOUND MANAGEMENT SKILL STATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 GENERAL WOUND MANAGEMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 BURN MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 • DETERMINE TOTAL BODY SURFACE AREA (TBSA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 • ESTIMATE DEPTH OF BURN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190 • FLUID RESUSCITATION IN BURN INJURY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 SNAKE BITE BANDAGING AND IMMOBILIZATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192 Wound management skill station assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192 7. Medication administration skill discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194 AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 145 SKILLS SKILL STATIONS are designed to allow you to practise new skills and demonstrate life- saving techniques. REMEMBER...ALWAYS WEAR PROPER PPE PRIOR TO CARING FOR A PATIENT AND PERFORMING ANY SKILL. 1. AIRWAY SKILL STATIONS AIRWAY SKILL STATION: BASIC AIRWAY MANOEUVRES Opening the airway: adult head-tilt and chin-lift To be used for patients with altered mental status who may not be able to protect the airway, with NO history of trauma: • Place person face up on flat, firm surface. • Tilt the head back with one hand and lift the chin with your fingers. – To do this, place one hand on the patient’s forehead and then place two fingers of the other hand on the chin. Rotate your hands, tilting the chin up away from the chest. • Remove foreign bodies if visible. • Use suction to remove any liquids or secretions from the airway if needed. • Hold the airway open – do not let the head drop back as this will close the airway. Opening the airway: paediatric head-tilt and chin-lift To be used with patients with altered mental status who may not be able to protect the airway, with NO history of trauma: • Remember, children’s heads are bigger than adults’ heads compared to body size, and their airways are softer and easier to block when the neck is bent. In older children, the airway can be opened by tilting the head backwards slightly (see figure). • Babies have the largest heads relative to their body size. Their heads should be placed in neutral (sniffing) position (see figure). • Inspect the mouth and remove visible foreign bodies. Take care not to push the foreign body deeper into the airway. Adult head-tilt and chin-lift page 1 Adult head-tilt and chin lift SKILLS 146 • Use suction to remove any liquids or secretions from the airway. • Hold the head as below in position to keep the airway open. Neutral position in infants Head-tilt and chin-lift in children (no trauma) Opening the airway: adult and paediatric jaw thrust Use when the patient has altered mental status and may not be able to protect the airway and there IS a history of trauma (cervical spine fracture is possible): • Ask an assistant to immobilize the cervical spine while you perform the jaw thrust. [See SKILLS] • Place fingers behind the angle of mandible (the curve on the jaw bone) on both sides of the jaw and push up so that the lower jaw moves. The head and neck should NOT move. • Inspect the mouth and remove foreign bodies if visible. • Use suction to remove any liquids or secretions from the airway if needed. • Hold the jaw in place to keep the airway open – do not let the jaw drop back as this will close the airway. Jaw thrust in children Jaw thrust in adults Head-tilt and chin-lift in children (no trauma) page 3 N utral position in infants page 2 Modified _02 Pediatric jaw thrust page 4_A AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 147 AIRWAY SKILL STATION: MANAGEMENT OF CHOKING Managing choking in an adult or larger child If respiratory distress occurs suddenly while eating, a person is clutching the throat, or there is silent coughing, cyanosis (skin turns blue in colour), stridor or noisy breathing, suspect a foreign body obstructing the airway. Encourage the person to speak or cough if possible and observe if the obstruction is removed. Do not perform the manoeuvres described below if the person is audibly coughing and/or able to make sounds. A person who is unable to speak or cough has complete airway obstruction and needs immediate help: • Tell the person that you are going to provide help. • Deliver five abdominal thrusts (see below for modifications for pregnant women). – Stand behind the person and lean the person forward. – Form a fist with one hand and place it in the centre of the abdomen between the umbilicus (belly button) and the bottom portion of breastbone. – Place your other hand over your fist. – NOTE: If the patient is pregnant, place the side of your fist in the center of the chest and pull sharply inward. – Pull in and up five times using hard, quick thrusts. This forces the air out of the patient’s lungs to try to “blow out” the obstruction. – If the obstruction persists, have the person bend at the waist and give five back blows (with the heel of your hand, strike the back between the shoulder blades in the direction towards the head). – Re-assess. – Repeat abdominal thrusts followed by back blows until patient speaks, coughs or becomes unconscious. – If the choking person becomes unconscious, lie him/her face up on a firm surface. Performing chest thrusts may relieve the obstruction. If a series of chest thrusts is not successful, continue with rescue breaths and chest compressions based on relevant CPR protocols. Chest thrusts for choking in late pregnancy page 6 Abdominal thrusts for choking adult page 5 Abdominal thrusts for choking adult Chest thrusts for choking in late pregnancy SKILLS 148 Managing choking in an infant or small child • Lay the infant on your arm or thigh in face down position with the head lower than the abdomen. • Give five back blows (with the heel of your hand, striking the back sharply between the shoulder blades in the direction towards the head). • If obstruction persists, turn the infant over. • Give five chest thrust with two fingers, just below the nipple line in the midline of the chest. • If obstruction persists, check infant’s mouth for any visible obstruction that can be removed. (Caution for biting.) • If necessary, repeat entire process until the foreign body is removed. Chest thrusts for choking in infants page 7 Back blows for choking in infants page 8 Chest thrusts for choking in infants Back blows for choking in infants AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 149 AIRWAY SKILL STATION: AIRWAY SUCTIONING The purpose of suctioning is to remove any liquids or secretions from the upper airway. Suctioning may be necessary to maintain an open airway if a person cannot clear secretions without help. • Check to see if your suction canister or handheld device is working. • Attach a rigid or soft suction catheter to the end of the suction tubing. • Explain what you are doing. • Insert the suction catheter into the back of the mouth (only as far back as you can see), cover the side hole on the catheter (NOT the tip of the catheter) to create suction. Suction only while pulling the catheter out and release suction when advancing the catheter forward (advancing the catheter further into the mouth while suctioning can cause injury). Repeat to suction all of the fluid in the back of the mouth. • Do not suction for more than 10 seconds at a time unless the airway is completely blocked with fluid. • To avoid trauma to the mouth, do not place the end of the suction tip directly against the soft tissue or hold it in just one place. Suction only in the oral cavity, do not suction up the nose. AIRWAY SKILL STATION: BASIC AIRWAY DEVICE INSERTION Oropharyngeal airway (OPA) insertion • An oropharyngeal airway (OPA) should only be inserted when the person is unconscious. A conscious person will not tolerate an OPA and will push it out. If the person resists, gags or vomits, remove the device immediately. • Always protect the cervical spine when there is a history of trauma. • Measure the appropriate size of the OPA by measuring from the tip of the earlobe to the corner of the mouth. • Open the person’s mouth using care not to insert your fingers between the teeth (to avoid accidentally being bitten). • Insert the OPA with the curved portion sideways and the tip pointing towards the cheek. • Push the OPA gently into the mouth and, when you can push no further, rotate the OPA 90 degrees, so that the tip now points down the throat and follows the curve of the tongue (see figure). • Push the OPA the remainder of the way in if necessary so that the flange (the wide, flat end) rests on the person’s lips. If you have to do this, be sure that the tip of the OPA does not push the tongue down to obstruct the back of the throat. • Check again to make sure the OPA did not push the tongue down and obstruct the airway. • Give oxygen if available. Oropharyngeal airway (OPA) insertion page 10 Oropharyngeal airway (OPA) insertion SKILLS 150 Nasopharyngeal airway (NPA) insertion Nasopharyngeal airways (NPA) are better tolerated in people who are semi-conscious or when there is a possibility of gagging with oropharyngeal airways. DO NOT use an NPA in people with head and facial trauma. • Assess the nasal passage for any obvious airway obstruction. • Determine the appropriate size NPA to insert. Measure from the base of the nostrils to the earlobe. The diameter of the NPA itself needs to be smaller than the person’s nasal passage. • Lubricate the NPA well and insert it into the nostril, directing it along the floor of the nose posteriorly towards the throat until the wide, flat portion (flange) of the tube rests against the nostril. • Give oxygen if available. Nasopharyngeal airway (NPA) insertion page 9 Nasopharyngeal airway (NPA) insertion Airway skill station assessments Skills station marking criteria 1st pass 2nd pass 3rd pass Safety: Personal protective equipment used or verbalized. BASIC AIRWAY MANOEUVRES Skill 1 – Open the airway: head-tilt and chin-lift List the indications for use – non-trauma cases only. Tilt the head with one hand on the forehead and lift chin with fingers. State that a baby must be placed in a neutral (sniffing) position. Remove foreign bodies if visible. Suction airway if required. Hold the airway open. Do not let the head drop back as this will close the airway. Comments: Skill 2– Open the airway: jaw thrust List the indications for using jaw thrust versus head-tilt and chin-lift (trauma with possible cervical spine injury). Ask for an assistant to immobilize the cervical spine. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 151 Place fingers behind the angle of mandible (the curve on the jaw bone) on both sides of the jaw and push up so that the lower jaw moves. Note that the head and neck should NOT move. Remove any visible foreign bodies. Hold the airway open – do not let the jaw drop back as this will close the airway. Comments: MANAGEMENT OF CHOKING Skill 3 – Choking: adult and larger child Be able to give the indication for abdominal thrusts (the person is unable to speak or cough). Tell the person what you are going to do. Stand behind the person and lean the person forward. Form a fist with one hand and place it in the centre of the abdomen between the umbilicus and the bottom portion of breastbone. Cover one fist with your other hand. Pull in and up five times using hard quick thrusts. This forces the air out of the patient’s lungs to try to “blow out” the obstruction. Assume the victim is still choking: have the person bend at the waist. Deliver five back blows with the heel of one hand between the shoulder blades, striking the back in the direction towards the head. State that you will re-assess the patient Repeat abdominal thrust then back blows until patient speaks or coughs or becomes unconscious. State how this would be modified for a pregnant woman: • Rather than abdominal thrust, place the side of fist in the centre of the chest, cover fist with other hand, and pull sharply inward. Comments: Skill 4 – Management of the choking infant and small child Lay the infant over your arm or thigh in the face down position with the head lower than the abdomen. Give five back blows to the infant’s back between the shoulder blades with the heel of one hand. If obstruction persists, turn the infant over. SKILLS 152 Give five chest thrusts with two fingers placed just below the nipple line in the middle of the chest. If obstruction persists, check infant’s mouth for any obstruction that can be removed. Repeat until obstruction is removed. Comments: Skill 5 – Suctioning the airway Check your suction canister or handheld device to make sure it is working. Attach a hard (yankauer) or soft suction catheter to the end of the suction tubing. Tell the person what you are doing. Insert the suction catheter into the back of the mouth (ONLY as far back as you can see) and cover the side hole on the catheter (NOT the tip of the catheter). Do not suction while inserting the catheter into the mouth. Suction only while pulling catheter out. State how long the patient should be suctioned for (no more than 10 seconds at a time unless the airway is completely covered with fluid). State the need to constantly move the suction catheter and not put the suction tip against the soft tissue. Comments: BASIC AIRWAY DEVICE INSERTION Skill 6 – Oropharyngeal airway (OPA) List the indication for using an oropharyngeal airway (person is unconscious with no gag reflex). Determine the appropriate size OPA to insert: (participant should explain how to do this out loud). • Measure from the earlobe to the corner of the mouth on that side. Open the mouth using care not to insert your fingers between the teeth (to avoid accidentally being bitten). Insert the OPA with the curved portion sideways and the tip pointing to the cheek. Once the OPA is in as a far as it will go, rotate the oropharyngeal 90 degrees so that the tip now points down the throat and the curve follows the tongue. Push the OPA the remainder of the way in so that the flange (the flat end) rests on the person’s lips. Check to make sure the OPA did not push the tongue down to obstruct the airway. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 153 State that oxygen will be given if available. Comments: Skill 7 – Nasopharyngeal Airway (NPA) List the indications for an NPA. (Better tolerated in a person who is semi-conscious or who may still have a gag reflex). State that NPAs should not be used in people with head and facial trauma. Assess the nasal passage for any obvious airway obstruction. Explain how to determine the appropriate size NPA to insert: • Measure from the external portion of the nostril to the bottom of the earlobe. • The diameter of the tube should not be bigger than the nostril (nasal passage). Lubricate the NPA. Lift up the tip of the nose. Insert the lubricated NPA into the nostril and gently push it along the floor of the nose until the flared-out base (flange) rests against the nostril. State that oxygen will be given if available. Comments: Competency demonstrated YES NO Remediation required YES NO Signature of facilitator: SKILLS 154 2. BREATHING SKILL STATIONS BREATHING SKILL STATION: BREATHING EXAM • Assess and count the rate of breathing (normal is between 10–20 breaths per minute in an adult. See ABCDE module for normal paediatric values). • Look for increased work of breathing (nasal flaring, retractions or chest in-drawing). • Feel for chest rise and chest wall tenderness. • Percuss the chest wall: – Place one hand on the chest with fingers separated (the middle finger should lie between the ribs). – With the other hand, tap on the middle finger of the first hand and listen for changes in tone (hollow or dull). • Listen to the chest: – Always expose the chest. Never listen through clothes. – Make sure your stethoscope is not too cold. – Place your stethoscope lightly on the chest wall. Ask the patient to open his or her mouth and take a complete deep breath in and out. Listen to the sounds of the breathing and compare the left side to the right. Listen in the upper zone, middle zone and lower zones and listen to the front of the chest and the back. – Normal breath sounds like wind moving in and out, while abnormal breathing sounds like air going through water, crumpling paper bags, or no air moving at all. [See DIB] – Respect modesty and avoid placing the stethoscope directly on the breasts when possible. BREATHING SKILL STATION: GIVING SUPPLEMENTAL OXYGEN Supplemental oxygen should be given when the patient has signs and symptoms of hypoxia – fast breathing, anxiety, excessive sweating, cyanosis or chest pain. Where available, a pulse oximeter should be used to measure oxygen saturation. • If hypoxia does not appear severe, lower levels of oxygen (24–40% oxygen) can be provided to children and adults through nasal cannula (nasal prongs), but monitor closely in case a mask is needed. (Remember, regular air is approximately 21% oxygen) – Nasal cannula should be about half the size of the nostril. – Position the cannula in each nostril, making sure that it does not extend too far back or press on the tissues. – Secure the tubing to the cheeks or loop the tubing over the ears so that the nasal prongs and the tubing are both on the front side of the patient’s body (never put the head through the loop in the tubing – if patients become confused and hypoxic, they can accidentally strangle themselves). – Oxygen is delivered at a low rate: max 5 L/min. • If hypoxia appears more severe (or if signs of hypoxia continue with maximum oxygen flow via nasal cannula), a simple facemask may be used. Simple facemask is usually used with oxygen flow rates of 6–10 L/min and can deliver approximately 40–60% oxygen. – The facemask is applied to the face, ensuring the bridge of the nose is covered and as little as possible leaks along the side. The mask should rest below the lower lip, but not past the chin. The elastic strap should be placed over the head to secure the mask. • For patients who appear extremely hypoxic or who still have signs of hypoxia with a simple facemask, oxygen can be delivered through a non-rebreather facemask. This provides close to 100% oxygen if the reservoir bag is full. – To prepare the non-rebreather facemask, put one finger over the valve at the top of the reservoir bag inside the mask to inflate the bag. Then apply the non-rebreather facemask in the same way as the simple facemask, ensuring as little leakage as possible. – Make sure that the oxygen is attached to the wall or cannister and that the flow rate is between 10–15 L/min depending on the pressure in your oxygen system and how fast and deep the patient breathes. If the patient is still hypoxic or the non-rebreather facemask bag does not fill, increase the oxygen flow rate. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 155 – NEVER put a non-rebreather facemask on before it is connected to oxygen. A true non- rebreather mask will not allow outside air in and can worsen difficulty in breathing and hypoxia if there is no oxygen flowing through the tubing. Nasal cannula/prongs Simple facemask Non-rebreather BREATHING SKILL STATION: BAG-VALVE-MASK VENTILATION Assess and manage airway and provide bag-mask-ventilation (BVM) for any patient who is not breathing or not breathing adequately (too slow for age or too shallow), any unconscious patient with abnormal breathing (slow, shallow, gasping or noisy), or any patient with a pulse who is not breathing (for patients without a pulse, follow relevant CPR protocols). CAUTION! Avoid over-aggressive ventilation (using bag-valve-mask too fast or with too much pressure) as this will damage the lungs. Children have smaller lungs that are especially fragile. When ventilating a child, be particularly careful to only give enough pressure to make the chest rise and be sure to allow enough time between breaths for exhalation (for the air to escape). Large volumes of air or high pressures may result in pneumothorax or irreversible lung damage. Bag-mask-ventilation steps: • If you have oxygen available, attach the BVM tubing and set the flow to the highest rate available. DO NOT DELAY bag-mask-ventilation to prepare oxygen. (Oxygen can be attached later.) • Place the mask over the patient’s mouth and nose (if you have two people available one person squeezes the bag and other holds the mask on the patient’s face and keeps the airway open). • Create a seal so that air does not leak out. Put your hand or hands in the “EC” position – your thumb and first finger should make a “C” around the top of the mask and push down evenly, your last three fingers should reach just under the bony part of the jaw (looking like an “E”) and pull the jaw upward to open the airway. – Think about pulling the face up to the mask (thus opening the airway) and pushing the mask down onto the face (creating a seal). – If you push down too hard without pulling the face up to the mask, you will block the airway and the patient will be difficult to bag. If you have problems ventilating, reposition your hands and the mask and try again. • If the patient is breathing on his or her own, deliver breaths when the patient takes a breath (during inspiration). Do not attempt to deliver a breath as the patient exhales. • If you are still unable to ventilate the person after repositioning the mask, consider the possibility of foreign body obstruction or air leak. Insert an oral or nasopharyngeal airway device if not already in place (See SKILLS). Nasal cannula/prongs Simple facemask Non-rebreather page 11 SKILLS 156 • Hold the bag in one hand and depress the bag enough to make the chest rise (to about one third of its volume for an adult – make sure you are using the appropriate-sized bag: an adult bag should have a volume of about 2 litres). • Squeeze bag over 1–2 seconds to provide chest rise (giving the breath faster can cause lung damage). • Give one breath every 6 seconds (10 breaths per minute) in an adult; one breath every 4 seconds (15 breaths per minute) in older children; or one breath every 3 seconds (20 breaths per minute) in infants. CAUTION with volume of breaths given in small children (see SKILLS). Giving large volume breaths can cause pneumothorax. • After each breath allow the chest to fall before giving another breath. • Watch the chest rising and falling evenly with each breath. BVM: One provider BVM: Two providers BVM: Child BREATHING SKILL STATION: EMERGENCY NEEDLE DECOMPRESSION Needle decompression of the chest is a life-saving emergency procedure for suspected tension pneumothorax (presence of air or gas in the cavity between the lungs and the chest wall causing excessive pressure on the opposite lung, the great vessels, and the heart). Patients can die very quickly from a tension pneumothorax. These patients need an emergent chest tube, but emergency needle decompression will relieve the immediate pressure and allow time for handover/transfer for chest tube. Emergency needle decompression should only be performed for tension pneumothorax. • Expose the chest and assess breathing. • A tension pneumothorax is identified if shock and the following are present: – Difficulty in breathing – Absence of lung sounds on the affected side – Hypotension – Distended neck veins – Hyperresonance with percussion on the affected side – Tracheal shift away from affected side • Insert a large-bore (14–16G preferred) IV cannula along the upper edge of the third rib through the second rib (intercostal) space in line with the midpoint of the clavicle on the affected side. – In tension pneumothorax, there will be a gush of expelled air • Give oxygen at high concentration (non-rebreather mask). • Start IV lines and give IV fluids. • Refer and transport to definitive care immediately. BVM: One provider BVM: Two providers BVM: Child page 12 AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 157 Chest tube should be placed as soon as possible following needle decompression (even if there was no rush of air) or for any suspected haemothorax. Needle decompression BREATHING SKILL STATION: MANAGEMENT OF OPEN PNEUMOTHORAX (SUCKING CHEST WOUND) An open pneumothorax is an open chest wall wound that sucks air in when the patient breathes in. Normally, when the chest wall is expanded, air is drawn into the lungs through the airway (through a vacuum effect). If there is another hole in the chest wall (due to trauma) air will also be drawn in that hole, but, rather than going into the lungs, it goes into the space between the chest wall and lungs, creating a pneumothorax. A 3-sided dressing is placed to prevent more air from coming in during inhalation, but to allow air from the pneumothorax to escape during exhalation to avoid developing a tension pneumothorax. To manage a sucking chest wound (open pneumothorax): • Give high flow oxygen. • Cover the sucking chest wound with petroleum gauze or other non-adhesive dressing such as the plastic wrapper from gauze packaging. • Tape three sides of the dressing, leaving one side un-taped to act as a flap valve. • These patients need to be transferred as soon as possible to a centre where a chest tube can be placed. (DO NOT place a chest tube through the injury.) Caution! There is a danger of the dressing becoming stuck to the chest wall with clotted blood. When this happens, air cannot escape from the chest cavity and pressure can build up, leading to a tension pneumothorax. Remove the dressing completely if there is worsening respiratory status or evidence of worsening perfusion. If the patient cannot be observed continuously, a three-sided dressing should NOT be placed. Needle decompression page 13 SKILLS 158 BREATHING SKILL STATION: HOW TO MAKE A SPACER FROM A PLASTIC BOTTLE The purpose of a spacer is to hold the medication (salbutamol) released from a metered dose inhaler so the person has time to effectively inhale the medication. (Without experience and proper training, it can be difficult to use a metered dose inhaler effectively and medication is often lost into the mouth or throat). Spacers should be made in advance, however. Do not delay salbutamol delivery to make a spacer. Spacer made from a plastic bottle • Use a clean 300–500ml plastic bottle (wash with detergent and rinse and dry well). • Take the cap off the metered dose inhaler and trace the shape of the opening of the inhaler on the base of the bottle directly opposite the mouth of the bottle. • Cut an opening into the base of the bottle slightly smaller than the traced shape. You can cut this with scissors or a heated paper clip. • Insert the inhaler into the spacer to check the size (the inhaler should fit tightly into the cut opening). • Always remember to prime the spacer with five puffs before use to clear the dead space. Breathing skill station assessments Skills station marking criteria 1st pass 2nd pass 3rd pass Safety: Personal protective equipment used or verbalized use. Skill 1– Assess breathing Assess and count rate of breathing. Look for increased work of breathing (nasal flaring, retractions). Feel for chest rise and chest wall tenderness. Percuss the chest wall. Listen to the chest (auscultate). Comments: Skill 2 – Supplemental oxygen administration State the indication for oxygen (hypoxia, indicated by fast breathing, anxiety, excess sweating, cyanosis (blue tinted skin), or chest pain). Spacer made from a plastic bottle page 14 AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 159 Explain when nasal cannula should be used (mild hypoxia). Demonstrate applying a nasal cannula with a nasal prong in each nostril. Secure the tubing to the cheek or loop over the patient’s ears. (The participant should NOT put the patient’s head through the loop in the tubing.) State that the oxygen flow rate should be no more than 5 l/min. If the patient still has signs of hypoxia, explain which oxygen delivery method should be used next. (Simple facemask) Apply simple facemask – mask over nose bridge and below lower lip. Ensure minimal air leak – adjust elastic to hold in place. Explain that the oxygen flow rate should be between 6–10 L/min. If the patient still has signs of hypoxia, explain which oxygen delivery method should be used next. (Non-rebreather facemask) To prepare the non-rebreather facemask, put one finger over the valve at the top of the reservoir bag inside the mask to inflate the bag. Ensure that the bag is inflated. Apply non-rebreather facemask – mask over nose bridge and below lower lip. Ensure minimal air leak – adjust elastic to hold in place. Turn on oxygen to 10–15 L/min depending on patient’s breathing. Adjust non-rebreather mask, and adjust flow to ensure bag is filled partially. Comments: Skill 3 – Bag-valve-mask ventilation State the indication for bag-valve-mask ventilation. State that if oxygen is available, connect it to the bag – but do not delay BVM to prepare oxygen. Ensure adequate mask-face seal. State correct rate of ventilation. State relevant cautions when ventilating a child. Verbalize that over-aggressive ventilation can damage lungs and cause vomiting. State or demonstrate correct volume of ventilation. Assess chest rise. If no chest rise, reposition airway. Consider OPA or NPA. Comments: SKILLS 160 Skill 4 – Emergency needle decompression State the indication for this procedure. Explain procedure to patient. Expose the chest and clean the skin. Identify landmark: second intercostal space (between the 2nd and 3rd ribs) in the midclavicular line. Insert 14–16G IV cannula into the identified location. Slide cannula over needle, and remove needle. State plan to handover/transfer for chest tube Give oxygen and assess respiratory rate, vital signs and oxygen saturation (if available). Start IV line and give IV fluids. Comments: Skill 5 – Management of open pneumothorax (sucking chest wound) Give high flow oxygen. Cover with petroleum gauze. Tape 3 sides of gauze. State the need for a chest tube to be inserted. Describe the risk of a clotted dressing blocking outflow of air. Comments: Competency demonstrated YES NO Remediation required YES NO Signature of Facilitator: AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 161 3. CIRCULATION SKILL STATIONS CIRCULATION SKILL STATION: CIRCULATION EXAM • Check for anxiety, confusion or altered mental status. • Feel for a pulse, assessing rate and quality (normal range is 60–100 beats per minute in adults. See ABCDE for normal paediatric values). • Assess capillary refill (checked by pushing on the fingernail, palms, or soles and releasing to see how long it takes for the colour to return to the skin). The normal range is less than 3 seconds. • Assess the skin colour and touch the skin to assess the temperature. • Measure other vital signs: respiratory rate and blood pressure (normal adult values: RR 10–20 breaths per minute and systolic BP greater than 90 mmHG. See ABCDE for normal paediatric values). CIRCULATION SKILL STATION EXAM: EXTERNAL BLEEDING CONTROL Direct pressure for external bleeding A wound that is deep and bleeding heavily may not stop bleeding on its own. Applying direct pressure with a clean dressing such as gauze can help to slow or stop the bleeding (see figure). • Put on gloves. • Use gauze or another clean non-adherent dressing. • Do not use bulky dressings as they can make it difficult to put enough pressure in the right place. • Apply firm pressure as directly as possible to the source of bleeding, usually with two or three fingers. • If the wound is on a limb, elevate the limb above the heart. • If the first dressing becomes soaked with blood, do not remove as this will dislodge any clots that have formed. Instead add another pad and apply firm pressure. • When bleeding stops, apply a bandage to keep the gauze/pad in place. • If bleeding does not stop, consider deep wound packing or tourniquet (see next section). Applying direct pressure to a wound Applying direct pressure to a wound page 15 SKILLS 162 Deep wound packing for external bleeding If the wound is deep or gaping and simple pressure does not stop the bleeding, deep wound packing may help. However, deep wound packing is a temporary procedure to stop the bleeding since it can lead to infection if left for more than 24 hours. • Put on gloves. • Always assess pulses, capillary refill and sensation before and after dressing or splinting any wound. • Thoroughly wash out the wound by flushing with at least a litre of clean water (under pressure when possible; see next section). • Use gauze or another clean, compact material to completely fill the space within the wound. • Use additional gauze on top of the wound surface and apply direct pressure with your gloved hand or a bandage wrapped firmly around the wound/limb. • For limb wounds requiring packing, apply a splint to reduce the risk of re-bleeding. • A deep wound pack should not be left in place for more than 24 hours because of the risk of infection. • If bleeding does not stop, consider tourniquet (see next section). Tourniquet technique for uncontrolled external bleeding You will not be expected to perform the tourniquet technique BUT you will be expected to know what life-threatening conditions it can be used for, the special considerations around use of a tourniquet and the ongoing care of the patient. Use this technique ONLY if all other bleeding control measures have failed AND haemorrhage is life-threatening. If you place a tourniquet, there is a possibility that tissues below the tourniquet will be permanently damaged and even require amputation. If you are considering using a tourniquet, CALL FOR HELP IMMEDIATELY and plan for handover/transfer to a unit where surgery is possible. • If available, use a pneumatic tourniquet (like a blood pressure cuff) over padded skin and inflate until bleeding stops. If not, use a thick band or piece of cloth or belt (the wider, the better), over padded skin. • Apply as close to wound as possible, but do not place over a wound or a fracture. • Apply enough pressure to make distal pulses disappear and re-assess bleeding. • If bleeding stops, leave dressing in place if already present or dress the wound and prepare for handover/transfer to a surgical care unit. • If the bleeding does not stop, increase tourniquet pressure until major bleeding ceases. • Record the exact time the tourniquet was applied in the notes AND write it on the patient’s skin or the tourniquet itself. • Consult advanced provider as soon as possible (and never more than 2 hours) after placing a tourniquet. • The tourniquet should be released every 2 hours for at least 10 minutes. Hold direct pressure to the bleeding area during this time. Do not re-apply the tourniquet unless evidence of continued active bleeding. • Location of the tourniquet: tourniquets should only be placed on extremities and should be placed above the level of the bleeding. Because of the relationship between the bones and blood vessels, tourniquets on the upper arm or leg are often more effective than tourniquets placed below the elbow or knee. • Make sure the tourniquet is clearly visible. • Remember tourniquet should be placed as a last resort. If you place a tourniquet, you are cutting off blood supply to the limb, so only do this for life-threatening bleeding. When tourniquet use is absolutely necessary, use a wide, yet constrictive, band. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 163 CIRCULATION SKILL: UTERINE MASSAGE FOR POSTPARTUM HAEMORRHAGE Some bleeding will occur with every delivery. After delivery, the uterus should contract, which compresses vessels and limits bleeding. Failure of the uterus to contract is the top cause of abnormal bleeding after delivery (postpartum haemorrhage). Call for help, arrange for rapid handover/transfer, start uterine massage and give oxytocin immediately. Postpartum Haemorrhage 1. Arrange immediate transfer to qualifi ed obstetric provider! 2. Attempt to control bleeding while arranging and during transfer. 3. Check: 4. Transfer immediately Heavy bleeding after delivery? Has the placenta delivered? Still bleeding? Is there a perineal or lower vaginal tear? Massage uterus until it is hard. Give oxytocin IM. Give IV uids and IV oxytocin. Empty bladder. Continue uterine massage. When uterus is hard, the placenta will likely deliver. Collect placenta and keep with patient. Continue oxytocin. Continue oxytocin for at least 1 hour after bleeding stops. Apply pressure with sterile gauze, put legs together. Continue to massage uterus until hard. Continue oxytocin. Continue IV uids with oxytocin. Insert second IV line. YES YES NO NO YES SKILLS 164 Performing uterine massage for postpartum haemorrhage • Explain to the woman what you will do and why. • The goal is to compress the uterus between your hand and bony structures behind the uterus (e.g. sacrum/lower back). • Place your hand on the woman’s abdomen. Through the abdominal wall, feel for the uterus and cup it with your hand. This will ensure it stays under your hand whilst you are massaging it. Do not simply squeeze the uterus, but ensure that you are applying strong pressure toward the patient’s back while massaging with a circular motion. • Massage the uterus until it is very firm. It should feel like a 10 cm rock in the lower abdomen when contracted. • Do not stop massaging until the uterus is contracted (hard). • Make sure the uterus does not become relaxed (soft) after you stop uterine massage. If it becomes relaxed, resume massage. • Continuously re-assess for vaginal bleeding. • Perform frequent vital signs. Uterine massage for postpartum hemorrhage Uterine massage for postpartum hemorrhage page 17 AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 165 CIRCULATION SKILL: IV CANNULATION Insertion of IV cannula (adult) Inserting an IV cannula is an essential skill required for the treatment of shock. If an adult displays any signs and symptoms of shock, insert two large-bore cannulae (14 or 16 gauge). • Prepare cannula, IV fluid of choice, tourniquet, gloves, dressing to cover the cannula and alcohol swab. • Put on gloves. • Place an elastic band or glove around the arm to function as a temporary tourniquet to help the veins engorge (this “tourniquet” is different from the one above and should not be so tight as to cut off arterial blood flow). Avoid placing an IV in any arm that might have a fistula for treatment of kidney disease. • Look and feel for a vein that is straight. Avoid blood vessels that have a pulse. If a person is in shock, it may be difficult to find a vein. In this case search for a vein in the antecubital fossa (where the elbow bends, see figure). IV in antecubital fossa • Use alcohol or other appropriate skin cleanser to wipe the skin around the vein you plan to use. • DO NOT insert an IV through skin that is broken or appears infected. • Prepare the cannula. Preparation may vary depending on local resources and types of cannula. • Tell the patient what you are doing. • Remove the safety covering over the cannula (the only thing that should be inserted is the needle with overlying plastic cannula). • Insert the needle directly over and in line with the vein as flat and parallel to the skin as possible. Watch for flashback (flash of blood in the cannula) when you enter the vein. – If blood has a regular pumping pattern, you have likely hit an artery and you should remove the needle/catheter and apply firm pressure to the site for at least 5–10 minutes. • After seeing the flash of blood, insert the needle a few millimeters further, then advance the plastic cannula over the needle fully into the patient’s vein. (Do NOT let the needle move forward when you start to move the plastic cannula.) • Hold the cannula in place, applying pressure to the base of the cannula (to occlude it and stop the flow of blood) and withdraw the needle, leaving the cannula positioned in the vein. If needed, withdraw blood to send for laboratory testing. • Remove the IV tourniquet and flush the cannula with normal saline. • Place a cap on the end of the cannula, secure the cannula well and dress the site. Document the date the cannula was inserted in the notes. • Ensure the needle is placed into a sharps container. Check IV site daily for signs of infections such as skin redness, pain and swelling. Ensure the cannula is still in the vein and not sitting in the skin next to the vein allowing fluid to be infused under the skin creating pain and swelling. If any sign of swelling or infection, remove the IV cannula and re-assess. IV in antecubital fossa page 16 SKILLS 166 Insertion of IV cannula (paediatric) Attempt to place the cannula in the hand of the child first. Other sites that can be used to insert a cannula include: • Scalp veins • External jugular veins • Antecubital veins • Femoral veins When preparing for IV cannulation in children ask another assistant or parent to help keep the child’s arm still. Veins in infants • Prepare a 21 or 23 gauge cannula. • When inserting the cannula into the back of the hand, keep the hand bent to obstruct venous return and make the veins visible. Place an “IV tourniquet” (as above) if needed. If you use an IV tourniquet, be sure you don’t forget to remove it. • Insert the cannula using the same technique used in adults. Again, be sure that the blood flows smoothly from the catheter and is not pumping. After insertion, withdraw blood if required for laboratory investigation. Remove the tourniquet and flush the cannula with a small amount of normal saline after insertion. • Secure the cannula well. Children will attempt to remove the cannula and will undo dressings. Avoid placing a single piece of tape (plaster) that goes all the way around an extremity as this may limit blood flow. • If the IV is placed near a joint (hand, antecubital fossa, femoral area) splint the joint to stop it from bending and preventing the IV fluid flowing in, and lightly bandage the IV site with bulky dressings to prevent the child from pulling at the adhesive dressing underneath. Veins in infants Scalp veins External jugular veins Antecubital veins Veins on dorsum of hand Femoral veins Ankle veins page 18 AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 167 Securing an IV in a child page 20 Securing an IV in a child Inserting IV in a small child's hand page 19 Inserting IV in a small child’s hand Check IV site daily for signs of infections such as skin redness, pain and swelling. Ensure the cannula is still in the vein and not sitting in the skin next to the vein allowing fluid to be infused into the skin creating pain, swelling and another source of infection. If any sign of infection, remove the IV cannula and re-assess. CIRCULATION SKILL: IV FLUID – ADJUSTING FLUID VOLUME FOR SPECIAL CONDITIONS Shock should be treated with IV fluids. Fluid volume must be adjusted for patients with three conditions: malnutrition, severe anaemia and fluid overload. When administering IV fluid to any patient, look for signs of new or worsening fluid overload: difficulty in breathing, crackles in the lungs, increasing respiratory rate or increasing heart rate. Stop IV fluids if there are any of these signs and plan for immediate handover to an advanced provider. Recognizing conditions needing IV fluid adjustment in patients with shock – fluid overload, malnutrition, and severe anaemia. 1. Is there fluid overload? In some patients, such as those with heart or kidney failure, there may be extra fluid in the tissues (for example, in the lungs or the soft tissues of the legs). These patients can be fluid “overloaded” even when they have poor perfusion (because the extra fluid is not in the blood vessels). These patients still need IV fluid if they are in shock, but IV fluid must be given more slowly with careful monitoring so that the fluid overload does not get worse. SKILLS 168 CHECK FOR: Signs of fluid overload. • Difficulty in breathing with crackles on chest exam • Lower body swelling (usually in the legs) • Unable to lie flat • Distended neck veins – If signs of fluid overload are present, you must adjust fluids: Small amount of fluids may be given (250–500 ml boluses in adults). Slow the rate of fluid administration. Monitor closely for worsening signs of fluid overload (increasing respiratory rate or heart rate, new or worsening difficulty breathing and increasing crackles in the chest). Stop IV fluids if any of these signs develop. REMEMBER: It is important to go slowly so you can stop for early signs of fluid overload. If you don’t stop IV fluid when these early signs develop, too much IV fluid can cause a patient’s lungs to fill with fluid and create severe difficulty in breathing, or even death. 2. Does the patient have severe anaemia? In patients with severe anaemia, IV fluid can dilute the blood and lower its capacity to carry oxygen to dangerous levels. Additionally, patients with severe anaemia tend to show signs of fluid overload more quickly with IV fluid administration. Remember: you should only give IV fluids to someone with severe anaemia if there are signs of shock (see figure). CHECK FOR: Signs of severe anaemia. • Severe pallor to the palms of the hands (compare to your own palm) or the mucous membranes. • Fast breathing or fast heart rate • Confusion or restlessness • May also have signs of heart failure/fluid overload • If these signs of severe anaemia are present, you must adjust fluids: Slow the rate of fluid administration. Monitor closely and stop IV fluids for worsening. Rapid handover/transfer to a centre capable of blood transfusion. 3. Is the patient severely malnourished? • IV fluid can cause life-threatening swelling and heart failure in malnourished patients and must be adjusted very carefully. Malnourished patients are also at very high risk of hypoglycaemia. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 169 CHECK FOR: Signs of malnourishment. • Visible wasting: a child with severe wasting does not look just thin, but is visibly bony with skin that appears too large for the body. The arms, legs and buttocks may be thin, and the head may appear relatively large because of wasting of the body. • Oedema of both feet: take shoes or socks off and assess both feet for oedema. Press the top of the foot gently with your thumb for a few seconds to see if a dent remains in the tissues. Remember that a severely malnourished child may not appear very thin if there is a lot of oedema. – If these signs of severe malnutrition are present, you must adjust fluids. [See FLUID ADMINISTRATION IN SHOCK (CHILD WITH SEVERE MALNUTRITION) for detailed fluid choice and administration rates] Oral fluid is preferred if the patient can tolerate it. Add dextrose: use dextrose-containing fluids or give a dose of dextrose with IV fluids. Slow the rate of fluid administration. Monitor closely and stop IV fluids for any signs of fluid overload. Switch to oral fluid as soon as possible. Visible severe wasting in a child: Assessing for bilateral oedema in severe malnutrition in children: • Skin looks too large for the body • There is no fat on the child • Outlines of ribs can be seen • Severe muscle wasting of the arms, legs and buttocks • The head may appear relatively large because of wasting of the body (see figure) Visible severe wasting in a child • Use your thumb to press gently for a few seconds on the top of each foot – the child has oedema if there is an impression when you lift your thumb • Repeat on the other foot (see figure) Assessing for pitting edema in children with malnutrition Visible severe asting in a child page 23 Assessing for pitting edema in children with malnutrition page 22 SKILLS 170 CIRCULATION SKILL: IV FLUID – ADMINISTRATION Fluid administration for shock in adults • Attach normal saline or Lactated Ringer’s solution to the cannula. • In adults give 1 litre over less than 30 minutes. • Assess response to fluid immediately after the fluid bolus. Assess perfusion (capillary refill, mental status, urine output), and check for pulse rate and blood pressure. If improving, the pulse rate should lower and the blood pressure should increase. Mental status may also improve. • Assess for fluid overload (see signs above). • If still in shock with no evidence of fluid overload, give another 1 litre bolus. • If still in shock after 2 litres of IV fluid, re-assess for ongoing blood loss (external and internal) or spinal injury, and call for advanced provider. If there is evidence of severe malnutrition, severe anaemia or fluid overload: • Patients with shock still need IV fluids, but it is important to re-assess frequently for signs of worsening overload. – For these adult patients who are at high risk for fluid overload, bolus with 500 ml IV fluid initially, then re-assess. If no signs of fluid overload or fluid in the lungs, give additional 500 ml. Fluid administration for shock in children The appropriate amount of fluid for critically ill children is controversial given recent evidence that bolus fluids can worsen outcomes in some children. In addition, relevant criteria for poor perfusion and shock may vary by context. The 2016 WHO guidelines for the care of critically ill children (see WHO Sources section) use the presence of three clinical features to define shock requiring bolus fluids: cold extremities, capillary refill greater than 3 seconds, and weak and fast pulse. For children with poor perfusion that is due to loss of fluid, such as those with bleeding, burns or severe diarrhoea/vomiting, bolus fluids are also recommended. For other children with evidence of poor perfusion, smaller amounts of fluids given more slowly may be safer. Country teams should consider the clinical presentation of the child, the capacity of providers to detect signs of fluid overload, and the availability of monitoring and support equipment when adapting recommendations to the national context. To give IV fluid resuscitation to a child in shock WITHOUT severe malnutrition, severe anaemia or overload: • Insert IV cannula as described above. • Weigh the child or ask the parents for a recent weight. • Give normal saline or Lactated Ringer’s: 10–20 ml per kilogram of body weight over 30 minutes. Re-assess the child after the first infusion. • If no improvement, repeat 10 ml per kilogram of body weight over 30 minutes. Call for help and plan to handover to an advanced provider and unit with the capacity for blood transfusion. IV fluid resuscitation for a child in shock WITH severe malnutrition Children that are in shock AND have severe malnutrition require specialized fluids (if available) with different rates of infusion. Children with severe malnutrition and shock are at very high risk of hypoglycaemia and will need sugar in addition to fluids. [See MEDICATIONS] If the child can take oral fluids, give oral rehydration with ReSoMal (unless the child is in shock due to cholera, then use ORS). If the child is lethargic, unconscious or not capable of taking oral fluids, then give IV fluids. CAUTION! Intravenous fluid administration can be dangerous in malnourished children. While giving fluid in any way, you must check every 5 minutes for the following danger signs: new or worsening DIB, respiratory rate increase of >5 per minute or heart rate increase of >15 beats per minute. Stop fluids if any danger sign develops. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 171 • Insert IV line as above. • Weigh the child. • Give 10–15 ml per kilogram of IV fluid over 1 hour. If specialized fluids are available, give one of the following according to availability: – Ringer’s Lactate with 5% glucose (dextrose) – Half-strength Darrow’s solution with 5% glucose (dextrose) – 0.45% normal saline with 5% glucose (dextrose). • If you do not have dextrose-containing fluids, then give one of the following: – Ringer’s Lactate AND give a separate oral or IV dose of dextrose [See MEDICATIONS] – Normal saline AND give a separate oral or IV dose of dextrose. [See MEDICATIONS] Re-assess the child after the first 5–10 minutes of the infusion and then every 5 minutes: If the child worsens during rehydration (increased difficulty in breathing, breathing rate increases by 5/min and pulse rate increases by 15/min or lung crackles develop): • Stop the fluids. • Call for help and plan for handover to an advanced provider. If there is no improvement after the first infusion: • Call for help. Plan for handover to an advanced provider at a centre with blood transfusion capabilities. • Give fluid at 4 ml per kilogram over 1 hour while awaiting transfer to the advanced provider. If the child displays signs of improvement (improved capillary refill, lower pulse rate and respiratory rate): • Switch to oral or nasogastric rehydration with ReSoMal (low sodium oral rehydration solution) 10 ml per kilogram per hour for up to 10 hours. • Transfer to a malnutrition unit. SPECIAL CONSIDERATIONS: Children with severe anaemia and poor perfusion need urgent handover to an advanced provider and unit with the capacity for blood transfusion. Children who need IV fluids, but in whom bolus fluids are not indicated should be given maintenance fluids. See the WHO Child Health publications page (www.who.int/maternal_child_adolescent/ documents/child/) for recommended maintenance fluid rates in children. Circulation skill station assessments Skills station marking criteria 1st pass 2nd pass 3rd pass Safety: Personal protective equipment used or states intent to use Skill 1 – Assess circulation Look for anxiety, confusion, AMS Feel for pulse: rate, quality Assess capillary refill: >3 seconds indicates poor perfusion Assess skin colour and temperature Verbalize to measure other vital signs: respiratory rate and blood pressure Comments: SKILLS 172 Skill 2 – Bleeding control: direct pressure Put on gloves Uses gauze or another clean, non-adherent dressing, apply firm pressure to the wound Verbalize to not use bulky dressings Apply firm pressure as directly as possible to the source of bleeding, usually with two or three fingers Demonstrate how to elevate a limb with a wound above the heart Verbalize to not remove the first dressing Apply second dressing with firm pressure when wound continues to bleed Apply bandage when bleeding ceased Verbalize the need to call for help Comments: Skill 3 – Bleeding control: deep wound packing Put on gloves Identify deep or gaping wound as an indication for deep wound packing Assesses pulses, capillary refill and sensation after dressing or splinting any wound Irrigate with 1L clean water before packing. Use gauze or another clean, compact material to pack the space within the wound Put additional gauze on top of the wound surface and apply direct pressure with your gloved hand or a bandage wrapped firmly around the wound/limb If a wound is on a limb and requires packing, consider applying a splint to reduce the risk of re-bleeding Assesses pulses, capillary refill and sensation after dressing or splinting any wound State that a deep wound pack should not be left in place for more than 24 hours because of the risk of infection Comments: Skill 4 – Bleeding control: tourniquet Identify continued bleeding as an indication for a tourniquet States intent to use a blood pressure cuff or thick band or piece of cloth or belt (the wider, the better) after padding skin Identifies appropriate location for tourniquet States to tighten tourniquet until the distal pulses disappear. Then re-assess the bleeding to see if it has stopped AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 173 States to secure tightened tourniquet in place States plan to release for 10 minutes every 2 hours. Only re-apply if bleeding resumes States documentation time of tourniquet placement States will not leave tourniquet on for more than 2 hours without consulting advanced provider Comments: Skill 5 – Uterine massage for postpartum haemorrhage States to call for help and initiate handover/transfer States the indication for performing uterine massage States the need to prepare oxytocin and IV fluid States that the goal is to compress the uterus between the hand and bony structures behind the uterus (e.g. sacrum/lower back) Demonstrates how to cup the uterus through the abdominal wall to ensure that it stays under the hand Demonstrates how to apply strong pressure toward the patient’s back while massaging with a circular motion States that massaging should not stop until the uterus is contracted (feels hard) States that the uterus should not become relaxed (soft) after uterine massage has stopped. If it does, resume uterine massage States to continuously re-asses for vaginal bleeding and perform frequent vital signs Comments: Skill 6 –Inserting an iv cannula Prepare equipment: gloves, IV cannula, administration set , fluids, IV tourniquet, swab Tell the patient what you are about to do Place IV tourniquet on limb Identify a straight vein Clean the skin over the vein Remove the safety covering and insert the cannula, keeping cannula flat and in line with vein When flashback is achieved, advance needle slightly and then slide cannula over needle into the vein Hold this in place and withdraw the needle while putting pressure over base of cannula Remove the IV tourniquet Flush with saline or connect IV line SKILLS 174 Secure with tape or dressing States to check IV site daily to assess for redness or signs of infection Disposes of any sharps appropriately Comments: Skill 7 – Recognizing conditions requiring IV fluid re-adjustment State the special considerations for fluid resuscitation: malnutrition/severe anaemia/fluid overload State how to assess for fluid overload: difficulty in breathing with crackles on chest exam, lower body swelling (usually in the legs), unable to lie flat due to shortness of breath, distended neck veins State ways to adjust fluids in patients in shock with fluid overload: • Small amounts of fluids (250–500 ml boluses in adults) • Slow the rate of fluids • Monitor closely for signs of worsening fluid overload Verbalize how to assess for signs of severe anaemia State ways to adjust fluids in patients with severe anaemia: • Slow the rate of fluids • Monitor closely for signs of fluid overload State need for rapid handover/transfer to a centre capable of blood transfusion Verbalize how to assess muscle wasting in severe malnutrition Demonstrate how to assess for bilateral oedema in the feet State ways to adjust fluids in patients with severe malnutrition: • Give oral fluids if possible • Add dextrose to IV fluids or give dextrose with IV fluids • Slow the rate of fluids • Monitor closely for signs of fluid overload Comments: Skill 8 – IV fluid resuscitation for shock Verbalize caution in administering IV fluid in a malnourished, anaemic or fluid-overloaded patient Insert an IV cannula as described above Attach the IV cannula to the correct fluid for administration Fluid administration for an adult should be normal saline or Ringer’s Lactate States fluid administration for shock in an adult should be 1L given over <30 minutes AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 175 Assess perfusion, if still in shock, give another 1L bolus over <30 minutes State that, if still in shock after 2 L IV fluids, suspect ongoing blood loss and plan for handover to higher-level care Give mechanism for modifying fluid for an adult if severe malnutrition, severe anaemia or fluid overload is present: give fluid in smaller boluses and re-assess frequently for signs of worsening fluid overload Signs of fluid overload are: Fluid in the lungs and difficulty in breathing • Oedema • Patient is unable to lie flat • Distended neck veins For a child in shock (WITHOUT severe malnutrition, anaemia or overload): • Obtain the child’s weight • Give 10–20 ml/kg normal saline or Lactated Ringer’s over 30 minutes • Re-assess after the bolus, if no improvement, repeat bolus • If shock persists, transfer For a child in shock (WITH severe malnutrition, anaemia or overload): • Weigh the child • State that these children need specialized IV fluids – Ringer’s Lactate with 5% glucose – Half-strength Darrow’s solution with 5% glucose – 0.45% (HALF) normal saline with 5% glucose • Give 10–15ml/kg IV fluid over 1 hour • Re-assess the child every 5–10 minutes while receiving fluids • State if no improvement, transfer Verbalize to stop IV fluid in any patient if signs of fluid overload develop Dispose of any sharps appropriately Comments: Competency demonstrated YES NO Remediation required YES NO Signature of Facilitator: SKILLS 176 4. EXTENDED PHYSICAL EXAMINATION SKILL STATIONS EXTENDED PHYSICAL EXAMINATION SKILL STATION: NEUROLOGIC EXAM Glasgow Coma Scale (GCS) The GCS is a 15-point scale for assessing and monitoring people with head injury. The person is assessed for eye opening, verbal and motor response, and given a score for the highest level of function in each area. The totals are combined to determine the overall score. The lower the score, the more severe the head injury may be. Please note that the lowest score a patient can receive is 3. Severe head injury – GCS 8 or less Moderate head injury – GCS 9–12 Mild head injury – GCS 13–15 Calculating The Glasgow Coma Score (GCS) Glasgow Coma Score (GCS) Function Response Score Eyes (4) Open spontaneously 4 Open to command 3 Open to pain 2 None 1 Verbal (5) Normal 5 Confused talk 4 Inappropriate words 3 Inappropriate sounds 2 None 1 Motor (6) Obeys command 6 Localizes pain 5 Flexes limbs normally to pain 4 Flexes limbs abnormally to pain 3 Extends limbs to pain 2 None 1 AVPU Scale The AVPU scale is a simplified assessment that can give you an indication of level of consciousness by assessing response to stimuli. The AVPU scale is particularly useful for children and infants. • A= Alert. People who are fully awake and interactive (even if not fully oriented) are alert. • V= Voice. Those who are not fully alert before stimulus (may have eyes closed or appear sleepy), but do respond to voice without being touched (the response may be words, moaning or movement). • P= Pain. Those who do not respond to voice, but do respond to pain: hard chest (sternal) rub in adults, pinch to the sole of the foot in children, or pinch to bridge of nose in suspected spinal injury. The response may be words, moaning or movement. • U= Unresponsive. Those who do not make any movement or verbal response to painful stimuli are unresponsive. • For any patient who is P or U on the AVPU scale, stop and return to the ABCDE as rapid intervention may be needed to protect the airway. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 177 EXTENDED PHYSICAL EXAM SKILL STATION: SECONDARY SURVEY TRAUMA ASSESSMENT A secondary survey (head-to-toe assessment) of an injured person is conducted ONLY when the ABCDE has been completed and life-threatening complications have been addressed. The purpose of a head-to-toe assessment is to identify all injuries, plan ongoing management and plan the appropriate disposition. If the person deteriorates during the head-to-toe assessment, stop and re-assess the ABCDE immediately. Ensure clothes have been removed but the person is kept warm with gown, sheet or blanket. For this session use the workbook section on secondary survey from the TRAUMA module. Extended physical examination skill station assessment Skills station marking criteria 1st pass 2nd pass 3rd pass Safety: Personal protective equipment used or verbalized use HEAD-TO-TOE TRAUMA ASSESSMENT Skill 1 – HEENT examination Look at scalp, face, eyes, and in mouth, nose, ears Listen for stridor, gurgling or other airway sounds Feel for abnormal facial bone or jaw movement, loose teeth, or crepitus. Comments: Skill 2 – Neck examination Look for neck wounds, trauma, haematoma or distended neck veins Feel for air in tissue or pain/deformity of the cervical spine Check for reduced ability to move neck or pain Comments: Skill 3 – Chest examination Look for bruising, uneven chest movement, burns Listen for breath sounds, muffled heart sounds Feel for crepitus Comments: Skill 4 – Abdominal examination Look for distension, wounds, bruising, burns Feel for rebound tenderness, guarding, location of pain Comments: SKILLS 178 Skill 5 – Pelvis and genitourinary examination Look for bruising, lacerations, blood, priapism, urine colour Feel for pelvis instability or tenderness Comments: Skill 6 – Extremity examination Look for swelling, bruising, deformity or open fractures, wounds, pale extremity Feel for pulses, cold extremity, tenderness, firm/painful muscle compartments Comments: Skill 7 – spine/back examination Log roll patient with assistance Look for bruising or deformity Feel for tenderness, deformity in spine and scapulae Comments: Skill 8 – Skin examination Look for bruising, abrasions, lacerations, burns Comments: Skill 9 – Neurologic examination Check level of consciousness (AVPU or GCS) Check movement and strength in each limb Check for priapism Check sensation on face, chest, limbs Comments: Competency demonstrated YES NO Remediation required YES NO Facilitator’s signature: AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 179 5. IMMOBILIZATION SKILL STATIONS Approach to spinal immobilization There are two types of spinal immobilization: cervical spine and thoracic/lumbar spine. Together, these are called full spine immobilization. Immobilization stabilizes the bones to avoid further injury to the spine. Provide spinal immobilization to any person with a history of polytrauma who is unconscious; or who is conscious and has neck pain, spine tenderness, numbness or weakness. Remember, immobilized patients cannot move normally and are at a higher risk of airway blockage (by secretions or vomit) and pressure sore development. Monitor closely. IMMOBILIZATION SKILL STATION: CERVICAL SPINE IMMOBILIZATION To immobilize the cervical spine: • Keep the patient flat on his or her back and face up on a level surface such as a bed. • Tell the patient what you are doing. • Hold the patient’s head in line with the spine with two hands on either side of the head. • Prevent the patient’s neck from moving with locally available materials (towel rolls, newspaper, sandbags, or bags of IV fluids) or cervical collar if available. These can be secured to the head with tape (plaster) but should never be secured to the bed. (If the patient vomits, you will not be able to turn him or her and if the patient falls, the tape (plaster) could cause a cervical spine injury.) • If the patient vomits, use the log-roll technique (see below) to turn the whole patient onto his or her side, keeping the head in line with the body. • Keep someone with the patient at all times to watch the airway. • Remember, a patient who has severe pain/injury elsewhere may not be able to feel neck pain, even if there is a fracture. A concerning mechanism should raise suspicion. SKILLS 180 IMMOBILIZATION SKILL STATION: LOG ROLL To move any immobilized patient or anyone with a suspected spine injury (e.g. if the patient has to vomit or needs to be transferred), use the log-roll technique (see figure): • Ask for assistance. Ideally, have one person at the head to hold the neck, one or two people to hold the body and one for the legs. • The provider at the head must keep the head, neck and torso aligned with the rest of the spine. The provider should place their forearms tightly alongside the head with hands gripping the shoulders to keep the head and neck in line with the rest of the spine. Keep this alignment when turning the patient. • The person controlling the head and neck leads the team and will say, “1–2-3 roll” to guide timing of the roll for all assistants. • Working together, roll the patient onto his or her side, keeping the spine in line. • During the roll, the person providing head and neck control must ensure the cervical spine remains aligned with the rest of the spine. The people rolling the body should also ensure that the rest of the spine stays in as straight a line as possible. • When the patient is turned onto one side, a provider can examine the back, place or remove a backboard and/or manage back wounds as needed. • To lie the patient flat again, the person controlling the head and neck uses the “1–2–3 roll” command to ensure coordinated movement. • Always remove a backboard as soon as possible using the log-roll technique. Time on a backboard increases the risk of pressure sores. Check pressure areas frequently using the log roll. Preparing for log roll page 24 Preparing for log roll AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 181 IMMOBILIZATION SKILL STATION: FULL SPINAL IMMOBILIZATION To immobilize the thoracic and lumbar spine (see previous section for cervical spine immobilization): • Immobilize the cervical spine as in previous section. • Keep the person on a flat surface with instructions to lie flat and not to move. • For transport, log roll the patient onto a flat surface (such as a backboard) to prevent movement of the spine. Do not attach the backboard to the bed, as you will be unable to log roll (see above) if needed. • Before immobilizing, be sure there is no glass or debris on or under the patient’s back. Use the log roll to check. Immobilized patients must be checked regularly to avoid pressure point wounds. • If the person needs to vomit, use the log-roll technique to roll the person to the side so that no vomit enters the airway. • Spine boards should ONLY be used to move patients. Leaving patients on spine boards for long periods of time can cause pressure sores. Remove patients from boards as soon as they arrive at the facility and can be laid flat. Spinal immobilization for moving a patient page 25 Spinal immobilization for moving a patient IMMOBILIZATION SKILL STATION: POSITIONING OF THE PREGNANT PATIENT • If a patient is over 20 weeks pregnant and needs spinal immobilization, immobilize the spine as above. Then place padding under the side of the board near the back and hips to tilt the patient onto her left side. This helps to prevent compression of the large internal blood vessels by the pregnant uterus which could decrease blood returning to the heart. SKILLS 182 IMMOBILIZATION SKILL STATION: RECOVERY POSITION • If the patient is unconscious or semiconscious and if there is NO TRAUMA, place the patient on his or her left side. Stabilize the patient by bending the top leg forward. The left arm should be straight with the patient’s head resting on the arm to elevate the head and position the mouth downward. This position will allow for vomit and other secretions to drain from the mouth with less risk of airway obstruction. This is called the recovery position (see figure). Recovery position page 26 Recovery position AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 183 IMMOBILIZATION SKILL STATION: FRACTURE IMMOBILIZATION FRACTURE IMMOBILIZATION Splints are used for immobilizing suspected fractured limbs, preventing pain caused by movement of broken bones and minimizing further bleeding and damage. Always assess and record perfusion of the limb beyond the fracture by assessing pulses and capillary refill time. Always assess pulses, capillary refill and sensation before AND after dressing or splinting any wound. • If no perfusion (limb cold, pale, no pulse, slow or no capillary refill), rapid re-alignment (reduction) of the limb is required to restore circulation. • If there is still no perfusion after re-alignment of the limb, splint and plan for rapid handover/ transfer to a specialist unit. • If you cannot re-align the limb, rapidly handover/transfer to an advanced provider. Goal of fracture management: • Restore circulation • Treat and reduce pain • Prevent further injury and bleeding • Re-align bony fragments so that healing and union can take place and normal function is restored Splinting materials include: • Padding to protect the skin and allow swelling • Pre-formed splint for base or modified local resources • Bandages to secure the splint • Adhesive tape (plaster) Before applying a splint, tell the person what you are doing and give pain relief. • Remove clothing to clearly see the injury. • Remove all jewelry. • Check pulses, capillary refill, sensation and movement of the limb. Document this before and after application of the splint. • Size the splint to immobilize the joint above and below the fracture site. • If the limb is visibly deformed and pulses beyond the fracture are weak or absent, first straighten (reduce) the fracture prior to applying the splint. Do not force realignment of a deformed limb if the limb has a good pulse. • Place the joint in the desired position and if the injury involves fingers or toes, pad between toes and fingers. • If stocking gauze is available, place it over the limb without wrinkles to avoid skin damage. • Pad the side of the splint that will be in contact with the skin, and pad the limb, especially bony protrusions (like the elbow). • Wrap the limb and splint with a bandage to hold the splint. Ask the patient how it feels to ensure it is not too tight. The splint should be secure, but remember that the limb will swell, so it is important that the splint and bandaging are not too tight. • Check pulses, sensation and movement of the limb following the application of the splint and every hour afterward. SKILLS 184 FRACTURE IMMOBILIZATION: OPEN Consider an open fracture if there is a wound near a fracture site. Open fracture sites can often be contaminated and will require cleaning and potentially surgical debridement before the fracture can be fixed. If an open fracture is suspected, plan for handover/transfer to a surgical or orthopaedic unit after splinting. • Give pain relief prior to splinting. • Control haemorrhage with direct pressure. In limb amputation, if bleeding is uncontrolled apply tourniquet (see above), commence fluid resuscitation and plan for rapid handover/transfer. • Straighten (reduce) the limb if there are signs of poor perfusion or absent pulses in the limb. • Remove any dirt, grass, obvious glass or other debris from the wound and irrigate the wound with 2 litres of normal saline. • Cover the wound with saline-soaked gauze. • Splint as above, but leave a window so you can continue to monitor the wound. • In amputation, cover wound with sterile, saline-soaked gauze or towel. • Give tetanus vaccination. • Begin IV antibiotics. IMMOBILIZATION SKILL STATION: APPLYING A PELVIC BINDER Pelvic fractures can cause life-threatening haemorrhage by damaging blood vessels adjacent to the fractures. If a person has been injured and has pain in and around the pelvis, apply a binder (see figures). As the pelvis is shaped in a ring, the binder will bring together the displaced bones and help limit internal bleeding. Signs of pelvic fractures include pain or abnormal movement of the pelvis on exam; bruising around the hips, at the top of legs, or to the genitals; and signs and symptoms of shock. • Place bed sheet or similar under the pelvis. If the bed sheet is wide, fold it over so that it spans from the lower back to the end of the buttocks. • You may need to log roll the patient in order to get the binder in position. • The sheet should be centered over the greater trochanters (hip bones, as demonstrated by the instructor) and firmly cross-over at the front. • Pull firmly and tie, but do not cause the person undue pain. It should feel firm but not overly painful. • Document what time the pelvic binder was applied. • Check the binder each hour. Confirm that the binder is still applying pressure around the pelvis. Ensure that that skin is intact where the binder has been applied and around the genitals. Normal pelvis Open pelvic fracture page 27 Normal pelvis Open pelvic fracture AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 185 Pelvic immobilization page 28 Pelvic immobilization Immobilization skill station assessments Skills station marking criteria 1st pass 2nd pass 3rd pass Safety: Personal protective equipment used or verbalized use Skill 1 – Cervical spinal immobilization Keep the patient lying flat. Tell the patient what you are doing. Hold the patient’s head in line with the spine using your two hands on either side of the head. A partner should use rolled sheets, shoes, or IV fluid bags on either side of the head. May be secured with tape (plaster) but do not secure to the bed. State that if the patient vomits, log-roll technique will be used to protect the airway, keeping the head aligned with the rest of the body. Comments: Skill 2 – Log roll State indications for a log roll. Ask for assistance. Place one person at the head to hold the neck, one or two people to hold the body and one for the legs. The person with head control must hold the cervical spine firmly aligned with the rest of the spine before and during the roll. When the provider at the head and neck instructs, roll the patient onto the side. Use “1–2–3 roll” to guide the roll. The person controlling the head and neck uses the “1–2–3 roll” to return the patient to his or her back. SKILLS 186 State that the patient should be removed from the backboard as soon as possible to prevent pressure sores. Comments: Skill 3 – Full spine immobilization State indication for full spine immobilization. Ask for assistance to help with the movement. Perform log roll on to backboard for transfer. Ensure no glass or debris on or under the patient’s back. Secure patient to backboard device for transfer (Do NOT attach backboard or patient to bed). State to log roll if patient needs to vomit. Skill 4 – Positioning of the pregnant patient Verbalize the indications for positioning (greater than 20 weeks pregnant and needs spinal immobilization). Left lateral position with cervical spine immobilization and a pillow or wedge under the backboard or bed. Comments: Skill 5 – Recovery position Verbalize the indications. Controlled manoeuver into left lateral position ensuring open airway. Appropriately position the patient (top leg bent forward, left arm straight with the patient’s head resting on the arm to elevate the head and position the mouth downward). Comments: Skill 6 – Fracture immobilization Remove clothing to clearly see the injury, remove all jewelry. Check pulses, sensation and movement of the limb and document findings. Size the splint against the limb. Immobilize the joint above and below the injury. Identify special considerations: • Straighten the limb if signs of poor perfusion or absent pulses in the limb. • Control haemorrhage as needed. • Remove debris and irrigate an open fracture wound with 2 L of normal saline. • Cover open fractures with sterile saline gauze. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 187 Place the joint in the desired position. Pad in between toes and fingers if injury involves digits. If stockinette is available, place it over the limb without wrinkles or pad the side of the splint that will be in contact with the skin. Pad the patient’s limb, especially bony prominences. Wrap the limb and splint with a bandage to hold the splint. Check pulses, sensation and movement of the limb following the application of the splint. State patients with an open fracture will require tetanus vaccination, if not up to date, and antibiotics. Comments: Skill 7 – Applying a pelvic binder Identify pelvic pain after trauma. Place bed sheet under the pelvis. If bed sheet is wide, fold it over so that it is the size of the pelvis (lower back to end of buttocks). Push the binder under the small of the back and pull it into position or log roll patient onto binder. Centre over the great trochanters (hip bones) and firmly cross over at the front. Pull firmly and tie, but do not cause the person undue pain. It should feel firm but not overly painful. Document the time the pelvic binder was applied. Comments: Competency demonstrated YES NO Remediation required YES NO Signature of facilitator: SKILLS 188 6. WOUND MANAGEMENT SKILL STATIONS WOUND MANAGEMENT: GENERAL WOUND MANAGEMENT • Haemorrhage control: stop bleeding as above. • Prevent infection: – Clean wound of blood clots, dirt, dead or dying tissue, foreign bodies. – Clean skin around the wound thoroughly with soap and water or antiseptic. – Thoroughly wash out wound by flushing with at least 1 litre of clean water. The water should be under pressure to thoroughly clean the wound. To create a high pressure stream, use a syringe (with 14 g needle or IV catheter attached) or poke a small hole in a clean bottle and squeeze the bottle. Be sure to use the entire litre. – If not vaccinated or not up to date, give tetanus vaccination. • Dressing wounds: – Dress wound with sterile gauze if available. – Use a pressure dressing if the wound is still bleeding. – Check perfusion (capillary refill and/or distal pulses) and sensation beyond the wound before AND after dressing wounds. • Pain management: – Give local anaesthetic before cleaning the wound if staff and equipment are available. – Splint large lacerations and fractures. WOUND MANAGEMENT: BURN MANAGEMENT It is important to cover burns early in order to keep the area moist and reduce the risk of infection. Burns can be very painful so ensure you give pain relief. • Use sterile technique and normal saline to clean the burn. • Carefully remove any loose, dead skin and broken, tense or infected blisters. • Apply a non-adherent dressing to the burn to provide a moist healing environment. Clean clear plastic wrap can be used over the burn as an interim measure and if you are transferring the person to a surgical unit shortly. • Ensure the entire burn is covered with the dressing. • If the person has presented with an old burn that is now infected, apply a topical antibiotic (such as bacitracin or silver sulfadiazine). This person may also require IV or intramuscular antibiotics. • If there is delay in handover or transfer, ensure the dressings are changed daily. Always give pain control with dressing changes. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 189 ADULT BURN MANAGEMENT: DETERMINE TOTAL BODY SURFACE AREA (TBSA) This is used to calculate the fluids needed using the Parkland Formula. Use the Rule of Nines body chart for adults and modified chart for children and infants (see figure). The body is divided into portions that each make up 9% of the total body surface. Children have different percentages due to the different body proportions, such as a larger head and smaller limbs (see figures). • Assess the person using the diagram below. • Note the areas of burn and shade them in on the diagram. • Next to where you are shading, write the burn depth (see burn depth estimate below). • Once you have marked the diagram (front and back) with all the burns you have assessed on the person, add the percentages. • This will give you the total burn surface area (TBSA). Burn surface area in adults 4.5%4.5% 18% 18% 9% 9%9% 9% 4.5%4.5% 4.5% 4.5% 1% page 29 Burn rface area in adults SKILLS 190 Burn surface area in children 13% A D C B C B F E F E 2% 2% 2% 2% 13%2% 2% 2% 2% 1% 2% 2% 2% 2% 1% 1% 1% 1% page 30 Area Head (A/D) Thigh (B/E) Leg (C/F) 10% 3% 2% 7% 4% 3% 6% 5% 3% 9% 3% 3% By age in years 0 1 5 10 Burn surface area in children PAEDIATRIC BURN MANAGEMENT: DETERMINE TOTAL BODY SURFACE AREA (TBSA) Area By age in years 0 1 5 10 Head (A or D) 10% 9% 7% 6% Thigh (B or E) 3% 3% 4% 5% Leg (C or F) 2% 3% 3% 3% BURN MANAGEMENT: ESTIMATE DEPTH OF BURN The best way to estimate burn depth is by gently pressing two fingers onto the burn to assess capillary refill. • Put gloves on. • With care, press down on the centre of the burn with two fingertips for 3–4 seconds, and then let go. The faster the capillary refill the more superficial the burn is. • Now assess the outer edge of the burn (burn depth can vary for different areas of the burn). • Use the chart below to guide your assessment findings. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 191 Burn type Skin findings Superficial (formerly first degree) • Red or pink • Painful, skin intact, no blisters • When pressed, skin is pink with quick capillary refill Partial thickness (formerly second degree) • Red or mottled red • Intact or broken blisters, wet • Painful • May temporarily turn white when pressed then red colour returns Full thickness (formerly third degree) • White or black • Leathery and dry • No sensation • When pressed, no change in colour BURN MANAGEMENT: FLUID RESUSCITATION IN BURN INJURY As discussed in the TRAUMA module, an adult or child with a burn injury may require fluid resuscitation. Start fluid resuscitation in the following cases: • Full or partial thickness burns greater than or equal to 15% total burn surface area in adults. • Full or partial thickness burns greater than or equal to 10% total burn surface area in children. BURN MANAGEMENT: PARKLAND FORMULA CALCULATION FOR THE FIRST 24 HOURS 4 ml IV fluid X weight in kilograms X % total burn surface area* *% total burn surface area = % partial thickness burn area + % full thickness burn area (% superficial burn area is NOT used in the calculation) The Parkland Formula is a fluid resuscitation management strategy for the initial 24 hours following a burn. Patients presenting beyond 24 hours after the initial burn will also need fluid resuscitation, but the Parkland Formula is not used beyond 24 hours. • The first half of the fluid should be given within the first 8 hours after the burn (NOT after arrival to care). • The second half is to be given over the subsequent 16 hours. • For adults, give normal saline or Ringer’s Lactate. • For children, use a dextrose-containing fluid (Ringer’s Lactate with 5% dextrose or normal saline with 5% dextrose for initial resuscitation). If no dextrose-containing fluids are available, give an additional dose of dextrose (either IV or orally) with IV fluids (see MEDICATIONS). For ongoing care of children, the Parkland emergency resuscitation fluids calculated above MUST BE ADDED to any required maintenance fluids based on hospital care protocols (see WHO Pocket book of hospital care for children, 2013). Your facilitator will review examples using the Parkland Formula. REMEMBER: Patients with serious burns to >15% of their body, burns involving the hand, face, groin area, joints, or burns that go completely around the body or a body part need to be transferred/ handed over for specialized care. SKILLS 192 WOUND MANAGEMENT: SNAKE BITE BANDAGING AND IMMOBILIZATION Note: When possible, take a picture of the snake and send with the patient. Immobilizing a limb after a snake bite is important to reduce movement and absorption of venom. • Always assess pulses, capillary refill and sensation before and after dressing or splinting any wound. • You may choose to use a broad pressure bandage and wrap upwards from the lower portion of the bite. The bandage should be firm, but should not cut off pulses in the limb. Extend the bandage as high up the limb as possible. – This is recommended if the snakes in your area produce a toxin that damages the nerves, causes paralysis, causes the person to become very ill or if there will be prolonged transport time. – This is NOT recommended if the snakes in your area produce toxins that primarily cause tissue damage near the wound and do not cause body-wide symptoms. • Bind a splint to the limb to immobilize as much of the limb as possible. • Note the time the bandage was placed. • Keep the person still and lying down. • DO NOT put a tourniquet around the snake bite or limb. • DO NOT cut the bite out as this will lead to unnecessary bleeding. • DO NOT suck on the bite to remove the venom. Wound management skill station assessments Skills station marking criteria 1st pass 2nd pass 3rd pass Safety: Personal protective equipment used or verbalized use SKILL 1– General wound management Haemorrhage control: stops bleeding as per earlier taught skill. Preventing infection Cleans wound of blood clots, dirt and foreign bodies. Cleans skin around the wound thoroughly with soap and water or antiseptic. Thoroughly washes out wound by flushing with water (state 1 litre of clean water or more). Gives tetanus vaccination as needed. Dressing wounds Assesses pulses, capillary refill and sensation before dressing or splinting any wound. Dresses wound with sterile gauze if available. Applies pressure dressing if the wound is still bleeding. Checks perfusion beyond the wound (capillary refill and/or distal pulses) before and after dressing wounds. Pain management AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 193 Gives local anaesthetic before cleaning the wound if staff and equipment are available. Splints large lacerations and fractures. Assesses pulses, capillary refill and sensation after dressing or splinting any wound. Comments: BURN MANAGEMENT Skill 2 – Burn wound management Uses a sterile technique and normal saline to clean the burn. Removes any loose, dead skin and broken, tense or infected blisters. Applies a non-adherent dressing to the burn to provide a moist healing environment. Ensures the entire burn is covered with the dressing. Considers antibiotics. States transfer or handover plan. Comments: Skill 3 – Fluid resuscitation in burn injury Correctly states indications: • Partial or full thickness burns greater than or equal to 15% total burn surface area in adult. • Partial or full thickness burns greater than or equal to 10% total burn surface area in children. Estimates depth of burn. Determines total body surface area (TBSA). Calculates Parkland Formula. Explains delivery of fluids. (First half in first 8 hrs; second half in next 16 hrs) Chooses correct fluid for initial bolus. (Children weighing less than 20 kg: Ringer’s Lactate with 5% dextrose, normal saline with 5% dextrose) Comments: Skill 4: Snake bite bandaging and immobilization Uses a broad pressure bandage and wrap upwards from the lower portion of the bite. Extends the bandage as high up the limb as possible. SKILLS 194 Immobilize as much of the limb as possible with a splint. Notes the time the bandage went on. Keeps the person still. States DO NOT put a tourniquet around the snake bite or limb. States DO NOT cut or suck on the bite wound. Comments: Competency demonstrated YES NO Remediation required YES NO Facilitator’s signature: 7. Medication administration skill discussion The table below summarizes the medications discussed in this course, which represent only a very basic set of treatments for emergency conditions. They have been included based on their wide availability, their appropriateness for use by all of the frontline providers targeted by this course, their feasibility of use in pre-hospital or facility settings, and for their potential importance as early treatments for emergency conditions. Be sure to check locally available drug concentrations, as these can vary. The most common concentrations are used in this table for dosing reference. Almost every condition discussed will require additional treatments beyond these, and many important emergency treatments that may be used by advanced providers are not included here. Table: Medications used in the Basic Emergency Care course Drug indication Dosage Adverse effects Adrenaline (Epinephrine) Anaphylaxis/severe allergic reaction and severe wheezing [see ABCDE, DIB] Solution: 1 mg in 1 ml ampoule (1:1000) Note: • The doses below are for intramuscular not IV administration. • The preferred site for injection is the outer mid-thigh. Adults: Intramuscular(IM): 50 kg or above: 0.5 mg IM (0.5 ml of 1:1000) 40 kg: 0.4 mg IM (0.4 ml of 1:1000) 30 kg: 0.3 mg IM (0.3 ml of 1:1000) • May repeat at 5-minute intervals Paediatrics: Anaphylaxis: 0.15 mg IM (0.15 ml of 1:1000), repeat every 5–15 minutes as needed Severe asthma: 0.01 mg/kg IM up to 0.3 mg, repeat every 15 minutes as needed • Anxiety/fear • Palpitations • Tachycardia (elevated heart rate) • Dizziness • Sweating • Nausea • Vomiting • Hyperglycaemia (elevated blood glucose) • Chest pain • High blood pressure • Tissue necrosis at injection site AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 195 Drug indication Dosage Adverse effects Antibiotics Specific drugs in this category will be determined by local treatment protocols and availability. These should include a broad-spectrum regimen for life-threatening infections that can be used empirically (before the infectious source is definitively identified) in very ill patients. • Allergic reactions • Gastrointestinal upset • Other specific effects vary by antibiotic Acetylsalicylic acid (Aspirin) Suspected heart attack Tablet: 100 mg, 300 mg Oral: 300 mg (preferably chewed or dispersed in water) given immediately as a single dose. Do NOT give aspirin until evaluated by an advanced provider if there is: 1. any active bleeding, or 2. chest pain that is sudden, maximum at onset, sharp and tearing, and radiating to the back (can indicate a tear in the aorta). • Gastrointestinal irritation with blood loss • Tinnitus • Anaphylaxis Benzodiazepines – Diazepam Seizures/convulsions [see AMS] Tablet: 2 mg, 5 mg Solution: 5 mg/1 ml ampoule Adults: First dose: 10 mg slow IV push OR 20 mg rectally Second dose after 10 minutes: 5 mg slow IV push or 10 mg rectally Maximum IV dose: 30 mg Children: First dose: 0.2 mg/kg slow IV push or 0.5 mg/kg rectally. Can repeat half of first dose after 10 minutes if seizures/convulsions continue. Maximum IV dose: 20 mg Do not give second dose if respiratory rate is less than 10 breaths per minute. Do not give diazepam intramuscularly (unpredictable absorption). How to give rectal diazepam: • Draw up the dose from an ampoule of diazepam into a small syringe (tuberculin if available). Base the dose on the weight of the child, when possible. • Remove the needle. • Insert the syringe 4–5 cm into the rectum, and inject the diazepam solution. • Hold the buttocks together for a few minutes. • Sedation • Respiratory depression • Low blood pressure • Bradycardia (low heart rate) • Nausea and vomiting • Abdominal cramps SKILLS 196 Drug indication Dosage Adverse effects Glucose (dextrose) Hypoglycaemia (low blood sugar) [see ABCDE, ALTERED MENTAL STATUS] Solution: 50% dextrose (D50), 25% dextrose (D25), 10% dextrose (D10) NOTE: Dextrose should NEVER be given intramuscularly as it may cause serious tissue damage. Adults and children greater than 40 kg: 25–50 ml IV of D50, or 125–250 ml IV of D10 Children up to 40 kg: 5 ml/kg IV 10% dextrose (D10) • Hyperglycaemia (high blood glucose) • Dizziness • Skin necrosis if injected outside the vein D10 is preferred in children under 40 kg. If D10 is not available, you can use the Rule of 50 to remember the equivalent amount of dextrose in another solution. All of the following contain the same amount of dextrose: 5 ml of D10 2 ml of D25 1 ml of D50 If no IV access: Place 2–5 ml of 50% dextrose in buccal space (inside the cheek) OR Give sugar solution (1 level teaspoon of sugar moistened with water every 10–20 minutes) in buccal space AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 197 Drug indication Dosage Adverse effects Magnesium sulphate Eclampsia or pregnant with seizure/convulsion [see ALTERED MENTAL STATUS] Solution forms: 1 g in 2 ml ampoule (50%) 5 g in 10 ml ampoule (50%) To give IV, make a 20% solution: *add 3 ml of sterile saline to the 2 ml ampule OR *add 15 ml of sterile saline to the 10 ml ampoule. Loading dose (IV + IM): * 4 g IV (dilute to a 20% solution and give 20 ml slowly over 20 minutes) AND *10 g IM (intramuscular): 5 g (10 ml of 50% solution) with 1 ml of 2% lidocaine in upper outer quadrant of each buttock. Magnesium can cause low blood pressure; monitor carefully. IF unable to give IV, give 10 g IM injection only (as above, 5 g in each buttock). If seizures/convulsions recur: after 15 minutes give an additional 2 g (10 ml of 20%) IV over 20 minutes. If transport delayed, continue treatment: Give 5 g of 50% solution IM with 1 ml of 2% lidocaine every four hours in alternate buttocks. • Low blood pressure • Respiratory depression • Drowsiness • Confusion • Loss of reflexes • Muscle weakness • Nausea • Vomiting • Flushed skin • Thirst STOP if: • Respiratory depression (respiratory rate <16) develops. Toxicity: • Low blood pressure • Respiratory depression • Loss of knee jerk • Urine output <100 ml/4 hours Naloxone Opioid overdose [see ABCDE, ALTERED MENTAL STATUS, DIFFICULTY IN BREATHING] Solution: 400 mcg/ml (hydrochloride) in 1 ml ampoule IV: 100 mcg single dose OR IM: 400 mcg in single dose May repeat every 5 minutes as needed. May require continuous infusion at 0.4 mg/ hour for several hours for long-acting opioids. • Hypertension (high blood pressure) • Cardiac arrhythmias • Hyperventilation • Difficulty in breathing • Agitation *** Naloxone effects only last 1–3 hours. Many opioid medications are longer- acting and may need more doses of naloxone or a naloxone infusion. Any patient treated with naloxone must be monitored closely*** SKILLS 198 Drug indication Dosage Adverse effects Oxytocin Treatment of postpartum haemorrhage Solution: 10 IU in 1 ml ampule Initial dose: Give 10 IU IM AND start IV fluids with 20 IU/L at 60 drops/minute. Once the placenta is delivered, continue IV fluids with 20 IU/L at 30 drops/minute if still bleeding. If placenta has to be manually removed or uterus does not contract: Repeat 10 IU IM. Continue IV fluids with 20 IU/L at 20 drops/ minute for 1 hour after bleeding stops. Max Dose: 3 L of IV fluids containing oxytocin. • Nausea/vomiting • Headache • Rash • Anaphylaxis • Uterine spasm (at low doses) • Uterine hyperstimulation (at high doses) Paracetamol (acetaminophen) Mild to moderate pain, fever and headache Tablet: 250 mg, 500 mg Rectal suppositories: 250 mg, 500 mg Adults: 500mg – 1 g every 6 hours Max 4 g daily or max 2 g daily if liver impairment, cirrhosis Children: 10–15 mg/kg up to six times a day • Rash • Liver damage following overdoses Salbutamol (albuterol) Severe wheezing [see ABCDE, DIFFICULTY IN BREATHING] Where available, can use nebulizer with appropriate dose. Inhaler: 100 mcg per puff Inhaler with spacer Adult: Prime with five puffs and give two puffs via spacer every two minutes until improved. Child: Prime with five puffs and give two puffs into spacer. Keep spacer in the child’s mouth for three to five breaths. Repeat until six puffs of the drug have been given to a child < 5 years or 12 puffs for > 5 years of age. Repeat regularly until condition improves. In severe cases, 6 or 12 puffs can be given several times in an hour. • Palpitations • Fine tremor • Headache • Tachycardia (high heart rate) Remember: child must be able to seal mouth around spacer opening. Babies will likely require spacer mask or nebulizer. Nebulizer: (ADULT) 5mg in 5 ml sterile saline. (CHILD) 2.5mg in 3 ml sterile saline. For severe wheezing, above doses can be given several times in an hour. Tetanus vaccination Solution: 5 units per 0.5 ml IM 0.5 ml Give to all injured children whose vaccinations are not up to date and in all adults who have not had this vaccination in the past 5 years. If immunization status is unknown, give vaccination. • Pain to injection site • Allergic reaction • Fever • Nausea AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 199 8. Transfer and handover skills discussion This course is intended for providers working in the field, on ambulances and in health-care facilities. Transferring patients from the scene to first facility, or between facilities, require special attention to destination planning, ongoing management and handover. DESTINATION PLANNING Many patients treated on the scene will require transport to a health-care facility for further management. Additionally, patients already at a facility may require transfer to a different facility for more advanced care. For example, a pregnant woman with seizures will need handover for advanced care and emergency delivery; a patient with severe burns will require transfer for advanced airway management and surgical care; a patient in shock from blood loss will require handover to a centre capable of blood transfusion. When planning any transport, make sure that: the level of services at the destination facility matches the needs of the patient (e.g. there is an operating theatre if surgery is needed); that the expected resources are currently available (e.g., the operating theatre is running, and there is blood for transfusion); and that the destination can be reached in the necessary time frame given the patient’s condition. Do not delay transport for tests or interventions that are not critical to patient safety if they can be performed at the receiving facility. Follow local transfer and destination protocols where they exist. Where there are no clear protocols, balance transport times with facility capabilities – the goal is to reach needed care as soon as possible. It is usually better to have a longer initial transport time than to arrange a second transfer because appropriate care was not available at the first destination. Once the appropriate facility has been determined, communication with a provider at the receiving facility is essential (see ‘Handover’ below). This will allow the receiving centre to prepare for the patient’s arrival and arrange resources (e.g. blood, operating theatre preparation). Follow specific local communication protocols where they exist. Wherever possible, formal protocols for both pre-hospital transport and transfer between facilities should be in place. These should include explicit criteria for when a patient should be transferred. TRANSPORT Transfer includes two aspects: transporting the patient and caring for the patient at all times during transport. One person cannot do both jobs. During transport, at least one provider should always be in the same part of the vehicle as the patient to allow for ongoing monitoring, assessment and management. The ABCDE approach should be used to assess and re-assess ALL patients during transportation; vital signs (including AVPU or GCS) should be checked every 15 minutes, and patients should be closely monitored for response to treatments and for signs of worsening. Remember to plan overall transportation time and route, and check road conditions and weather. This is essential in order to anticipate the patient’s needs during transport (e.g. IV fluid and medication needs). Ensure that the patient and family are aware of the transport plan. Allow a family member to accompany children whenever possible. SKILLS 200 HANDOVER Formal handover should be given any time care is transferred to a new provider, including: between providers within a facility, to or from transport providers, or remotely from a sending facility to a receiving facility provider. In addition to a verbal report at the time a patient is handed over to a new provider, written documentation of the clinical condition and treatment should accompany the patient at all times. You will practise handover summaries throughout the course in the case scenarios. The Situation, Background, Assessment, Recommendations (SBAR) format is a structured way of communicating key information and can be used for all of the handovers mentioned above. SBAR components and examples are: SITUATION Basic patient information (e.g. age, sex). Chief complaint (the patient’s initial description of the problem, such as difficulty in breathing for 3 days, or arm pain after a fall, etc.). BACKGROUND The 2–4 most important and relevant aspects of the patient’s case and/or condition (these may be elements of the history, physical exam, or testing results, depending on the case). Include any important ABCDE findings/interventions. ASSESSMENT What you think is wrong with the patient. The reason for the handover/transfer. RECOMMENDATIONS Specific things the new provider should prepare for: – next steps in the treatment plan; – potential worsening of the patient’s condition (e.g. need for close airway observation if inhalation burn is suspected); – cautions regarding prior therapies or interventions (e.g. time of last adrenaline dose to anticipate return symptoms, need to monitor mental status if sedating medications have been given, need to monitor 3-way dressing for clotting, etc.). Examples: Case 1: A 22 year-old man was riding a motorcycle when he crashed into another vehicle at high speed. He was thrown from his motorcycle and was not wearing a helmet. His airway is open; he has normal breath sounds on both sides of his chest; his pulses are strong and around 90 beats per minute; he is only responsive to pain and has a femur fracture with bone visible in an open wound; there are abrasions on his forehead. You have immobilized his spine, started an IV and splinted the fracture. You and your colleague have transported him from the scene of injury and are handing him over to a hospital provider. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 201 Handover summary: This is a 22-year-old man who was in a motorcycle crash, was not wearing a helmet and was thrown from his motorcycle; he is only responsive to pain and has an open femur fracture, but is currently protecting his airway and has no evidence of shock. We are concerned for his altered mental status, and open femur fracture, but are unable to tell if he has a spinal injury. He needs transfer for surgical management and further neurological assessment. Spinal immobilization should be maintained and he should be monitored for worsening bleeding and mental status changes. Case 2: A 14-year-old girl had a seizure/convulsion at school. She was brought to you by her teachers because she did not stop seizing. You administered a benzodiazepine, which caused the seizures to stop. After, you were able to perform the ABCDE survey and then a complete head-to-toe exam. She does not have a fever; she has a normal heart rate, blood pressure, and respiratory rate. She responds to voice. Her tongue is bitten and she urinated on herself; she has no other injuries or rashes. Handover summary: This is a 14-year-old girl who had a prolonged convulsion and was convulsing on arrival; her seizures were stopped with one 10 mg dose of diazepam and now she remains sleepy, has normal vital signs and no fever. She is being transferred for further evaluation of her seizure. Monitor the airway as she has received sedating medications (diazepam). Case 3: A 75-year-old man had chest pain while walking home from the market. He was brought to you by taxi. He says that the chest pain started 30 minutes ago and felt like a lot of pressure in the centre of his chest. He has no allergies. He takes a blood pressure medication, but cannot recall the medication’s name. He had a heart attack 2 years ago that felt very much like the pain he was having today. His last meal was 6 hours ago. The pain started while he was walking home carrying several heavy bags, though he now has no pain. His vital signs, ABCDE survey, and head-to-toe examination are normal. You have given aspirin and started an IV line and will now handover to an inpatient provider. Handover summary: This is a 75-year-old man with a history of a heart attack who has had chest pain similar to his prior heart attack. The pain started while he was walking and lasted for more than 30 minutes, but is now gone. He has received aspirin and has an IV line. I am concerned he might have problems with his heart. He should be monitored for change in ABCDE or return of the chest pain. 202 Notes ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE GLOSSARY REFS & QUICK CARDS 203 PARTICIPANT WORKBOOK GLOSSARY ABCDE The initial steps of any patient assessment, which includes assessing and treating Airway, Breathing, Circulation, Disability and Exposure. Accessory muscle use Use of muscles other than the diaphragm to assist in breathing (commonly the neck, chest wall, and abdominal muscles). May appear as indrawing/retractions between the ribs, or in the neck muscles. Altered mental status (AMS) Term used for a range of presentations from changes in behaviour or memory, to disorientation, confusion and coma. AMS See altered mental status. Anaemia Decreased concentration of red blood cells, leading to a decreased ability to carry oxygen. Anaphylaxis A severe allergic reaction that can cause shock. Asthma A condition causing mucus production and intermittent spasm in the bronchial airways, resulting in narrowing that causes wheezing. AVPU A system to assess level of consciousness: Alert, Verbal, Pain, and Unresponsive. Bag-valve-mask (BVM) device A manual handheld device consisting of an air-filled bag connected to a mask. The bag is compressed by hand to deliver a breath as the mask is held to the patient’s face. Bolus A defined volume of fluid or other substance given rapidly, usually intravenously. Bradycardia Heart rate lower than normal range. BVM See “bag-valve-mask device”. GLOSSARY 204 Capillary refill A marker of perfusion, checked by pushing on the fingernail, palms or soles and releasing to see long it takes for the colour to come back to the skin (blood flow to return). The normal range is less than 3 seconds. Cardiopulmonary resuscitation (CPR) Performing chest compressions and ventilation with the goal of resuscitating a patient with no pulse. Cervical spine (C-spine) The part of the spine in the neck, containing the first seven vertebrae. Circumferential burn Burns that extend around a body part can act like a rigid band and may limit blood supply (to a limb) or breathing (burn around the chest or abdomen). Cholera Bacterial infection causing a profound watery diarrhoea, often described as rice-water stools. Chronic obstructive pulmonary disease (COPD) Term describing breakdown of lung structure (emphysema) and chronic inflammation causing spasm of the lower airways and wheezing. Coma Prolonged state of unconsciousness. Compartment syndrome A condition of increased pressure from swelling in an area of the body that cannot expand, such as compartments in the forearm or lower leg. Compartment syndrome reduces blood flow to the area and may result in severe pain as well as damage to nerves and other tissues. Confusion Problems with clarity, recall and organization of thought. Convulsion See Seizure. CPR See cardiopulmonary resuscitation. Crackles High pitched sound, like crumpling of a paper bag, heard with a stethoscope. Crackles are caused by fluid in the airspaces of the lungs. Also called rales or crepitations (creps). SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 205 Crepitations See “Crackles”. Crepitus Crackling or popping when pressing on the skin or bones. Cyanosis Blue colouring to the skin or lips, resulting from low blood oxygen levels. Decontamination Removing a dangerous substance, such as chemicals, toxins or infectious materials, from a person’s skin or clothes. Depending on the substance, this is done by brushing off the substance or irrigating with water. Deep wound packing Tight packing of a large or gaping wound with clean, compact gauze to ensure that external pressure can effectively compress an area of bleeding that is too large or too deep to compress otherwise. Defibrillator Machine that delivers high-energy electrical current to convert abnormal heart rhythms. Dehydration Decreased fluid in the body. Delirium Rapidly changing state of confusion, characterized by agitation, loss of focus and inability to interact appropriately. Dementia Chronic condition characterized by abnormal mental state, including loss of memory and problems with thinking. There is often no change in ability to focus on the present. Destination planning Planning the choice of destination facility for transport or transfer in order to best match transport time and the level of services available at the receiving facility to the patient’s clinical needs. Diabetic ketoacidosis (DKA) A condition occurring in diabetics in which lack of insulin causes elevated blood sugar, leading to severe dehydration and build-up of acid in the blood. Diaphoresis Sweating. DIB See difficulty in breathing. GLOSSARY 206 DKA See Diabetic Ketoacidosis. Dilation (of blood vessels) The enlargement or stretching of a part of the body (e.g. blood vessels). Difficulty in breathing (DIB) The feeling of difficulty in breathing (sometimes also called shortness of breath, or SOB) can result from many causes, including problems with the lungs, problems with oxygen, airway blockage, fast breathing, weak respiratory muscles. Direct pressure A way to control external bleeding (haemorrhage) from a wound by applying firm pressure with two or three fingers at the site of bleeding. Disposition The next step in care of a patient – this may be handover of care to another provider through admission or transfer, or discharge to home. Drowning Compromise of breathing from water in the lungs, usually resulting from prolonged time under water. Eclampsia A condition when a pregnant or newly delivered woman has seizures, high blood pressure, and protein in the urine. It can progress to coma and is life-threatening. (“Pre-eclampsia” is diagnosed based on specific criteria and identifies a woman at high-risk of progression to eclampsia.) Ectopic pregnancy A pregnancy outside of the uterus, most often in the fallopian tubes. As an ectopic embryo grows, it may damage the surrounding structures, causing sudden severe bleeding. Ruptured ectopic pregnancy is a surgical emergency. Envenomation The process by which venom is injected by the bite (or sting) of a venomous animal. Escharotomy A surgical procedure to cut and release burned tissue that may restrict breathing or blood supply to a limb. Flail chest When multiple rib fractures in more than one place cause a segment of the rib cage to be separated from the rest of the chest wall and prevent normal breathing movement. SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 207 Fluid status The level of fluid in the body. It can be low (dehydration), normal, or high (fluid overload and/ or oedema). Fontanelle A gap (soft spot) between the developing bones of the skull in babies – changes in the volume of fontanelles may reflect fluid status. Fontanelles normally close between 12 and 18 months of age. Foreign body An object from outside the body (e.g. a foreign body in the airway). Fracture A broken or cracked bone. GCS See Glasgow Coma Scale. Gastroenteritis Infection or inflammation of the stomach and intestine that can cause vomiting, diarrhoea and abdominal pain. Glasgow Coma Scale (GCS) A system of assessing the neurologic function of a trauma patient. It is a score ranging from 3 (unresponsive) to 15 (normal) that assesses responsiveness based on eye movement, verbal response and motor response. Guarding Voluntary or involuntary contraction of the abdominal wall muscles when pressing on the abdomen. Handover A brief summary of critical patient information given by the current provider any time a patient is transferred to a new provider. Handover summarizes the clinical presentation, the care the patient has received, and alerts the new provider of any potential complications. Handover should always be given to transport providers, in addition to receiving-facility providers. Handover should also be given even when care is transferred to a new provider within the same facility. Haemorrhage Large volume bleeding. It may occur externally or within the body. Haemorrhagic shock A state of poor perfusion due to substantial blood loss. GLOSSARY 208 Haematoma Bleeding or a collection of blood within the tissues, outside of the vascular space. Also called bruising. Haemothorax Blood in the space between the chest wall and the lungs. Heart attack (Also called myocardial infarction). Death of heart muscle due to a lack of oxygen-rich blood getting to the heart. Heart failure When the heart fails to pump enough blood to perfuse the organs, usually resulting in oedema in the lungs or extremities. Hives Multiple itchy, red and raised areas on the skin suggestive of an allergic reaction. Human Immunodeficiency Virus (HIV) A virus that weakens the immune system and can lead to AIDS, a syndrome of multiple infections. Hyperthermia High body temperature. Hyperventilation Increased (fast) rate of breathing. Hyperresonance Hollow sounds with percussion. Hypoglycaemia Low blood sugar. Hypothermia Low body temperature. Hypotension Blood pressure lower than the normal range. Hypovolaemic shock Poor perfusion due to low blood volume, which may result from decreased fluid intake or severe fluid or blood loss. Hypoxia Low levels of oxygen in the blood. SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 209 Inflammation Redness and swelling that may result from trauma, infection, allergy or other causes. Ingestion Swallowing a substance – generally used for dangerous substances or doses. Inhalation injury Inflammation or oedema of the airways or lungs resulting from breathing hot gases or irritating chemicals (most commonly smoke inhalation in the setting of fire). Intubation Placing a breathing tube through the mouth, down the throat, and through the vocal cords to allow ventilation of the lungs by bag device or ventilator. Ischaemia Inadequate oxygen and blood supply to tissues that can lead to tissue death (myocardial ischaemia, or lack of oxygen to the heart muscle, is an example). IV (abbreviation for intravenous) Often used to refer to an intravenous catheter, or for the intravenous route of administration of a medication or fluid. Kangaroo care Using skin to skin contact between a newborn infant and mother and covering the child’s head and exposed body, to prevent hypothermia and promote bonding. Laceration A cut or slice to the tissues. Large-bore IV A large IV catheter is needed for rapid volume resuscitation. Ideally, these catheters should be placed in larger blood vessels (that tend to be closer to the heart, like the antecubital fossa in the arms or large veins in the neck). In adults, this is usually defined as 14- or 16-gauge, though in some settings, 18 may be the largest available gauge. Level of consciousness Describes the level of responsiveness or alertness to the environment. Lethargy Excessive drowsiness and slowness to respond. Log roll A method of rolling a person to the side while preventing the spine from bending. Usually performed when spinal injury is suspected to prevent additional damage. GLOSSARY 210 Nasal flaring The widening of nostrils during breathing – it results from increased effort, and is a sign of difficulty in breathing. Nasopharyngeal airway (NPA) A rubber tube inserted through the nostril that reaches to the opening of the throat to allow air to pass. Needle decompression Insertion of a needle into the chest wall to relieve the pressure of a tension pneumothorax. Oedema Abnormal swelling or fluid build-up in the body tissues, outside the vascular space. Oral rehydration solution (ORS) A water, glucose, and salt mixture given by mouth or nasogastric tube to dehydrated patients to replace fluid losses. Orientation Describes a person’s relationship to the surrounding world, including the ability to accurately identify one’s own name and location, as well as the current time and date. Oropharyngeal airway (OPA) A plastic device inserted through the mouth that reaches to the opening of the throat to prevent the tongue from blocking the airway and allows air to pass. ORS See “Oral rehydration solution”. Oxygen (O2) saturation Percent of oxygen in the blood. Parkland Formula A formula used to estimate the amount of IV fluid needed for resuscitation of a burn patient over the first 24 hours after the burn. It is: 4 ml fluid X weight in kilograms X total burn surface area. Half should be given over the first 8 hours, and half over the next 16 hours. Percussion Tapping on the chest wall to assess the lungs. The quality of the sound on tapping may indicate fluid or air in the lungs. Perfusion The delivery of blood to body tissues. Pericardial effusion Fluid in the sac around the heart (the pericardium). SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 211 Pericardial tamponade A critical build-up of fluid in the sac around the heart (the pericardium) that compresses the heart and interferes with normal pumping of blood to the body, leading to shock. Personal protective equipment (PPE) Equipment meant to be worn by a person to protect from infection or injury. This can include gloves, goggles, and protective clothing such as aprons or fluid resistant gowns. Pleural effusion Abnormal fluid collection around the lung that can cause difficulty in breathing and even lung collapse. Common causes include tuberculosis and other infections, heart failure and cancer. Pleuritic pain Pain that is worse with breathing, usually caused by inflammation. Pneumonia Infection of the lungs. Pneumothorax Air in the space between the lungs and the chest wall (pleural space) that causes the lung to collapse. Pre-eclampsia See Eclampsia. Priapism Persistent, abnormal erection of the penis. Psychosis Broadly defined as loss of contact with reality. Pulmonary embolism Blood clot travelling to and blocking the vessels of the lungs. The most common source is the legs. Pulse oximeter Device that detects oxygen saturation (the percentage of red blood cells saturated with oxygen). Rabies A virus that is transmitted through animal bites that affects the brain and nerves and can cause altered mental status. Rebound tenderness Pain that occurs when releasing pressure on the abdomen (as opposed to when pressing on the abdomen). GLOSSARY 212 Resuscitation Time-sensitive interventions performed in an attempt to manage life-threatening conditions. Retractions (sometimes also called “in-drawing” or “recessions”) The visible pulling in of tissues between the ribs or around the collarbones with strained inspiration. Retractions are a sign of serious difficulty in breathing. SAMPLE history An approach to asking key history findings for all patients. SAMPLE stands for: S – Signs and Symptoms, A – Allergies, M – Medications, P – Past history, L – Last oral intake, E – Events surrounding the illness or injury. Seizure Also called convulsions or fits. Abnormal electrical activity in the brain, often seen as altered mental status with abnormal repetitive movements. Seizures may be a primary condition or may be caused by infection, injury, toxins or chemical balance problems. Shock A state where organs do not get enough blood and oxygen (poor perfusion), leading to organs not working properly. Skin pinch testing An easy way to check hydration status in children by pinching the skin, usually on the abdomen. Well-hydrated skin should return to normal in less than 2 seconds. Sprain A stretched, pulled, or torn ligament. Stridor A high pitched sound on breathing in that is caused by swelling or a physical obstruction of the upper airway. Stroke Death of brain tissue due to ischaemia from either blood clot or haemorrhage. Sucking chest wound A wound in the chest wall that allows air in and out of the chest cavity, indicating an open pneumothorax. Tachycardia Heart rate faster than normal range. Tachypnoea Rapid breathing. SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 213 Tension pneumothorax Occurs when a pneumothorax causes sufficient pressure inside the chest cavity that blood vessels collapse (reducing the amount of blood that can return to the heart, and the heart cannot fill or pump enough blood to maintain perfusion of the organs). Tracheal shift Describes a change in the position of the trachea to either side of midline, a finding sometimes associated with tension pneumothorax. Trauma primary survey The trauma primary survey is another term for the ABCDE approach in injured patients. It includes initial assessment of an injured person and management of all immediately life- threatening injuries, in order of priority. The primary survey consists of the ABCDE: Airway, Breathing, Circulation, Disability and Exposure. Trauma secondary survey The head-to-toe (front and back) examination of the trauma patient that includes taking a SAMPLE history. The purpose of this survey is to identify and treat all injuries, with priority given to any hidden life-threatening conditions that were missed by the primary survey. Tripod position Sitting upright with neck extended but leaning slightly forward with hands on knees. People with severe difficulty in breathing will often sit in this position. Wheezing A whistling sound made when breathing out due to inflammation in the lungs, suggestive of lower airway swelling. WHO sources 214 WHO sources Emergency Triage Assessment and Treatment (ETAT). Geneva: World Health Organization; 2005. June 2016 update. Integrated Management of Adolescent and Adult Illness (IMAI) District Clinician Manual. Volume 1 and 2. Geneva: World Health Organization; 2011:Chapter 2–4; 6–8. Pocket book for hospital care of children. Second edition. Geneva: World Health Organization; 2013. GLOSSARY SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE REFS & QUICK CARDS PARTICIPANT WORKBOOK 215 Basic Emergency Care Quick Cards
217 ABCDE APPROACH REMEMBER... Always check for signs of trauma [see also TRAUMA card] ASSESSMENT FINDINGS IMMEDIATE MANAGEMENT Airway A Unconscious with limited or no air movement If NO TRAUMA: head-tilt and chin-lift, use OPA or NPA to keep airway open, place in recovery position or position of comfort. If possible TRAUMA: use jaw thrust with c-spine protection and place OPA to keep the airway open (no NPA if facial trauma). Foreign body in airway Remove visible foreign body. Encourage coughing. • If unable to cough: chest/abdominal thrusts/back blows as indicated • If patient becomes unconscious: CPR Gurgling Open airway as above, suction (avoid gagging). Stridor Keep patient calm and allow position of comfort. • For signs of anaphylaxis: give IM adrenaline • For hypoxia: give oxygen Breathing B Signs of abnormal breathing or hypoxia Give oxygen. Assist ventilation with BVM if breathing NOT adequate. Wheeze Give salbutamol. For signs of anaphylaxis: give IM adrenaline. Signs of tension pneumothorax (absent sounds / hyperresonance on one side WITH hypotension, distended neck veins) Perform needle decompression, give oxygen and IV uids. Will need chest tube Signs of opiate overdose (AMS and slow breathing with small pupils) Give naloxone. Circulation C Signs of poor perfusion/shock If no pulse, follow relevant CPR protocols. Give oxygen and IV uids. Signs of internal or external bleeding Control external bleeding. Give IV uids. Signs of pericardial tamponade (poor perfusion with distended neck veins and mu ed heart sounds) Give IV fl uids, oxygen. Will need rapid pericardial drainage Disability D Altered mental status (AMS) If NO TRAUMA, place in recovery position. Seizure Give benzodiazepine. Seizure in pregnancy (or after recent delivery) Give magnesium sulphate. Hypoglycaemia Give glucose if <3.5 mmol/L or unknown. Signs of opiate overdose (AMS with slow breathing with small pupils) Give naloxone. Signs of life-threatening brain mass or bleed (AMS with unequal pupils) Raise head of bed, monitor airway. Will need rapid transfer for neurosurgical services Exposure E Remove wet clothing and dry skin thoroughly. Remove jewelry, watches and constrictive clothing Prevent hypothermia and protect modesty. Snake bite Immobilize extremity. Send picture of snake with patient. Call for anti-venom if relevant. If cause unknown, remember trauma: Examine the entire body and always consider hidden injuries [see also TRAUMA card] REMEMBER: PATIENTS WITH ABNORMAL ABCDE FINDINGS MAY NEED RAPID HANDOVER/TRANSFER. PLAN EARLY. 218 SPECIAL CONSIDERATIONS IN THE ASSESSMENT OF CHILDREN A • Children have bigger heads and tongues, and shorter, softer necks than adults. Position airway as appropriate for age. • Always consider foreign bodies. B • Look for signs of increased work of breathing (e.g. chest indrawing, retractions, nasal aring). • Listen for abnormal breath sounds (e.g. grunting, stridor, or silent chest). AGE RESPIRATORY RATE (breaths per minute) <2 months 40–60 2–12 months 25–50 1–5 years 20–40 C • Signs of poor perfusion in children include: slow capillary re ll, decreased urine output, lethargy, sunken fontanelle, poor skin pinch • Look for signs of anaemia and malnourishment (adjust uids). • Remember that children may not always report trauma and may have serious internal injury with few external signs. AGE (in years) NORMAL HEART RATE (beats per minute) <1 100–160 1–3 90–150 4–5 80–140 D • Always check AVPU • Hypoglycaemia is common in ill children. • Check for tone and response to stimulus. • Look for lethargy or irritability. E INFANTS AND CHILDREN HAVE DIFFICULTY MAINTAINING TEMPERATURE • Remove wet clothing and dry skin thoroughly. Place infants skin-to-skin when possible. • For hypothermia, cover the head (but be sure mouth and nose are clear). • For hyperthermia, unbundle tightly wrapped babies. DANGER SIGNS IN CHILDREN • Signs of airway obstruction (unable to swallow saliva/ drooling or stridor) • Increased breathing e ort (fast breathing, nasal aring , grunting, chest indrawing or retractions) • Cyanosis (blue colour of the skin, especially at the lips and ngertips) • Altered mental status (including lethargy or unusual sleepiness, confusion, disorientation) • Moves only when stimulated or no movement at all (AVPU other than “A”) • Not feeding well, cannot drink or breastfeed or vomiting everything • Seizures/convulsions • Low body temperature (hypothermia) ESTIMATED WEIGHT in KILOGRAMS for CHILDREN 1–10 YEARS OLD: [age in years + 4] x 2 NORMAL ADULT VITAL SIGNS Pulse rate: 60–100 beats per minute Respiratory rate: 10–20 breaths per minute Systolic blood pressure >90 mmHg Oxygen Saturation > 92% Estimating systolic blood pressure (not reliable in children and the elderly): Carotid (neck) pulse SBP ≥ 60 mmHg Femoral (groin) pulse SBP ≥ 70 mmHg Radial (wrist) pulse SBP ≥80 mmHg SAMPLE History Signs & Symptoms Allergies Medications PMH Last oral intake Events APPROACH TO THE PATIENT WITH TRAUMA Key fi ndings from the Trauma Primary Survey [see also ABCDE card] ASSESSMENT FINDINGS IMMEDIATE MANAGEMENT Airway A Not speaking, with limited or no air movement Use jaw thrust with c-spine protection. Suction if needed, remove visible foreign objects. Place OPA to keep the airway open. Signs of possible airway injury (neck haematoma or wound, crepitus, stridor) Give oxygen. Monitor closely-- swelling can rapidly block the airway. Will need advanced airway management Signs of possible airway burns (soot around the mouth or nose, burned facial hair, facial burns) Give oxygen. Monitor closely-- swelling can rapidly close the airway. Will need advanced airway management Breathing B Signs of tension pneumothorax (hypotension with absent breath sounds/hyperresonance on one side, distended neck veins) Perform needle decompression. Give oxygen, IV uids. Will need chest tube Open (sucking) chest wound Give oxygen, place 3-sided dressing, monitor for tension pneumothorax. Will need chest tube Breathing not adequate Give oxygen, assist ventilation with BVM. Large burns of chest or abdomen (or circumferential burn to limb) Give IV uids per burn size, give oxygen, remove constricting clothing/jewelry. May need escharotomy Signs of ail chest (section of chest wall moving in opposite direction with breathing) Give oxygen. May need advanced airway management and assisted ventilation Signs of haemothorax (decreased breath sounds on one side, dull sounds with percussion) Give oxygen, IV uids. Will need chest tube Circulation C Signs of shock (capillary re ll >3 sec, hypotension, tachycardia) Give oxygen, IV uids, control external bleeding, splint femur/pelvis as indicated. Uncontrolled external bleeding Apply pressure, deep wound packing or tourniquet as indicated. Signs of tamponade (poor perfusion, distended neck veins, mu ed heart sounds) Give IV uids, oxygen. Disability D Signs of brain injury (AMS with wound, deformity or bruising of head/face) Immobilize cervical spine, check glucose, give nothing by mouth. Will need neurosurgical care Signs of open skull fracture (as above, with blood or uid from the ears/nose) As above, and give IV antibiotics per local protocol. REMEMBER: INJURED PATIENTS WITH ABNORMAL ABCDE FINDINGS MAY NEED RAPID HANDOVER/TRANSFER TO A SURGICAL SERVICE. PLAN EARLY. 219 APPROACH TO THE PATIENT WITH TRAUMA Key fi ndings from the Trauma Primary Survey [see also ABCDE card] ASSESSMENT FINDINGS IMMEDIATE MANAGEMENT Airway A Not speaking, with limited or no air movement Use jaw thrust with c-spine protection. Suction if needed, remove visible foreign objects. Place OPA to keep the airway open. Signs of possible airway injury (neck haematoma or wound, crepitus, stridor) Give oxygen. Monitor closely-- swelling can rapidly block the airway. Will need advanced airway management Signs of possible airway burns (soot around the mouth or nose, burned facial hair, facial burns) Give oxygen. Monitor closely-- swelling can rapidly close the airway. Will need advanced airway management Breathing B Signs of tension pneumothorax (hypotension with absent breath sounds/hyperresonance on one side, distended neck veins) Perform needle decompression. Give oxygen, IV uids. Will need chest tube Open (sucking) chest wound Give oxygen, place 3-sided dressing, monitor for tension pneumothorax. Will need chest tube Breathing not adequate Give oxygen, assist ventilation with BVM. Large burns of chest or abdomen (or circumferential burn to limb) Give IV uids per burn size, give oxygen, remove constricting clothing/jewelry. May need escharotomy Signs of ail chest (section of chest wall moving in opposite direction with breathing) Give oxygen. May need advanced airway management and assisted ventilation Signs of haemothorax (decreased breath sounds on one side, dull sounds with percussion) Give oxygen, IV uids. Will need chest tube Circulation C Signs of shock (capillary re ll >3 sec, hypotension, tachycardia) Give oxygen, IV uids, control external bleeding, splint femur/pelvis as indicated. Uncontrolled external bleeding Apply pressure, deep wound packing or tourniquet as indicated. Signs of tamponade (poor perfusion, distended neck veins, mu ed heart sounds) Give IV uids, oxygen. Disability D Signs of brain injury (AMS with wound, deformity or bruising of head/face) Immobilize cervical spine, check glucose, give nothing by mouth. Will need neurosurgical care Signs of open skull fracture (as above, with blood or uid from the ears/nose) As above, and give IV antibiotics per local protocol. REMEMBER: INJURED PATIENTS WITH ABNORMAL ABCDE FINDINGS MAY NEED RAPID HANDOVER/TRANSFER TO A SURGICAL SERVICE. PLAN EARLY. 220 MANAGEMENT OF SPECIFIC CONDITIONS Facial fracture Immobilize cervical spine if indicated, give IV antibiotics for open fractures, avoid nasal airway/ nasogastric tubes. Penetrating eye injury Avoid pressure on the eye, stabilize but do not remove foreign objects, give antibiotics and tetanus, elevate head of bed. Open abdominal wound Give IV uids, nothing by mouth. Cover visible bowel with sterile gauze soaked in sterile saline, give antibiotics. Pelvic fracture Give IV uids, stabilize with sheet or pelvic binder. Fracture with poor limb perfusion Reduce fracture, splint. Open fracture Irrigate well, dress wound, splint, give antibiotics, rapid handover for operative management. Penetrating object Leave object in place and stabilize it to prevent further injury. Crush injury Give IV uids, monitor urine output, monitor for compartment syndrome. Burn injury Assess size and calculate uid needs, give IV uids and oxygen, monitor for airway oedema. Blast injury Give oxygen, treat burns as below, give IV uids, monitor closely for delayed e ects of internal injury. REMEMBER: INJURED PATIENTS WITH WOUNDS, INCLUDING BURNS AND OPEN FRACTURES, NEED TETANUS VACCINATION. HIGH-RISK MECHANISMS AND INJURIES High-Risk Mechanisms High-Risk Injuries • Pedestrian or cyclist hit by a vehicle • Motorcycle crash or any vehicle crash with unrestrained occupants • Falls from heights greater than 3 metres (or twice a child’s height) • Gunshot or stabbing • Explosion or re in an enclosed space. • Penetrating injuries to head, neck or torso • Blast or crush injuries • Flail chest • Two or more large bone fractures, or pelvic fracture • Spinal injury • Limb paralysis • Amputation above wrist or ankle SPECIAL CONSIDERATIONS IN CHILDREN • Children can look well but then deteriorate quickly. • Children have more exible bones than adults and can have serious internal injuries with few external signs. • Use caution when calculating uid and medication dosages. Use exact weight whenever possible. • Watch carefully for hypothermia and hypoglycaemia. DISPOSITION Conditions that require handover or transfer to a specialist unit include: • ABCDE nding that has required intervention • Evidence of internal bleeding • Any pneumothorax or sucking chest wound • Shock, even if treated successfully • Altered mental status • Trauma during pregnancy • ABCDE abnormalities or any chest /abdomen injury in a child • Signi cant burn injuries Considerations for transfer: • Any patient who has required oxygen should have oxygen during transport and after handover. • For signs of shock, ensure IV uid started and continued during transfer. • Control any external bleeding and monitor site closely during transport. APPROACH TO THE PATIENT WITH DIFFICULTY IN BREATHING Key ABCDE Findings (Always perform a complete ABCDE approach rst!) IF YOU FIND... REMEMBER... Choking, coughing Foreign body Stridor Partial airway obstruction due to foreign body or in ammation (from infection, chemical exposure or burn) Facial swelling Severe allergic reaction, medication e ect Drooling Indicates a blockage to swallowing Soot around the mouth or nose, burned facial hair, facial burns Smoke inhalation and airway burns – rapid swelling can block the airway Signs of chest wall trauma Rib fracture, ail chest, pneumothorax, contusion, tamponade Decreased breath sounds on one side Pneumothorax (consider tension pneumothorax if with hypotension and hyperresonance to percussion), haemothorax, large pleural e usion/pneumonia Decreased breath sounds and crackles on both sides Pulmonary oedema, heart failure Wheezing Asthma, allergic reaction, COPD Fast or deep breathing DKA Low blood pressure, tachycardia, mu ed heart sounds Pericardial tamponade Altered mental status with small pupils and slow breathing Opioid overdose Key Findings from the SAMPLE History and Secondary Exam IF YOU FIND... REMEMBER... DIB worse with exertion or activity Heart failure, heart attack DIB that began with choking or during eating Foreign body, allergic reaction History of fever, cough Pneumonia, infection Pesticide exposure Poisoning Recent fall or other trauma Rib fracture, ail chest, pneumothorax, contusion, tamponade Known allergies, allergen exposure, bite or sting Allergic reaction Recent medication or dose change Allergic reaction or side e ect History of opioid or sedative drug use Overdose History of wheezing Asthma or COPD History of diabetes DKA History of tuberculosis or malignancy Pericardial tamponade, pleural e usion History of heart failure Pulmonary oedema History of sickle cell disease Acute chest syndrome 221 APPROACH TO THE PATIENT WITH DIFFICULTY IN BREATHING Key ABCDE Findings (Always perform a complete ABCDE approach rst!) IF YOU FIND... REMEMBER... Choking, coughing Foreign body Stridor Partial airway obstruction due to foreign body or in ammation (from infection, chemical exposure or burn) Facial swelling Severe allergic reaction, medication e ect Drooling Indicates a blockage to swallowing Soot around the mouth or nose, burned facial hair, facial burns Smoke inhalation and airway burns – rapid swelling can block the airway Signs of chest wall trauma Rib fracture, ail chest, pneumothorax, contusion, tamponade Decreased breath sounds on one side Pneumothorax (consider tension pneumothorax if with hypotension and hyperresonance to percussion), haemothorax, large pleural e usion/pneumonia Decreased breath sounds and crackles on both sides Pulmonary oedema, heart failure Wheezing Asthma, allergic reaction, COPD Fast or deep breathing DKA Low blood pressure, tachycardia, mu ed heart sounds Pericardial tamponade Altered mental status with small pupils and slow breathing Opioid overdose Key Findings from the SAMPLE History and Secondary Exam IF YOU FIND... REMEMBER... DIB worse with exertion or activity Heart failure, heart attack DIB that began with choking or during eating Foreign body, allergic reaction History of fever, cough Pneumonia, infection Pesticide exposure Poisoning Recent fall or other trauma Rib fracture, ail chest, pneumothorax, contusion, tamponade Known allergies, allergen exposure, bite or sting Allergic reaction Recent medication or dose change Allergic reaction or side e ect History of opioid or sedative drug use Overdose History of wheezing Asthma or COPD History of diabetes DKA History of tuberculosis or malignancy Pericardial tamponade, pleural e usion History of heart failure Pulmonary oedema History of sickle cell disease Acute chest syndrome 222 CRITICAL ACTIONS FOR HIGH-RISK CONDITIONS CHOKING unable to cough, not making sounds STRIDOR high pitched sounds on breathing IN WHEEZING high pitched sounds on breathing OUT SEVERE INFECTION TRAUMA Remove any visible foreign body Perform age- appropriate chest/ abdominal thrusts or back blows CPR if becomes unconscious Keep patient calm and allow position of comfort IM adrenaline for suspected allergic reaction Oxygen if concern for hypoxia Early handover/ transfer for advanced airway management Give salbutamol IM adrenaline for suspected allergic reaction Oxygen if concern for hypoxia Oxygen Antibiotics Oral/IV uids as appropriate Oxygen Needle decompression and IV uids for tension pneumothorax Three-sided dressing for sucking chest wound Rapid transfer to surgical service SPECIAL CONSIDERATIONS IN CHILDREN THE FOLLOWING ARE DANGER SIGNS IN CHILDREN WITH BREATHING COMPLAINTS: • Fast breathing • Increased breathing e ort (chest indrawing/retractions) • Cyanosis • Altered mental status (including lethargy) • Poor feeding or drinking, or vomits everything • Seizures/convulsions, current or recent • Drooling or stridor when calm • Hypothermia Wheezing in children is often caused by an object inhaled into the airway, viral infection or asthma. Stridor in children is often caused by an object stuck in the airway or airway swelling from infection. Fast or deep breathing can indicate diabetic crisis (DKA), which may be the rst sign of diabetes in a child. FAST BREATHING MAY BE THE ONLY SIGN OF A SERIOUS BREATHING PROBLEM IN A CHILD. DISPOSITION Salbutamol and IM adrenaline e ects last for about 3 hours, and life-threatening symptoms may recur. Monitor closely, always have repeat dose available during transport and caution new providers at handover. Naloxone lasts approximately 1 hour, and most opioids last longer. Monitor closely, always have repeat dose available during transport and caution new providers. Following immersion in water (drowning), a person may develop delayed breathing problems after several hours. Monitor closely and caution new providers. Never leave patients with di culty in breathing unmonitored during handover/transfer. Make transfer arrangements as early as possible for any patient who may require intubation or assisted ventilation. 223 CRITICAL ACTIONS FOR HIGH-RISK CONDITIONS CHOKING unable to cough, not making sounds STRIDOR high pitched sounds on breathing IN WHEEZING high pitched sounds on breathing OUT SEVERE INFECTION TRAUMA Remove any visible foreign body Perform age- appropriate chest/ abdominal thrusts or back blows CPR if becomes unconscious Keep patient calm and allow position of comfort IM adrenaline for suspected allergic reaction Oxygen if concern for hypoxia Early handover/ transfer for advanced airway management Give salbutamol IM adrenaline for suspected allergic reaction Oxygen if concern for hypoxia Oxygen Antibiotics Oral/IV uids as appropriate Oxygen Needle decompression and IV uids for tension pneumothorax Three-sided dressing for sucking chest wound Rapid transfer to surgical service SPECIAL CONSIDERATIONS IN CHILDREN THE FOLLOWING ARE DANGER SIGNS IN CHILDREN WITH BREATHING COMPLAINTS: • Fast breathing • Increased breathing e ort (chest indrawing/retractions) • Cyanosis • Altered mental status (including lethargy) • Poor feeding or drinking, or vomits everything • Seizures/convulsions, current or recent • Drooling or stridor when calm • Hypothermia Wheezing in children is often caused by an object inhaled into the airway, viral infection or asthma. Stridor in children is often caused by an object stuck in the airway or airway swelling from infection. Fast or deep breathing can indicate diabetic crisis (DKA), which may be the rst sign of diabetes in a child. FAST BREATHING MAY BE THE ONLY SIGN OF A SERIOUS BREATHING PROBLEM IN A CHILD. DISPOSITION Salbutamol and IM adrenaline e ects last for about 3 hours, and life-threatening symptoms may recur. Monitor closely, always have repeat dose available during transport and caution new providers at handover. Naloxone lasts approximately 1 hour, and most opioids last longer. Monitor closely, always have repeat dose available during transport and caution new providers. Following immersion in water (drowning), a person may develop delayed breathing problems after several hours. Monitor closely and caution new providers. Never leave patients with di culty in breathing unmonitored during handover/transfer. Make transfer arrangements as early as possible for any patient who may require intubation or assisted ventilation. APPROACH TO THE PATIENT WITH SHOCK Key ABCDE Findings (Always perform a complete ABCDE approach fi rst!) IF YOU FIND... REMEMBER... Di culty breathing, stridor/wheezing, skin rash, swelling of mouth Severe allergic reaction Hypotension with absent breath sounds and hyperresonance on one side, distended neck veins Tension pneumothorax Distended neck veins, mu ed heart sounds, tachycardia, hypotension Pericardial tamponade Sweet smelling breath, deep or rapid breathing DKA History of trauma or no known cause Hidden sources of signi cant blood loss (stomach, intestines, intra-abdominal, chest, long-bone trauma) or spinal injury Key Findings from the SAMPLE History and Secondary Exam IF YOU FIND... REMEMBER... Vomiting and diarrhoea Ask about contacts and report cases per protocol. Black or bloody vomit or stool Stomach or intestinal bleeding Rapid or deep breathing, dehydration, high glucose, sweet- smelling breath, history of frequent urination or known diabetes Diabetic ketoacidosis Burns Severe uid loss (calculate uid needs based on burn size) Fever or HIV Infection Recent fall or other trauma Internal AND external bleeding Pale conjunctiva or malnutrition Severe anemia (adjust uids) Chest pain Heart attack (give aspirin if indicated) Vaginal bleeding Pregnancy and non-pregnancy related bleeding Numbness, weakness or shock that does not improve with uids Spinal shock (immobilize spine if indicated) CRITICAL ACTIONS FOR HIGH-RISK CONDITIONS For all shock: • Give oxygen • Give IV uids – ADULTS: 1 liter RL or NS bolus – CHILDREN with NO severe anaemia, NO malnutrition, NO uid overload: 10–20 ml/kg bolus – CHILDREN with malnutrition or severe anaemia: give 10–15 ml/kg dextrose-containing uid over 1 hour and assess for uid overload every 5 minutes. – For suspected heart attack with shock, give smaller boluses, and monitor closely for uid overload. • Monitor vital signs, mental status, breathing and urine output AND for speci c conditions: SEVERE ALLER- GIC REACTION TENSION PNEUMO- THORAX TAMPONADE FEVER WATERY DIARRHOEA POSTPARTUM BLEEDING DKA TRAUMA IM adrenaline Monitor for recurrence, may need repeat doses Rapid needle decompression Transfer for chest tube Rapid transfer to advanced provider for drainage Antibiotics (and anti- malarials if indicated) Assess for source of infection Full contact precautions Monitor output and continue uids Assess for cholera and notify public health authorities Oxytocin and uterine massage Direct pressure for perineal and vaginal tears Rapid transfer to advanced obstetric care Close monitor- ing for uid over- load in children Handover/ transfer for insulin Control external haemorrhage with direct pressure, wound packing, tour- niquet if indicated Calculate uid needs based on burn size Rapid transfer for sur- gery/transfusion as needed 224 SPECIAL CONSIDERATIONS IN CHILDREN IV FLUID IMMEDIATELY AVAILABLE? IV FLUID AVAILABLE NEARBY? START ORS via NG NASOGASTRIC TUBE REASSESS IMMEDIATELY AFTER BOLUS DID PERFUSION IMPROVE? TRANSFER IMMEDIATELY CONTINUE ORS VIA NG YES YES YES YES No No No No DID PERFUSION IMPROVE? IV FLUIDS REASSESS IMMEDIATELY AFTER BOLUS CONTINUE E <30 MINUTES <30 MINUTES START IV FLUIDS RE-BOLUS GIVING FLUID IN SHOCK NO malnutrition, overload or severe anaemia DISPOSITION Patients with shock should be at a unit capable of providing IV uid resuscitation, blood transfusion, and/or surgery, depending on the type of shock. Maintain uids during transport. Repeat ABCDE approach and monitor perfusion and breathing closely at all times. ASSESSING SHOCK IN CHILDREN The 2016 WHO guidelines for the care of critically ill children use the presence of three clinical features to de ne shock: • Cold extremities • Weak and fast pulse • Capillary re ll greater than 3 seconds Additional important considerations include: • Young children may not be able to drink enough uid on their own. • Children have larger surface area to volume ratio and can lose uids more quickly than adults. • For a child in shock WITH severe malnutrition or uid overload, add dextrose and reduce uids to 10–15 ml/kg over 1 hour. Other important signs of poor perfusion include: • Sunken eyes; sunken fontanelles in infants • Abnormal skin pinch test • Pallor (dehydration with anaemia is more di cult to treat) • Decreased and dark urine (number of nappies for infants) • Low blood pressure • Fast breathing • Altered mental status • Very dry mouth and lips • Lethargy (excessive drowsiness, slow to respond, not interactive) In children without severe malnutrition, severe anaemia or uid overload, give uid resuscitation over 30 minutes. WEIGHT (kg) FLUID VOLUME (15ml/kg) 4 60 6 90 10 150 14 210 20 300 30 450 APPROACH TO THE PATIENT WITH ALTERED MENTAL STATUS (AMS) Key ABCDE Findings (Always perform a complete ABCDE approach fi rst!) IF YOU FIND... REMEMBER... Tachypnoea Hypoxia, DKA, toxic ingestion Poor perfusion/shock Infection, internal bleeding Tachycardia with normal perfusion Alcohol withdrawal Coma Hypoxia, high or low blood glucose, DKA and toxic ingestion Hypoglycaemia Infection, medication side e ect (eg, diabetes medications, quinine) Very small pupils with slow breathing Opioid overdose Seizure/convulsion Abnormal glucose, infection, toxic ingestion (eg, TB meds) or withdrawal (eg, alcohol). Consider eclampsia if current pregnancy or recent delivery. Weakness on one side or unequal pupil size Brain mass or bleed Signs of trauma or unknown cause of AMS Consider brain injury (with possible spine injury) Key Findings from SAMPLE History and Secondary Exam IF YOU FIND... REMEMBER... History of wheezing Severe COPD crisis can cause AMS History of diabetes High or low blood sugar, DKA History of epilepsy Post-seizure confusion and sleepiness should improve over minutes to hours. Prolonged AMS or multiple convulsions without waking up in between require further workup. History of agricultural work or known pesticide exposure Organophosphate poisoning History of regular alcohol use Alcohol withdrawal History of substance use or depression Acute intoxication, accidental or intentional overdose History of HIV Infection, medication side e ect Rash on the lower abdomen or legs or bulging fontanelle in infants Brain infection (meningitis) Fever/Hyperthermia Infectious, toxic, and environmental causes 225 APPROACH TO THE PATIENT WITH ALTERED MENTAL STATUS (AMS) Key ABCDE Findings (Always perform a complete ABCDE approach fi rst!) IF YOU FIND... REMEMBER... Tachypnoea Hypoxia, DKA, toxic ingestion Poor perfusion/shock Infection, internal bleeding Tachycardia with normal perfusion Alcohol withdrawal Coma Hypoxia, high or low blood glucose, DKA and toxic ingestion Hypoglycaemia Infection, medication side e ect (eg, diabetes medications, quinine) Very small pupils with slow breathing Opioid overdose Seizure/convulsion Abnormal glucose, infection, toxic ingestion (eg, TB meds) or withdrawal (eg, alcohol). Consider eclampsia if current pregnancy or recent delivery. Weakness on one side or unequal pupil size Brain mass or bleed Signs of trauma or unknown cause of AMS Consider brain injury (with possible spine injury) Key Findings from SAMPLE History and Secondary Exam IF YOU FIND... REMEMBER... History of wheezing Severe COPD crisis can cause AMS History of diabetes High or low blood sugar, DKA History of epilepsy Post-seizure confusion and sleepiness should improve over minutes to hours. Prolonged AMS or multiple convulsions without waking up in between require further workup. History of agricultural work or known pesticide exposure Organophosphate poisoning History of regular alcohol use Alcohol withdrawal History of substance use or depression Acute intoxication, accidental or intentional overdose History of HIV Infection, medication side e ect Rash on the lower abdomen or legs or bulging fontanelle in infants Brain infection (meningitis) Fever/Hyperthermia Infectious, toxic, and environmental causes 226 CRITICAL ACTIONS FOR HIGH-RISK CONDITIONS (Always check blood glucose in AMS, or give glucose if unable to check.) HYPOGLYCAEMIA OPIOID OVERDOSE LIFE-THREATENING INFECTIONS SEVERE DEHYDRATION TOXIC EXPOSURE OR WITHDRAWAL Give glucose Evaluate for infection Monitor for return of hypoglycaemia Naloxone Monitor need for repeat doses (many opioids last longer than naloxone) IV uids Antibiotics For AMS with fever or rash, consider brain infection (meningitis) – isolate patient and wear mask. Cool if indicated for very high fever (avoid shivering). IV uids Assess for infection Consider DKA Gather history and consult advanced provider for locally- appropriate antidotes. Treat alcohol withdrawal with benzodiazepine. Decontaminate for chemical exposures (eg, pesticides). PAEDIATRIC CONSIDERATIONS ALWAYS consider unwitnessed toxic ingestion Ask about any medications in the household, and any chemicals (eg cleaning products, antifreeze) in or near the house. Check and regularly re-check blood glucose Low blood glucose is common in ill young children. High blood glucose can present with AMS and dehydration. AVOID hypothermia Keep skin-to-skin with mother, cover child’s head. Uncover only the parts you need to see, one at a time, during exam. Danger signs with ingestions • Stridor • Oral chemical burns Monitor closely and arrange handover/transfer for advanced airway management. Monitor uid status closely Paediatric patients are more susceptible to both uid losses and uid overload. DISPOSITION CONSIDERATIONS Patients with AMS who may not be able to protect the airway should never be left alone. Monitor closely and give direct handover to new provider. Naloxone lasts approximately 1 hour. Most opioids last longer-- always alert new providers that patients may need repeat doses. Hypoglycaemia often recurs. Alert new providers to monitor blood glucose frequently in any patient who has been treated for hypoglycaemia. 227 MEDICATIONS MEDICATION DOSAGE INDICATION Adrenaline (Epinephrine) Solution: 1mg in 1ml ampoule (1:1000) Adults: 50 kg or above: 0.5 mg IM (0.5 ml of 1:1000) 40 kg: 0.4 mg (0.4 ml IM of 1:1000) 30 kg: 0.3 mg (0.3 ml IM of 1:1000) Repeat every 5 minutes as needed Children: Anaphylaxis: 0.15 mg IM (0.15ml of 1:1000). Repeat every 5–15 minutes as needed Severe Asthma: 0.01 mg/kg IM up to 0.3mg. Repeat every 15 minutes as needed Anaphylaxis/severe allergic reaction and severe wheezing Acetylsalicylic acid (Aspirin) Oral Tablet: 100 mg, 300 mg 300 mg (preferably chewed or in water) immediately as single dose. Suspected heart attack Diazepam Oral Tablet: 2 mg, 5 mg Solution: 5 mg /1 ml ampoule Adults: First dose: 10 mg slow IV push or 20 mg rectally Second dose after 10 minutes: 5 mg slow IV push or 10 mg rectally Maximum IV Dose: 30 mg Children: First dose: 0.2 mg/kg slow IV push or 0.5 mg/kg rectally. Can repeat half of rst dose after 10 minutes if seizures/convulsions continue. Max IV Dose: 20 mg MONITOR BREATHING CLOSELY in all patients given diazepam. Seizures/ convulsions Glucose (Dextrose) Solution: 50% dextrose (D50), 25% dextrose (D25), or 10% Dextrose (D10) Adults and children greater than 40kg: 25–50 ml IV of D50, or 125–250 ml IV of D10 Children up to 40kg: 5 ml/kg IV of D10 (PREFERRED) 2 ml/kg IV of D25 1 ml/kg IV of D50 If no IV access: 2–5 ml of 50% Dextrose OR sugar solution in buccal space Hypoglycaemia (low blood sugar) Magnesium Sulphate Solution: 1 g in 2 ml ampoule (50% or 500 mg/ml), 5 g in 10 ml ampoule (50% or 500 mg/ml) Give 4 g IV (dilute to a 20% solution and give 20ml) slowly over 20 minutes AND give 10 g IM: 5 g (10 ml of 50% solution) with 1 ml of 2% lidocaine in each buttock. If unable to give IV, give 10 g IM injection only (as above, 5 g in each buttock). If seizures/convulsions recur: after 15 minutes give additional 2 g (10 ml of 20%) IV over 20 minutes. If transport delayed continue: Give 5 g of 50% solution IM with 1 ml of 2% lidocaine every 4h in alternate buttocks. Eclampsia or Pregnant with seizure/convulsion Naloxone Solution: 400 mcg/ml (hydrochloride) in 1 ml ampoule IV: 100 mcg single dose OR IM: 400 mcg single dose May repeat every 5 minutes as needed. May require 0.4 mg/hr infusion for several hours for long-acting opioids. Opioid overdose 228 MEDICATION DOSAGE INDICATION Oxytocin Solution: 10 IU in 1ml ampule Initial Dose: Give 10 IU IM AND start IV uids with 20 IU/L at 60 drops/minute. Once placenta is delivered, continue IV uids with 20 IU/L at 30 drops/minute if still bleeding. If placenta has to be manually removed or uterus does not contract: Repeat 10 IU IM. Continue IV uids with 20 IU/L at 20 drops/minute for one hour after bleeding stops. Max Dose: 3 L of IV uids containing oxytocin. Treatment of postpartum haemorrhage Paracetamol (acetaminophen) Oral Tablet: 250 mg, 500 mg. Rectal Suppositories: 250 mg, 500 mg Adults: 500 mg–1 g oral/rectal every 6hrs Max 4 g daily or max 2 g daily if liver impairment, cirrhosis Children: 10–15 mg/kg oral/rectal up to six times per day Mild to moderate pain, fever, headache Salbutamol (Albuterol) Inhaler: 100 mcg per pu • Adult: Prime with 5 pu s and give 2 pu s via spacer every 2 minutes until improved. • Child: Prime with 5 pu s and give 2 pu s into spacer. Keep spacer in mouth for 3–5 breaths. Repeat until 6 pu s given for < 5 years, or 12 pu s for > 5 years. Nebulizer: (ADULT) 5 mg in 5 ml sterile saline. (CHILD) 2.5 mg in 3 ml sterile saline. For severe wheezing, above doses can be given several times in an hour. Severe wheezing Tetanus Vaccine IM Injection: 0.5 ml (Give for children not up to date; adults with none in 5 years; or status unknown) Wounds (including burns and open fractures) 229 MEDICATION DOSAGE INDICATION Oxytocin Solution: 10 IU in 1ml ampule Initial Dose: Give 10 IU IM AND start IV uids with 20 IU/L at 60 drops/minute. Once placenta is delivered, continue IV uids with 20 IU/L at 30 drops/minute if still bleeding. If placenta has to be manually removed or uterus does not contract: Repeat 10 IU IM. Continue IV uids with 20 IU/L at 20 drops/minute for one hour after bleeding stops. Max Dose: 3 L of IV uids containing oxytocin. Treatment of postpartum haemorrhage Paracetamol (acetaminophen) Oral Tablet: 250 mg, 500 mg. Rectal Suppositories: 250 mg, 500 mg Adults: 500 mg–1 g oral/rectal every 6hrs Max 4 g daily or max 2 g daily if liver impairment, cirrhosis Children: 10–15 mg/kg oral/rectal up to six times per day Mild to moderate pain, fever, headache Salbutamol (Albuterol) Inhaler: 100 mcg per pu • Adult: Prime with 5 pu s and give 2 pu s via spacer every 2 minutes until improved. • Child: Prime with 5 pu s and give 2 pu s into spacer. Keep spacer in mouth for 3–5 breaths. Repeat until 6 pu s given for < 5 years, or 12 pu s for > 5 years. Nebulizer: (ADULT) 5 mg in 5 ml sterile saline. (CHILD) 2.5 mg in 3 ml sterile saline. For severe wheezing, above doses can be given several times in an hour. Severe wheezing Tetanus Vaccine IM Injection: 0.5 ml (Give for children not up to date; adults with none in 5 years; or status unknown) Wounds (including burns and open fractures) TRANSFER AND HANDOVER Arrange transfer • Check that patient needs match the available services at the destination facility (eg, operating theatre open, blood available) • Communicate directly with an accepting provider at the receiving facility prior to departure • Ensure that destination facility can be reached in time given patient condition • Ensure that patient and family are aware of reasons, plan, and destination for transport • Record family contact name and number in sending facility chart and in paperwork sent with patient • Secure patient valuables for transport (whenever possible, leave with family) • A brief written record (including name, date of birth, clinical presentation and all interventions) should ALWAYS accompany the patient. Prepare for needs during transport • PPE for sta • Airway equipment and suction (check if working before departure) • Adequate oxygen (with replacement tank if needed) and bag valve mask (BVM) • IV access: Check that IV is secured prior to transport; consider second IV or backup supply • Medications: Bring additional doses of medications and uids, and consider other medications that may be needed • Prepare for new or recurrent symptoms. • Seizure/convulsion patients: place pads/pillows around patient to limit injury from a seizure during transport. • Watch for vomiting and ensure that airway remains clear, particularly for those with cervical spine immobilization. • Check that there is adequate fuel for transport. • Ensure that telephone or radio is present in vehicle and working Patient positioning • Position patient for best airway opening and breathing. • Use recovery position if no trauma. • If >20 weeks pregnant and NO spine injury: Place pillows along the length of her right back to tilt patient onto her left side. This avoids compression of the large blood vessels by the pregnant uterus. • Check that cervical spine has been immobilized if indicated. • Possible spine injury: use backboard and log-roll manoeuvre to move patients. Check for pressure spots every 2 hours; pad areas with soft material as needed. If >20-weeks pregnant: Tip backboard slightly to the left using a wedge or other materials. • Splint or immobilize fractures to protect soft tissues and decrease pain and bleeding. On-going care during transport • Re-assess the ABCDE approach at least every 15 minutes, including repeat vital signs and glucose checks if patient has been hypoglycaemic • Control bleeding prior to transport and monitor site for new bleeding • Perform regular re-assessment of any splinted extremity • Continue necessary treatments (e.g. oxygen, IV uids, oxytocin, glucose) • Keep the patient from getting too hot or too cold during transport. 230 Paediatric Considerations • Prepare appropriate size equipment and weight-adjusted dosages of critical medications. • Bring a family member or friend, and tell the receiving facility who is accompanying the child. • Remember that critically ill or injured children can look well initially and then worsen quickly. Monitor closely. • Hypothermia and hypoglycaemia are common in children. Monitor closely. SBAR handover • Situation: Basic patient information (e.g. age, sex); chief complaint (the patient’s initial description of the problem, such as di culty in breathing for 3 days, or arm pain after a fall) • Background: 2–4 most important and relevant aspects of patient’s case and/or condition; important ABCDE ndings/ interventions. • Assessment: What you think is wrong with the patient; reason for the handover/transfer. • Recommendations: next steps in treatment plan; potential worsening of the patient’s condition (e.g. need for close airway observation if inhalation burn is suspected); cautions regarding prior therapies or interventions (e.g. time of last adrenaline dose to anticipate return symptoms, need to monitor mental status if sedating medications have been given, need to monitor 3-way dressing for clotting, etc.).
ISBN 978-92-4-151308-1 World Health Organization Avenue Appia 20 1211 Geneva 27 Switzerland Email: emergencycare@who.int B A SIC EM ER G EN C Y C A R E: A pproach to the acutely ill and injured
PA R TI C IP A N T W O R K B O O K B A SIC EM ER G EN C Y C A R E: A pproach to the acutely ill and injured APPROACH TO THE ACUTELY ILL AND INJURED BASIC EMERGENCY CARE APPROACH TO THE ACUTELY ILL AND INJURED Basic emergency care: approach to the acutely ill and injured ISBN (WHO) 978–92–4-151308–1 ISBN (ICRC) 978–2-940396–58–0 © World Health Organization (WHO) and the International Committee of the Red Cross (ICRC), 2018. Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. 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Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/ licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization, the International Committee of the Red Cross or the International Federation for Emergency Medicine concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization, the International Committee of the Red Cross or the International Federation for Emergency Medicine in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization and the International Committee of the Red Cross and the International Federation for Emergency Medicine to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization or the International Committee of the Red Cross or the International Federation for Emergency Medicine be liable for damages arising from its use. Design by Inís Communication – www.iniscommunication.com BEC | Contributors Editors Teri Reynolds, Nikki Roddie, Andi Tenner, Heike Geduld. Other contributors of written material Kalie Dove-Maguire, Vijay Kannan, Sean Kivlehan, Nelson Olim, Max Ritzenberg, Stas Salerno Amato, Morgan Broccoli, Farrah Kashfipour, Harald Veen, Lee Wallis Peer reviewers Annet Alenyo, John Brown, Emilie Calvello, Brendan Carr, Keegan Checkett, Matthew Cooke, Megan Cox, Anne Creaton, Rochelle Dicker, Shaheem De Vries, Stephen Dunlop, Rajith Ellawala, George Etoundi, Sabariah Faizah, Scott Fruhan, Nicolaus Glomb, Renee Hsia, Christina Huwer, Muhumpu Kafwamfwa, Joseph Kalanzi, Gamal Khalifa, Olive Kobusingye, Clifford Mann, Edgardo Menendez, Juma Mfinanga, Nee-Kofi Mould-Millman, Hani Mowafi, Andrew Muck, Brittany Murray, Marcos Musafir, Theresa Olasveengen, Gerard O’Reilly, Tom Potokar, Junaid Razzak, Anthony Redmond, Andres Rubiano, Kelly Schmiedeknecht, Chris Stein, Janis Tupesis, Vikas Kapil, and Benjamin Wachira. The following members of the International Liaison Committee on Resuscitation (ILCOR) Pediatric Task Force provided essential peer review on relevant sections: Ng Kee Chong, Allan de Caen, Ian Maconochie, and Remigio Véiz. The following members of the International Federation for Emergency Medicine executive committee provided essential peer review: Peter Cameron, James Ducharme, Jim Holliman, Bob Schafermeyer, and Andrew Singer. Focus groups and pilots We thank the nurses and doctors of Muhimbili National Hospital in Dar es Salaam, United Republic of Tanzania, for their invaluable input during early focus groups: Ally M. Akrabi, Prosper J. Bashaka, Avelina N. Ijumba, Jennifer Jamieson, Khadija H. Juma, Bernard Kepha, Said Kilindimo, Josephine Lazaro, Wendy Lukwambe, Peter S. Mabula, Deogratius Mally, Nyakanda Marwa, Juma Mbugi, Felix D. Mlay, Victoria Mlele, Brittany Murray, Kissa Mwampagama, Meera Nariadhara, Catherine R. Shari, Patrick J. Shao, Shahzmah Suleman, Renatus Tarimo, Tito William. We are grateful to the African Federation for Emergency Medicine for overall coordination of pilots conducted in 2015–2017. Uganda course pilots were led by Joseph Kalanzi, and course facilitators included Aliga Cliff Asher, Charmaine Cunningham, Heike Geduld, Nemganga Kizega, Namaganda Lukia, Grace Magambo, Alex Makupe, Juma Mbugi, Josephine Nabulime, Annet Alenyo Ngabirano, Muzaza Nthele. Participants: Halima Adam, Douglas Akibua, Muhwezi Amos, Beatrice Babirye, Andrew Balinda, Evans Bonabana, Kamara Francis, Alele Franco, Muduwa Grace, Jagwe Hakim, Henry Kagaba, Shadia Kaggwa, Andrew Kagwa, Peter Kavuma, Winnie Kibirige, Bazibu Musa Kireka, Brian Kisembo, Nakiyemba Margaret, Edward Mugisha, Linda Nalugya, Gertrude Namidembe, Joanita Namuddu, Denis Onyang, and Emma Tukehayo. United Republic of Tanzania course pilots were led by Hendry Sawe, and course facilitators included Charmaine Cunningham, Jimmy Ernest, Upendo George, Nemganga Kizega, Deogratius Mally, Juma Mbugi, Juma Mfinanga, Felix Mlay, Brittany L Murray, Suzanna Ngalla, and Nikki Roddie. Participants: Ntuli Abraham, Thomas Bwire, Hamza Haji, Agripina Hugho, Stella Ibrahim, Philomena Jumanne, Teonila Kamba, Neema Kayembe, Sikudhani Khamsini, Clemence Luambono, Raymond Makona, Rosemary Marishay, Rashidi Matitu, Vicent Mboya, Erick Mhaiki, Rashid Mhina, Asha Mkwachu, Frank Mlaguzi, Leonidas Mutakosa, Piensia Nanyimbula, Kiohombo Phim, Mary Shauritanga, and Ndamba Sigonda. Zambia course pilots were led by Muhumpu Kafwamfwa, and course facilitators included: Namasiku Chime, Chipoya Chipoya, Ngandu Hassan, Mwandameda Kabuku, Irene Lufunda, Alex Makupe, and Mzaza Nthele. Participants: Gloria Chambeshi, Maureen Chikwa, Azelina Chulu, Mwanza Jackson, Usaliwa Jere, Tina Malunga, Pidini Mary, Mable Nakazwe Mulenga, Joy Judy Mweshi, Chicco Siame, Ivan Sinaulieni, and Franko Zulu. We wish to thank Morgan Broccoli, Simon Charwey, Catherine Haeffele, Farrah Kashfipour for input on visual design and illustration, and Tein Jung for the original illustrations throughout. INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 The ABCDE and SAMPLE history approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Module 1: The ABCDE and SAMPLE history approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Module 2: Approach to trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 Module 3: Approach to difficulty in breathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75 Module 4: Approach to shock. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95 Module 5: Approach to altered mental status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 WHO BASIC EMERGENCY CARE [SKILLS]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 GLOSSARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 WHO sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214 Basic Emergency Care Quick Cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 Contents vi INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 1 INTRODUCTION Overview Health emergencies happen every day, everywhere. They affect adults and children and include injuries and infections, heart attacks and strokes, acute complications of pregnancy and of chronic disease. While specialised care may never be available at all times in all places, a systematic approach to emergency conditions saves lives. The Disease Control Priorities Project estimates that nearly half of deaths and a third of disabilities in low- and middle-income countries result from conditions that could be addressed by emergency care. The World Health Organization (WHO), in collaboration with the International Committee of the Red Cross (ICRC) and the International Federation for Emergency Medicine (IFEM), has developed the Basic Emergency Care (BEC) course for frontline providers who manage acute life-threatening conditions with limited resources. These may include students, nurses, pre- hospital technicians, clinical officers and doctors who are working in field (pre-hospital) or hospital settings. Emergency care providers must respond to ‘undifferentiated’ patients, those with acute symptoms for which the cause may not be known. This course introduces a systematic approach to managing acute, potentially life-threatening conditions even before a diagnosis is known. BEC is based on the clinical recommendations of the WHO IMAI District Clinician Manual, WHO Pocket Book of Hospital Care for Children, WHO Emergency Triage Assessment and Treatment (ETAT) and WHO Integrated Management of Pregnancy and Childbirth. It includes modules on: the ABCDE and SAMPLE history approach, trauma, difficulty in breathing, shock, and altered mental status. The practical skills section covers the essential time-sensitive interventions for these key acute presentations. The WHO BEC package consists of: Participant workbook: the main reference source for participants, this interactive workbook provides all the necessary course content, and includes an in-depth guide to essential skills, a glossary of terms, review questions and case scenarios. Quick cards: these simple reference cards organize key assessment and management points for use in clinical settings beyond the course. These are found at the end of each module and together at the end of the workbook. Facilitator guide: this is an annotated version of the BEC workbook intended for facilitators. Challenging concepts are highlighted, and notes on teaching strategy and lecture preparation provided on each page. This volume also includes a Coordinator section with information on course planning and logistics, and offers guidance for selecting and training facilitators. Presentation slide sets: these cover all course modules and are provided to support course delivery. INTRODUCTION 2 The BEC course may be implemented in many different ways to meet local needs, but a recommended 5-day schedule is described in detail in the Coordinator section of the Facilitator guide. The BEC content might also be spread across a few weeks as a module in undergraduate nursing or medical curricula. The BEC package is designed to support the efforts of governments, educational institutions, professional societies and others to train emergency care providers acting within their designated scope of practice. WHO does not certify or accredit courses, instructors or providers. Scope of the course Key acute presentations These modules teach a practical and systematic approach to four acute and potentially life- threatening presentations: Trauma Difficulty in breathing Shock Altered mental status Most life-threatening conditions, whether the original cause was medical or surgical, infection or injury, will present with one of these. In some cases the diagnosis may be known, while in others, intervention may be required before a diagnosis can be made, perhaps because of limited diagnostic resources, but often because of the acuity of the condition. These modules introduce a systematic approach to assessment and management that can be used whether or not a diagnosis has been made. Frontline health-care providers will face many more presentations than are covered in this course. This material is not meant to cover every acute condition, but to help providers address time-sensitive conditions where early intervention has the potential to save lives. The course is designed to lay a foundation for broader emergency assessment and management. Many participants may already, or will later, be trained to provide care beyond what is described here. Recommendations for handover to an “advanced provider” are meant to signal the need for care beyond the scope of this course. In some cases, participants themselves may already be trained to provide this additional care. Other emergency presentations There are other complaints that may represent a life-threatening condition requiring emergency care even before it progresses to any of the key acute presentations listed above. These include: chest discomfort; poisoning/ingestion/exposure; envenomation (bites/stings); any severe pain from an unclear source; INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 3 contractions, pain or bleeding in late pregnancy. These complaints may represent the early stage of a critical illness requiring rapid intervention even when the person appears relatively well. The complete assessment and management of these conditions is beyond the scope of this course, but they should always trigger transport to, or consultation with, an advanced provider. In addition, there are certain infectious exposures that require time-sensitive prophylaxis (preventive treatment) whose effectiveness may be reduced by delays. These include: needle stick injury in a health care worker; unprotected sexual encounter, including in the context of assault; exposure to the saliva of an animal with suspected rabies. These exposures should be evaluated as soon as possible at a center capable of providing timely prophylaxis. Special considerations for fever Fever is a very common complaint and may be a sign of a life-threatening condition, or simply a sign of a mild condition that will resolve itself. Because fever does not reliably indicate an emergency condition, it is not addressed in a separate module here, but is covered in each of the core modules. When associated with abnormal ABCDE findings (see “Approach to the emergency patient” section), or any of the acute presentations above (trauma, difficulty in breathing, shock, altered mental status), fever can be an important clue to severe illness and should be taken very seriously. There are many more causes of fever than can be covered in this basic course, but most causes of fever requiring emergency treatment are associated with one of the four key acute presentations. There is no single approach to fever that is right for all emergencies, but there are some general principles that can help in the assessment and management of emergency patients. • Always consider infection in a person with fever (e.g. malaria, meningitis, pneumonia). • Never use the absence of fever to rule out infection. People with overwhelming infection or immune system problems may not be able to produce a fever and may have a normal or low body temperature. • Fever with abnormal vital signs and/or any of the four key acute conditions listed above will likely require early antibiotic (and/or anti-malarial) treatment. • Always consider whether local screening protocols for infectious disease outbreaks (e.g. for haemorrhagic fevers) require further action (e.g. special reporting or management) in a person with fever. Obstetric delivery and neonatal resuscitation Management of obstetric delivery and neonatal resuscitation are critical topics covered else- where in existing WHO materials and are not covered in this course. See the WHO Maternal, Newborn, Child and Adolescent Health department website (http://www.who.int/maternal_ child_adolescent/documents/en/) for training materials on these topics. INTRODUCTION 4 Expected participant background knowledge This course assumes a basic knowledge in the following areas: Use of personal protective equipment Basic human anatomy Basic history taking Basic physical examination skills, including taking vital signs, chest auscultation and abdominal assessment Use of a glucometer Set up of an intravenous (IV) infusion Safe intramuscular injection Cardiopulmonary resuscitation (CPR) Cardiopulmonary resuscitation (CPR) The decision about whether or not CPR is appropriate for a specific patient depends on many factors, including understanding of the cause of the condition, knowledge of available resources, and awareness of relevant institutional protocols and practices. There are many situations where it may be appropriate to initiate and then terminate CPR after a certain interval, and others where it may not be appropriate to initiate CPR. While this course addresses several aspects of resuscitation, it does not cover general CPR protocols, as they may vary greatly by setting. Course facilitators should direct participants to the appropriate source for relevant CPR protocols. Medication The medications discussed in this course are widely available and appropriate for use by the frontline providers for whom the course is designed. They can be used in pre-hospital or facility- based settings and are important early treatments for emergency conditions. The included medications provide a foundation for initial emergency care, but almost every condition discussed in this workbook will require treatments beyond those listed. Many important emergency treatments used by advanced providers are not included in this course. Handover/transfer This course is designed to help providers identify and provide initial management for acute, life-threatening conditions. Most acutely ill patients will require care beyond this initial stage. This may be ongoing care delivered by the same provider, but more often will require handover to a more advanced provider or facility. This process of deciding the appropriate disposition – or next step of care – for the acutely ill patient is a vital part of emergency care. Choosing an appropriate disposition involves assessing severity; estimating how rapidly the condition may progress; considering whether transfer for a specific intervention (e.g. surgery, blood transfusion) is needed; and identifying any specific risks based on a suspected or known diagnosis (e.g. risk of recurrent seizure/convulsion, or worsening airway blockage). The special disposition considerations for each key acute presentation and its associated diagnoses are covered in the modules. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 5 Planning for handover/transfer requires communicating essential information with the receiving facility, creating a transport plan, and ensuring availability of the necessary supplies to protect providers and care for patients. These components will be covered in detail in “Transfer and handover” in the Skills section. Triage Triage is the systematic process of classifying patients by acuity to ensure the best match between available resources and user needs. Triage is an essential component of emergency care during routine and surge conditions, and is a higher-level process applied to all patients, allowing assessment of the individual patient in context. As such, it is not addressed in this course, but is often taught at the same time. WHO and ICRC, in collaboration with Médecins Sans Frontières (MSF) and the South African Triage Score (SATS) team, have developed a set of integrated triage tools and an associated open-access training module. Contact emergencycare@who.int to request these materials. Approach to the emergency patient The BEC course is intended for a wide range of frontline providers and offers a basic approach for life-threatening presentations. Emergency conditions often require urgent intervention long before a diagnosis is established, and a presentation-based approach is essential to managing patients effectively. The modules in this course teach the elements of a general approach that can be used for any emergency patient. Aaron The ABCDE approach allows rapid assessment and intervention for life threats using the following categories: A: AIRWAY B: BREATHING C: CIRCULATION D: DISABILITY E: EXPOSURE Essential ABCDE considerations are listed in the modules for each of the four key presentations. The SAMPLE history is a method of rapidly gathering the history critical to the management of the acutely ill patient. The SAMPLE history categories are: S: SIGNS AND SYMPTOMS A: ALLERGIES M: MEDICATIONS P: PAST MEDICAL HISTORY L: LAST ORAL INTAKE E: EVENTS SURROUNDING ILLNESS Essential SAMPLE questions are listed in the modules for each of the four key presentations. INTRODUCTION 6 The secondary survey is a complete physical examination based on the specific condition. The essential relevant components of the secondary survey are listed in the modules for each of the four key presentations. Further details are covered in the Skills section. How to use this Participant Workbook This Participant Workbook is linked with the WHO BEC course presentations and is designed to help participants prepare for each lesson to maximize learning. Each module provides reading material and exercises to complete before the lesson. Participants should not worry if there are elements they do not fully understand while reading alone, as all workbook content will be reviewed during the lessons. Before each lesson, participants should: write out the definitions for the Key terms of the relevant module by copying from the Glossary in the back of the workbook; complete all workbook review questions in the relevant modules. The multiple choice questions and case scenarios at the end of each module will be covered in the small group sessions during the course, but participants should read through them before the session. On completion of the course, participants can use this book for reference. Accompanying the book are reference quick cards. These cards provide a summary of the essential points from the course and are designed to be carried in the clinical setting to guide day-to-day practice. Module format This course includes one module on the general approach to all emergency patients (ABCDE and SAMPLE); one module on the approach to injured patients (trauma); three modules on other specific clinical presentations (difficulty in breathing, shock, and altered mental status); a skills section; and a Glossary. The modules include the following sections: Objectives: A list of things participants should be able to do by the end of the course. Essential skills: A list of skills relevant to the module (and later taught in the Skills section). Key terms: Important words and phrases needed to understand the module. All definitions can be found in the Glossary and should be written in the space provided prior to the lecture. Overview: A brief introduction to the clinical presentation being discussed in the module. Goals of initial assessment: The main purpose of the assessment of the clinical presentation. Goals of acute management: The desired result of the management of the clinical condition. ABCDE key elements: ABCDE findings and interventions related to the specific clinical condition addressed in the module. Key history findings (ASK): Specific SAMPLE history elements related to the clinical presentation that are critical for management. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 7 Secondary survey findings (CHECK, including Look, Listen and Feel): Relevant secondary examination findings to check for in the clinical presentation the module addresses. Possible causes: Specific diseases, injuries, or illnesses that can cause the condition presented in the module (along with their specific signs and symptoms). Management (DO): These sections describe management of specific conditions. Note that the ABCDE and Trauma modules have much longer lists of possible emergency conditions, and the Possible causes and Management sections are presented in tables. The Trauma module has a separate table for Primary Survey conditions. Special considerations in children: Important differences in the signs and symptoms and management needs of children. Disposition considerations: Specific things to consider when transferring or handing over patients. Facilitator-led case scenarios: These scenarios test participants’ ability to use what they have learned to manage a patient. These scenarios will be led by the instructor. Multiple choice questions (MCQ): There are five multiple choice questions to test your knowledge at the end of each module in preparation for the final written exam. Participant requirements Participants should confirm course requirements with their facilitator. When implemented in full, the Basic Emergency Care course requires completion of ALL components listed below. Pre-test. Before receiving the Basic Emergency Care course workbook, participants should have completed this brief confidential test, which helps facilitators understand their current knowledge level. Attendance report. Participants must sign in for both the morning and afternoon sessions each day. Participants must attend all sessions to pass the course. Workbook completion. As described above, participants should complete all key terms and workbook questions in the relevant module prior to each lesson. All key terms must be defined, and all workbook questions answered for the workbook to be considered completed. The workbooks will be reviewed each day by facilitators. Participants must complete the workbook to pass the course. Skill stations. During the skills day, facilitators will demonstrate skills at a practical station. Participants will have an opportunity to practise the skill at each station several times. Participants may practise a skill as many times as needed within the allotted station time. During practice, participants may use the workbook and skill checklist for reference, and may ask questions as needed of facilitators. During assessment, no reference materials will be allowed, so participants should also practise without references, and have another participant observe for any missed steps. Participants will have plenty of time to practise and feel confident with the skills prior to assessment, and when ready, should request that an instructor assess them performing the skill. All steps in the skill checklist must be performed to pass the assessment. Participants must pass the skill station assessments to pass the course. INTRODUCTION 8 Case scenarios. All participants must successfully lead and manage a case scenario to pass the course. These scenarios give participants an opportunity to practise an integrated approach to management in small groups of 3–4 participants. Facilitators will discuss with the group how to approach the case scenarios using the ABCDE approach. In the later modules, each participant will be assessed on the ability to lead and manage a case scenario. Leading a case scenario includes identifying critical aspects of assessment and management, as well as presenting a handover summary (see the Handover section in Skills). Facilitators will complete the checklist below to assess the participant leading the case. Participants who are unsuccessful in identifying and managing the critical conditions in the scenario will be given a second case in the same or a subsequent session. Assessments are based on a standardized guide and reported on the form below. Case scenario assessment Not identified Identified some Identified all Critical airway interventions Critical breathing interventions Critical circulation interventions Critical disability interventions Critical exposure interventions Critical medications (if needed) Gave appropriate brief handover summary Yes No Participant performed all essential components Yes No Comments (including notation of any missed elements): Written final exam To qualify to sit the final examination participants must: complete the pre-test; complete the key terms and workbook questions; attend all course sessions; lead a case scenario; pass all skill stations as examined by an instructor. The final examination will include multiple choice questions. Participants must score at least 75% to pass. Your input will help improve future training courses. Please send any comments, corrections or questions to emergencycare@who.int. We encourage all participants and facilitators to fill out a short pre- and post-course survey at www.who.int/emergencycare. PARTICIPANT WORKBOOK 9 The ABCDE and SAMPLE history approach 10 Notes ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 11 Module 1: The ABCDE and SAMPLE history approach OBJECTIVES On completing this module you should be able to: 1. list the hazards that must be considered when approaching an ill or injured person; 2. list the elements to approaching an ill or injured person safely; 3. list the components of the systematic ABCDE approach to emergency patients; 4. assess an airway; 5. explain when to use airway devices; 6. explain when advanced airway management is needed; 7. assess breathing; 8. explain when to assist breathing; 9. assess fluid status (circulation); 10. provide appropriate fluid resuscitation; 11. describe the critical ABCDE actions; 12. list the elements of a SAMPLE history; 13. perform a relevant SAMPLE history. Essential skills • Assessing ABCDE • Cervical spine immobilization • Full spine immobilization • Head-tilt and chin-lift/jaw thrust • Airway suctioning • Management of choking • Recovery position • Nasopharyngeal and oropharyngeal airway placement • Bag-valve-mask ventilation • Oxygen administration • Skin pinch test • AVPU (alert, voice, pain, unresponsive) assessment • Glucose administration • Needle decompression for tension pneumothorax • Three-sided dressing for chest wound • Intravenous (IV) line placement • IV fluid resuscitation • Direct pressure for haemorrhage control, including deep wound packing • Tourniquet for haemorrhage control • Pelvic binding • Wound management • Fracture immobilization • Snake bite management Module 1: The ABCDE and SAMPLE history approach 12 KEY TERMS Write the definition using the Glossary at the back of the workbook. ABCDE: Accessory muscle use: Altered mental status (AMS): Anaphylaxis: AVPU: Bag-valve-mask (BVM): Capillary refill: Cardiopulmonary resuscitation (CPR): Cervical spine (c-spine): Convulsion: Crackles (crepitations): Crepitus: Deep wound packing: Defibrillator: Diaphoresis: Difficulty in breathing (DIB): Disposition: Foreign body: INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 13 GCS (Glasgow Coma Scale): Hives: Haematoma: Haemorrhage: Haemothorax: Hyperresonance: Hyperthermia: Hypoglycaemia: Hypothermia: Hypotension: Hypoxia: Inhalation injury: Intubation: Large bore IV: Nasal flaring: Nasopharyngeal airway (NPA): Needle decompression: Oedema: Oropharyngeal airway (OPA): Oxygen saturation (O2 sat): Module 1: The ABCDE and SAMPLE history approach 14 Percussion: Perfusion: Pericardial tamponade: Personal protective equipment (PPE): Pleural effusion: Pneumothorax: Pulse oximeter: Retractions: SAMPLE history: Seizure: Shock: Stridor: Sucking chest wound: Tachypnoea: Tension pneumothorax: Wheezing: INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 15 OVERVIEW Approaching every patient in a systematic way ensures that life-threatening conditions are recognized promptly and that the most critical interventions are done first. In a stable patient, the initial ABCDE approach may only take seconds to a few minutes. The ABCDE should be followed by a rapid history using the SAMPLE approach (Signs and Symptoms, Allergies, Medications, Past medical history, Last oral intake and Events). The SAMPLE history categories are described in general below, and essential questions for a specific presentation are listed in the relevant module. Using the standard SAMPLE and ABCDE approach together ensures that different providers can easily communicate about acutely ill patients. The goal of the ABCDE approach is to rapidly identify life-threatening conditions; ensure the airway stays open; and ensure that breathing and circulation are adequate to deliver oxygen to the body. The goal of the SAMPLE approach is to rapidly gather history critical to the management of the acutely ill patient. This module will address: Safety considerations Elements of the ABCDE approach In-depth: acute life-threatening conditions (signs, symptoms and management) Paediatric considerations in the ABCDE approach Elements of the SAMPLE history Disposition considerations SAFETY CONSIDERATIONS A critical part of the approach to any ill or injured patient is keeping providers and others safe. An ill or injured provider will be unable to help anyone, and instead becomes an extra patient for other responders to treat. Safety consideration involves checking for: scene hazards. Is there a fire, electrical wire or chemical spill that could injure providers or bystanders? At a road traffic crash, is the scene closed to oncoming traffic? If a building has collapsed, is it safe to enter? At the scene of an explosion, always consider the possibility of further explosions. Remember that delayed building collapse may follow explosions, fires and earthquakes. violence. Is there a chance that providers may be harmed by the patient or by others? For patients who are aggressive or agitated, request help as needed from security personnel or police before beginning your assessment. infectious disease risk. Is there a possibility for disease exposure (such as flu or haemorrhagic fever)? Module 1: The ABCDE and SAMPLE history approach 16 USE PERSONAL PROTECTIVE EQUIPMENT You may not know the cause of illness or injury when you first approach a patient, and without appropriate personal protective equipment (PPE), may expose yourself to diseases, chemicals or poisons. You must use appropriate PPE every time you approach a patient. Always protect yourself from any exposure to bodily fluids. This will almost always require gloves and eye protection, and may require a gown and mask. Some circumstances, such as suspected or confirmed haemorrhagic fever outbreaks, require specific protective practices. Always be sure that you are up-to-date on current local recommendations. CLEANING AND DECONTAMINATION Infectious disease exposure is a significant risk. Use PPE and wash your hands before and after every patient contact. At the scene, hand washing may not be immediately possible; carry an alcohol gel cleanser if possible. Between patients, clean and disinfect all facility and vehicle surfaces and all reusable equipment. Decontamination may be required after exposure to pesticides or other chemicals (dry or wet) and, depending on the chemical, may include washing or brushing to remove the substance. Not all chemicals can be safely washed away, and some must be removed in specific ways to avoid further injury. You must wear appropriate PPE for this. Refer to local decontamination protocols for people and equipment. ASK FOR MORE HELP IF NEEDED If multiple people are injured or ill, call for help or send someone to call. If advanced care is needed, begin making arrangements as early as possible for consultations or transfers. Know the relevant local agencies to contact for suspected outbreaks or hazardous exposures, such as chemical spills or radiation. There is often support and guidance available for containment and decontamination. Workbook question 1: Safety A person walks into your health post vomiting, bleeding from the mouth, and complaining of abdominal pain. Using the workbook section above, describe what is needed to safely approach this person: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 17 ELEMENTS OF THE ABCDE APPROACH The ABCDE approach The ABCDE approach provides a framework for the systematic and organized evaluation of acutely ill patients in order to rapidly identify and intervene for life-threatening conditions: A – Airway: check for and correct any obstruction to movement of air into the lungs B – Breathing: ensure adequate movement of air into the lungs C – Circulation: evaluate whether there is adequate perfusion to deliver oxygen to the tissues; check for signs of life-threatening bleeding D – Disability: assess and protect brain and spine functions E – Exposure: identify all injuries and any environmental threats and avoid hypothermia This stepwise approach is designed to ensure that life-threatening conditions can be identified and treated early, in order of priority. If a problem is discovered in any of these steps, it must be addressed immediately before moving on to the next step. The ABCDE approach should be performed in the first 5 minutes and repeated whenever a patient’s condition changes or worsens. Module 1: The ABCDE and SAMPLE history approach 18 THE ABCDE ASSESSMENT AND MANAGEMENT REMEMBER... Always check for signs of trauma in each of the ABCDE sections, and reference the trauma module as needed. [see TRAUMA] ASSESSMENT IMMEDIATE MANAGEMENT Airway A Can the patient talk normally? If YES, the airway is open. If the patient cannot talk normally: • look to see if the chest wall is moving and listen to see if there is air movement from the mouth or nose. • listen for abnormal sounds (such as stridor, grunting, or snoring) or a hoarse or raspy voice that indicates a partially obstructed airway. – Stridor plus swelling and/or hives suggest a severe allergic reaction (anaphylaxis). • Look and listen for fluid (such as blood, vomit) in the airway. • Look for foreign body or abnormal swelling around the airway, and altered mental status. • Check if the patient is able to swallow saliva or is drooling. • If the patient is unconscious and not breathing normally and: – NO TRAUMA: open the airway using the head-tilt and chin-lift manoeuvre. [See SKILLS] – CONCERN FOR TRAUMA: maintain cervical spine immobilization and open the airway using the jaw thrust manoeuvre. [See SKILLS] – Place an oropharyngeal or nasopharyngeal airway to maintain the airway. [See SKILLS] • If a foreign body is suspected: – If the object is visible, remove it – be careful not to push the object any deeper. – If the patient is able to cough or make noises, keep the patient calm and encourage coughing. – If the patient is choking (unable to cough, not making sounds) use age-appropriate chest thrusts/ abdominal thrusts/back blows. [See SKILLS] – If the patient becomes unconscious while choking, follow relevant CPR protocols. • If secretions or vomit are present, suction when available, or wipe clean. Consider placing patient in the recovery position if the rest of the ABCDE is normal and no trauma is suspected. [See SKILLS] • If the patient has swelling, hives or stridor, consider severe allergic reaction (anaphylaxis), and give intramuscular adrenaline. [See SKILLS] • Allow the patient to stay in a position of comfort and prepare for rapid handover/transfer to a centre capable of advanced airway management, if needed. If the airway is open, move onto “Breathing”. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 19 ASSESSMENT IMMEDIATE MANAGEMENT Breathing B • Look, listen, and feel to see if the patient is breathing. • Assess if breathing is very fast, very slow, or very shallow. • Look for signs of increased work of breathing (such as accessory muscle use, chest indrawing/ retractions, nasal flaring) or abnormal chest wall movement. • Listen for abnormal breath sounds such as wheezing or crackles. [See DIFFICULTY IN BREATHING] • With severe wheezing, there may be limited/no breath sounds on examination because narrowing of the airways may be so severe that breathing cannot be heard. • Listen to see if breath sounds are equal on both sides. • Check for the absence of breath sounds and dull sounds with percussion on one side (large pleural effusion or haemothorax). [See SKILLS] • If there are no breath sounds on one side, and hypotension, check for distended neck veins or a shifted trachea (tension pneumothorax). • Check oxygen saturation with a pulse oximeter when available. • If unconscious with abnormal breathing, start bag-valve-mask ventilation and follow relevant CPR protocols. • If not breathing adequately (too slow for age or too shallow), begin bag-valve-mask ventilation with oxygen [See SKILLS]. If oxygen not immediately available, DO NOT DELAY ventilation. Start ventilation while oxygen is being prepared. Plan for rapid handover/transfer. • If breathing fast or hypoxic, give oxygen [See SKILLS] • If wheezing, give salbutamol. [See SKILLS] Repeat salbutamol as needed. • If concern for severe allergic reaction (anaphylaxis), give intramuscular adrenaline. [See SKILLS] • If concern for tension pneumothorax, perform needle decompression immediately and give IV fluids and oxygen. [See SKILLS] Plan for rapid handover/ transfer. • If concern for large pleural effusion or haemothorax, give oxygen and plan for rapid handover/transfer. • If cause unknown, remember the possibility of trauma [See TRAUMA] If breathing is adequate, move onto “Circulation”. Circulation C • Look and feel for signs of poor perfusion (cool, moist extremities, delayed capillary refill greater than 3 seconds, low blood pressure, tachypnoea, tachycardia, absent pulses). • Look for both external AND internal bleeding, including bleeding: – into chest; – into abdomen; – from stomach or intestine; – from pelvic or femur fracture; – from wounds. • Look for hypotension, distended neck veins and muffled heart sounds that might indicate pericardial tamponade. • For cardiopulmonary arrest, follow relevant CPR protocols. • If signs of poor perfusion, give IV fluids and oxygen [See SKILLS] and: – For external bleeding, apply direct pressure or use other technique to control. [See SKILLS] – If internal bleeding or pericardial tamponade are suspected, refer rapidly to a centre with surgical capabilities. If cause unknown, remember the possibility of trauma: Bind pelvic fractures and splint femur fractures, or any fracture with compromised blood flow. [See TRAUMA and SKILLS] If circulation is adequate, move onto “Disability”. Module 1: The ABCDE and SAMPLE history approach 20 ASSESSMENT IMMEDIATE MANAGEMENT Disability D • Assess level of consciousness with the AVPU scale (Alert, Voice, Pain, Unresponsive) or in trauma cases, the Glasgow Coma Scale (GCS). [See SKILLS] • Always check glucose level in the confused or unconscious patient. • Check for pupil size, whether the pupils are equal, and if pupils are reactive to light. • Check movement and sensation in all four limbs. • Look for abnormal repetitive movements or shaking on one or both sides of the body (seizure/convulsion). • If altered mental status and no evidence of trauma, place in recovery position. [See SKILLS] • If glucose low (<3.5 mmol/L) or glucose test not available and patient has altered mental status, give glucose. [See SKILLS] • For active seizures, give a benzodiazepine. [See SKILLS] • If pregnant and having seizures, give magnesium sulphate. [See SKILLS] • If pupils are small and breathing slow, consider opioid overdose and give naloxone. [See SKILLS] • If pupils are not equal, consider increased pressure on the brain and raise head of bed 30 degrees if no concern for spinal injury. Plan for rapid transfer to an advanced provider or facility with neurosurgical care. If cause unknown, remember possibility of trauma: Immobilize the cervical spine if concern for trauma. [See TRAUMA and SKILLS] Exposure E • Examine the entire body for hidden injuries, rashes, bites or other lesions. • Rashes, such as hives, can indicate allergic reaction, and other rashes can indicate serious infection. • If snake bite is suspected, immobilize the limb. [See SKILLS] Take a picture of the snake if possible from a distance and send with patient. Do not risk additional bites to catch/kill snake. • Remove constricting clothing and all jewelry. • Cover the patient as soon as possible to prevent hypothermia. Acutely ill patients have difficulty regulating body temperature. • Remove any wet clothes and dry patient thoroughly. • Respect the patient and protect modesty during exposure. If cause unknown, remember the possibility of trauma: Log roll if suspected spinal injury [See TRAUMA and SKILLS] INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 21 ABCDE IN DEPTH: ACUTE, LIFE-THREATENING CONDITIONS This section takes a deeper look at conditions that must be managed during the ABCDE approach. AIRWAY conditions A CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT Obstruction due to foreign body • Visible secretions, vomit or foreign bodies in the airway • Abnormal sounds from the airway (such as stridor, snoring, gurgling) • Mental status changes leading to airway obstruction from the tongue • Poor chest rise The airway can become obstructed by secretions, vomit or foreign bodies. • Remove the foreign body if possible and suction fluid. Be careful not to push a foreign body further into the airway. Do not try to remove a foreign body unless clearly visible. • Use age-appropriate chest thrusts/abdominal thrusts/back blows if the airway is completely obstructed. [See SKILLS] • The tongue may obstruct the airway in patients with a decreased level of consciousness. – Open the airway using a head-tilt and chin- lift manoeuvre, or use jaw thrust (if there is concern for trauma); and place an oral or nasopharyngeal airway as needed. [See SKILLS] – These patients may also not be able to protect their airway and need to be watched for vomiting and aspiration. • Plan for rapid handover/transfer to advanced provider capable of advanced airway management if the obstruction cannot be removed. Obstruction due to burns • Burns to head and neck • Burned nasal hairs or soot around the nose or mouth • Abnormal sounds from the airway (such as stridor) • Change in voice • Poor chest rise Burns can cause airway swelling due to inhalational injuries. • Give oxygen to ALL patients with suspected airway burn even if they do not show signs of hypoxia. [See SKILLS] • Open the airway using appropriate manoeuvre and place an oral or nasopharyngeal airway as needed. [See SKILLS] • Maintain cervical spine immobilization if there is evidence of trauma. [See SKILLS] • The airway can swell and close off very quickly in burn patients. Plan for rapid handover/transfer to a provider capable of advanced airway management. Module 1: The ABCDE and SAMPLE history approach 22 CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT Obstruction due to severe allergic reaction (anaphylaxis) • Mouth, lip, and tongue swelling • Difficulty breathing with stridor and/or wheezing • Rash or hives (patches of pale or red, itchy, warm, swollen skin) • Tachycardia and hypotension • Abnormal sounds from the airway (such as stridor, snoring, gurgling) • Poor chest rise Severe allergic reactions can cause swelling of the airway that can lead to obstruction. • Give intramuscular adrenaline for airway obstruction, severe wheezing or shock. [See SKILLS] – Adrenaline can wear off in minutes so be prepared to give additional doses. • Place an IV and give IV fluids. [See SKILLS] • Reposition airway as needed (sit patient upright if no trauma) and give oxygen. [See SKILLS] • If severe or not improving, prepare for rapid handover/transfer for advanced airway management. Obstruction due to trauma • Neck haematoma or injuries to head and neck • Abnormal sounds from the airway (such as stridor, snoring, gurgling) • Change in voice • Poor chest rise Airway obstruction may result from injuries to the head or neck. Blood, bone or damaged tissue may block the airway. Penetrating wounds to the neck may also cause obstruction due to swelling or expanding haematoma. • Suction to remove any blood that might block the airway. • Open the airway using jaw thrust only (do not use head-tilt/chin-lift); and place an oral airway as needed (do not use nasopharyngeal airways if there is facial trauma). [See SKILLS} • Maintain cervical spine immobilization if there is evidence of trauma. [See SKILLS] • Plan for rapid handover/transfer to advanced provider capable of advanced airway management or surgical intervention. For any abnormal airway sounds, re-assess airway frequently as partial obstruction may worsen rapidly and block airway. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 23 BREATHING conditions B CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT Tension pneumothorax Hypotension WITH difficulty in breathing AND any of the following: • distended neck veins • absent breath sounds on affected side • hyperresonance with percussion on affected side [See SKILLS] • tracheal shift away from affected side Any pneumothorax can become a tension pneumothorax. Air in the cavity between the lungs and the chest wall can collapse the lung (simple pneumothorax). Building pressure (tension) from a large pneumothorax can displace and block flow from the main vessels back to the heart, causing shock (tension pneumothorax). • If tension pneumothorax is suspected, perform emergency needle decompression. [See SKILLS] • Give oxygen. [See SKILLS] • Give IV fluids. [See SKILLS] • Arrange for rapid handover/transfer to an advanced provider capable of placing a chest tube. Suspected opioid overdose • Slow respiratory rate • Hypoxia • Very small pupils Opioid medications (such as morphine, pethidine, and heroin) can decrease the body’s drive to breathe. • Give naloxone to reverse the effects of opioids. [See SKILLS] – Monitor closely as naloxone will wear off and additional doses may be needed. • Give oxygen. [See SKILLS] Asthma/ COPD (chronic obstructive pulmonary disease) • Wheezing • Cough • Accessory muscle use • May have history of asthma/COPD diagnosis, allergies or smoking Asthma and COPD are conditions causing spasm in the lower airways, resulting in narrowing that causes difficulty in breathing and wheezing. • Administer salbutamol as soon as possible. (Salbutamol helps to relieve the spasm in the air passages) [See SKILLS] • Give oxygen if indicated. [See SKILLS] Large pleural effusion/ haemothorax • Decreased breath sounds on affected side • Dull sounds with percussion on affected side [See SKILLS] • If there is a large amount of fluid, may have shock Pleural effusion occurs when fluid builds up in the space between the lung and the chest wall or diaphragm. As the fluid builds up, it limits expansion of the lungs. • Give oxygen. [See SKILLS] • Arrange for handover/transfer immediately (many of these patients will need a procedure to drain fluid). If cause unknown, remember the possibility of trauma [See TRAUMA] Module 1: The ABCDE and SAMPLE history approach 24 CIRCULATION conditions C CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT Pulselessness • No pulse • Unconscious • Not breathing Follow relevant cardiopulmonary resuscitation (CPR) protocols. Shock • Rapid heart rate (tachycardia) • Rapid breathing (tachypnoea) • Pale and cool skin • Capillary refill>3 seconds • Sweating (diaphoresis) • May have dizziness, confusion, altered mental status • May have hypotension Poor perfusion is the failure to deliver enough oxygen-carrying blood to the vital organs. When poor perfusion continues until organ function is affected, this is called shock and can lead rapidly to death. • Initial treatment for shock includes laying the patient flat (if tolerated). • Give oxygen. [See SKILLS] • Control bleeding. [See SKILLS] • Start an IV and give IV fluids. [See SKILLS] • If there are signs of infection, give antibiotics if available. • Prepare for rapid handover/transfer. Severe bleeding (haemorrhage) • Bleeding wounds • Bruising around the umbilicus (belly button) or over the flanks can be a sign of internal bleeding • Bleeding from the rectum or vagina or in vomit • Pelvic fracture • Femur fracture • Decreased breath sounds on one side of the chest (haemothorax) • Signs of poor perfusion (such as hypotension, tachycardia, pale skin, diaphoresis) External bleeding that is not controlled can lead quickly to shock. A large quantity of blood can also be lost into the chest, pelvis, thigh and abdomen before the bleeding is recognized. • Stop the bleeding. Depending on the source, use: – direct pressure [See SKILLS] – deep wound packing [See SKILLS] – a tourniquet [See SKILLS] – pelvic binder or femur splint. [See SKILLS] • Give IV fluids. [See SKILLS] • Refer for blood transfusion and ongoing surgical management if needed. A tourniquet should be used only for life- threatening bleeding. Pericardial tamponade • Signs of poor perfusion (tachycardia, tachypnoea, hypotension, pale and cool skin, cold extremities, capillary refill >3 seconds) • Distended neck veins • Muffled heart sounds • May have dizziness, confusion, altered mental status Pericardial tamponade occurs when fluid builds up in the sac around the heart. The pressure from this fluid can collapse the chambers of the heart and keep them from filling properly, limiting blood flow to the tissues and causing shock. Treatment is drainage by pericardiocentesis. • In order to keep the patient alive until the fluid around the heart can be drained, give IV fluids to ensure that as much volume as possible enters the heart. [See SKILLS] • Refer rapidly for surgical management. If cause unknown, remember the possibility of trauma [See TRAUMA] INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 25 DISABILITY conditions D CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT Hypoglycaemia • Sweating (diaphoresis) • Altered mental status (ranging from confusion to unconsciousness) • Seizures/convulsions • Blood glucose <3.5 mmol/L • History of diabetes, malaria or severe infection • Responds quickly to glucose Patients with hypoglycaemia (low blood sugar) need glucose immediately. [See SKILLS] • If the person can speak and swallow, give oral glucose. • If the person cannot speak or is unconscious, give IV glucose if possible. • If IV glucose is not possible or available, give buccal (inside of the cheek) glucose. [See SKILLS] Increased pressure on the brain • Headache • Seizures/convulsions • Nausea, vomiting • Altered mental status • Unequal pupils • Weakness on one side of the body Increased pressure on the brain can occur from trauma, tumours, increased fluid, bleeding or infections. Because the skull is rigid, any swelling, fluid, or mass increases the pressure around the brain, limiting blood flow and possibly displacing brain tissue, causing death. • Raise the head of the bed to 30 degrees if there is no concern for trauma and there is no hypotension. • Check glucose. [See SKILLS] • If there are seizures/convulsions, give a benzodiazepine. [See SKILLS] • The pressure must be reduced as quickly as possible. Arrange for rapid handover/transfer to a surgical centre. Seizure/ convulsion Signs and symptoms of active seizure: • Repetitive movements, gaze fixed to one side or alternating rhythmically and not responsive. Sign and symptoms of recent seizure: • Bitten tongue • Urinated on self • Known history of seizures/convulsions • Confusion that gradually improves over minutes to hours The goal in managing seizures/convulsions is to prevent hypoxia and injury. • Protect the seizing person from falls and from any hard or sharp objects nearby. • Do not place anything in the mouth of a person with active seizure except to suction airway. [See SKILLS] • Give oxygen. [See SKILLS] • Check blood glucose. Give glucose if <3.5 mmol/L. [See SKILLS] • Treat with a benzodiazepine [See SKILLS] and monitor closely for slowing or difficult breathing. • Place patient in recovery position if there is no trauma suspected. [See SKILLS] • If the patient is pregnant, or recently gave birth, give magnesium sulphate. [See SKILLS] If cause unknown, remember the possibility of trauma [See TRAUMA] Module 1: The ABCDE and SAMPLE history approach 26 EXPOSURE conditions E CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT Snake bite • History of snake bite • Bite marks may be seen • Oedema • Blistering of the skin • Bruising • Hypotension • Paralysis • Seizures • Bleeding from wounds The goal of managing snake bites is to limit the spread of the venom and the effects of venom on the body. • Immobilize the extremity. [See SKILLS] • Take a picture of the snake when possible and send with the patient (for example, with the patient’s mobile phone). • Give IV fluids if evidence of shock. [See SKILLS] • These patients may have delayed shock or airway problems. Monitor closely and plan early for rapid handover/transfer. Vital signs should be checked at the end of the ABCDE A full set of vital signs (blood pressure, heart rate, respiratory rate, and oxygen saturation if available) should be performed after the ABCDE approach. Do not delay ABCDE interventions for vital signs. ABCDE SHOULD BE REPEATED FREQUENTLY The ABCDE approach is designed to quickly identify reversible life-threatening conditions. Ideally, the ABCDE approach should be repeated at least every 15 minutes or with any change in condition. Workbook question 2: ABCDE approach Using the workbook section above, list the management for airway blocked by a foreign body. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 27 PAEDIATRIC ABCDE CONSIDERATIONS While the ABCDE approach is used in both adults and children, there are some aspects of assessing and managing children that are different from adults. The “Paediatric considerations” sections throughout the workbook highlight these differences. Paediatric considerations Pediatric airway conditions A Excessive drooling, stridor, airway swelling and unwillingness to move the neck are all high-risk signs in children. Look carefully in the airway for foreign bodies, burns or obstruction. Allow the child to remain in a position of comfort. Position airway as needed below. Compared to adults, children have: So you must do this: Bigger tongues. • Place the child in the “sniffing” position (modified head-tilt, chin-lift – like the slight upward and forward tilt of the head when sniffing a flower). Shorter necks with airways that are softer and more easily blocked. • Avoid over-extending or flexing the neck. A larger head compared to the rest of the body. • Watch closely for airway obstruction. • Use the jaw thrust if airway is not open. [See SKILLS] • Position head (using padding under shoulders for very small children) to open airway if no trauma. [See SKILLS] Neutral position in infants page 2 For choking, use age-appropriate chest thrusts/abdominal thrusts/back blows. [See SKILLS] Module 1: The ABCDE and SAMPLE history approach 28 Pediatric breathing conditions B • Nasal flaring, head bobbing, grunting and chest indrawing OR retractions, are signs of respiratory distress in children. • CYANOSIS – a blue/grey discoloration around the lips, mouth or fingertips – is the result of a lack of oxygen and is a danger sign. • CHEST INDRAWING is a common presentation of paediatric accessory muscle use. – Look at the lower chest wall (lower ribs). The child has chest indrawing if the lower chest wall goes IN when the child breathes IN. – In normal breathing, the whole chest wall (upper and lower) and the abdomen move OUT when the child breathes IN. • A SILENT CHEST (no breath sounds when you listen to the chest) is a sign of severe respiratory distress in a child. With severe spasm and narrowing of the airways, there may be limited air movement and few breath sounds on exam. Give salbutamol and oxygen and re-assess frequently. [See SKILLS] • STRIDOR signals severe airway compromise, and there are many possible causes. Children with stridor should be allowed to stay in a position of comfort and transferred immediately to an advanced provider. Further treatment will often include nebulized adrenaline. If immediate transfer is not possible, consider intramuscular adrenaline as per severe allergic reaction treatment. [See SKILLS] Pediatric circulation conditions C • MANAGEMENT OF POOR PERFUSION IN CHILDREN MAY CHANGE based on the cause and on the condition of the child. [See SHOCK and SKILLS modules] • LOW BLOOD PRESSURE IN A CHILD IS A SIGN OF SEVERE SHOCK. Children are able to maintain normal blood pressure for longer than adults when in shock. Closely monitor other signs of poor perfusion, such as decreased urine output and altered mental status. • THE AMOUNT OF INTRAVENOUS FLUID GIVEN TO CHILDREN IS DIFFERENT FROM ADULTS. [See SKILLS] • IN MALNOURISHED CHILDREN, both the rate of fluid administration and the type of fluid are different. [See SKILLS] • SEVERE SIGNS: Sunken fontanelle, poor skin pinch [See SKILLS], lethargy, altered mental status. Chest indrawing page 33 Chest indrawing INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 29 Pediatric disability conditions D • LOW BLOOD GLUCOSE is a very common cause of altered mental status in sick children. – If possible, check blood glucose in children with altered mental status. – When it is not possible to check the blood glucose level, administer glucose. • Always check for seizure/convulsions. • It is sometimes difficult to determine if infants are acting normally. Always ask the person caring for the child. Pediatric exposure conditions E • INFANTS AND CHILDREN HAVE DIFFICULTY MAINTAINING TEMPERATURE and can very quickly become hypothermic (low body temperature) or hyperthermic (high body temperature). – Remove wet clothing and dry skin thoroughly. Place infants skin-to-skin when possible. – For hypothermia, be sure to cover infants’ heads (but do not obstruct face). – For hyperthermia, unbundle tightly wrapped infants. PAEDIATRIC DANGER SIGNS IN ABCDE In addition to performing a thorough ABCDE approach, all paediatric patients should be evaluated for the presence of danger signs. Children with danger signs need URGENT attention and referral/ handover to a provider able to provide advanced paediatric care. Paediatric danger signs include: • Signs of airway obstruction (stridor or drooling/unable to swallow saliva) • Increased breathing effort (fast breathing, nasal flaring, grunting, chest indrawing or retractions) • Cyanosis (blue colour of the skin, especially at the lips and fingertips) • Altered mental status (including lethargy or unusual sleepiness, confusion, disorientation) • Moves only when stimulated or no movement at all (AVPU other than “A”) • Not feeding well or cannot drink or breastfeed • Vomiting everything • Seizures/convulsions • Low body temperature (hypothermia) Module 1: The ABCDE and SAMPLE history approach 30 Workbook question 3: ABCDE approach Using the workbook section above, list one of each of the following: a paediatric airway consideration ______________________________________________________________________ a paediatric breathing consideration ______________________________________________________________________ a paediatric circulation consideration ______________________________________________________________________ a paediatric disability consideration ______________________________________________________________________ a paediatric exposure consideration ______________________________________________________________________ Elements of the SAMPLE history The SAMPLE approach is a standard way of gathering the key history related to an illness or injury. Sources of information include: the ill/injured person, family members, friends, bystanders, or prior providers. SAMPLE stands for: S: Signs and symptoms The patient/family’s report of signs and symptoms is essential to assessment and management. A: Allergies It is important to be aware of medication allergies so that treatments do not cause harm. Allergies may also suggest anaphylaxis as the cause of acute symptoms. M: Medications Obtain a full list of medications that the person currently takes and ask about recent medication or dose changes. These may affect treatment decisions and are important to understanding the person’s chronic conditions. P: Past medical history Knowing prior medical conditions may help in understanding the current illness and may change management choices. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 31 L: Last oral intake Record the time of last oral intake and whether solid or liquid. A full stomach increases the risk of vomiting and subsequent choking, especially with sedation or intubation that might be required for surgical procedures. E: Events surrounding the injury or illness Knowing the circumstances around the injury or illness may be helpful in understanding the cause, progression and severity. Workbook question 4: SAMPLE history Using the workbook section above, list what the letters in SAMPLE stand for: S: ______________________________________________________________________ A: _____________________________________________________________________ M: _____________________________________________________________________ P: ______________________________________________________________________ L: ______________________________________________________________________ E: ______________________________________________________________________ DISPOSITION CONSIDERATIONS If you have to intervene in any of the ABCDE categories, immediately plan for handover/ transfer to a higher level of care. Once you have completed the ABCDE approach, take a SAMPLE history and complete a physical examination based on the specific condition (secondary examination). A good handover summary [See SKILLS] to the next provider requires: – brief identification of the patient; – relevant elements of the SAMPLE history; – physical examination findings; – record of interventions given; – plans for care needed next and other concerns you may have. Module 1: The ABCDE and SAMPLE history approach 32 FOR REFERENCE: NORMAL VITAL SIGNS NORMAL ADULT VITAL SIGNS Pulse rate: 60–100 beats per minute Respiratory rate: 10–20 breaths per minute – A respiratory rate of less than eight breaths per minute is a danger sign and may require intervention. Systolic blood pressure >90 mmHg Oxygen saturation >92% If you cannot take a blood pressure reading, you can use the pulse to estimate systolic blood pressure. Feeling for a pulse at the locations below can provide an estimate of systolic blood pressure in an adult (although this method may not work well in the elderly): • Carotid (neck) pulse ≥ 60 mmHg • Femoral (groin) pulse ≥ 70 mmHg • Radial (wrist) pulse ≥ 80 mmHg NORMAL PAEDIATRIC VITAL SIGNS Vital signs are age-dependent in children. Normal heart rate and respiratory rate are higher in younger children, and normal blood pressures are lower. The brachial (middle of the upper arm) artery should be used to check the pulse in infants and small children. Normal paediatric vital signs AGE (in years) NORMAL HEART RATE (beats per minute) ≤1 100–160 1–3 90–150 4–5 80–140 AGE RESPIRATORY RATE (breaths per minute) ≤2 months 40–60 2–12 months 25–50 1–5 years 20–40 * To estimate a child’s (1–10 years old) weight in kilograms use the formula: [age in years + 4] x 2 or use weight-estimation tools such as PAWPER, Mercy TAPE, or Broselow tape. Children are able to maintain normal blood pressure for longer than adults when they are in shock. You must check closely for signs of poor perfusion. The amount of IV fluid appropriate for children is different from that for adults. [See SKILLS] Location of brachial pulse in a child page 35 Location of brachial pulse in a child INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 33 FACILITATOR-LED CASE SCENARIOS These case scenarios will be discussed in small groups. These cases in this module will NOT be assessed and are for practice only. It is important that you practise with these scenarios since you will be assessed on how you lead a case in later modules. To complete a case scenario, the group must identify the critical findings and management needed and formulate a 1–2 line handover summary that includes assessment findings and interventions. You should use the Quick Cards to manage these scenarios. CASE #1: ADULT ABCDE A 70-year-old man is brought in by taxi. The driver states the patient lost consciousness while talking with his daughter. There was no trauma, but the daughter poured water on him to try to wake him up. Initially he was confused and vomiting. Now he is unconscious with a respiratory rate of 3 breaths per minute. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate 1–2 sentences to summarize this patient for handover. Module 1: The ABCDE and SAMPLE history approach 34 CASE #2: PAEDIATRIC ABCDE A mother brings in her 2-year-old son for difficulty in breathing. She reports that he has had a fever for 3 days and has had worsening difficulty in breathing. He has been coughing a lot and today will not eat or drink. 1. What is your initial approach to this patient? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator for specific findings when you look, listen and feel; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate a 1–2 sentence summary of this patient for handover. MULTIPLE CHOICE QUESTIONS Answer the questions below. Questions and answers will be discussed within the session. 1. A mother brings in her 3-year-old child because of difficulty in breathing. On assessment, you hear loud, high-pitched sounds when the child breathes in. What is the most immediate concern? A. Severe infection B. Shock C. Asthma attack D. Upper airway obstruction 2. An elderly woman fell at home. She had normal vital signs, but complained of neck and knee pain prior to transport. During transport, she starts snoring and gurgling when taking a breath. What is the most appropriate method to immediately manage this problem? A. Placing her in the recovery position B. Administering salbutamol C. Jaw thrust D. Head-tilt/chin-lift INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 35 3. A 50-year-old man has collapsed in a store and you are called to assist him. He is unconscious, has a respiratory rate of four breaths per minute and a pulse of 100 beats per minute. The collapse was witnessed and there is no trauma. What is the best next step? A. Begin chest compressions B. Open the airway C. Begin bag-valve-mask ventilations D. Check pupils 4. A 2-year-old boy is brought to you for being more sleepy than normal. He is unconscious. You open his airway, and insert an oropharyngeal airway. What is your next step? A. Check blood pressure B. Check AVPU scale C. Check glucose D. Check breathing 5. You are listening to the lungs of a 26-year-old man who has sudden onset chest pain and he is taking 30 breaths a minute. Which lung-sound finding is most suggestive of pneumothorax? A. Crackles on both sides B. Absent lung sounds on one side C. Stridor D. Wheezing on both sides 36 Notes ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS 37 PARTICIPANT WORKBOOK Module 2: Approach to trauma Objectives On completing this module you should be able to: 1. recognize key history findings suggestive of high-risk injuries; 2. recognize physical examination findings suggestive of high-risk injuries; 3. perform Trauma Primary Survey (the ABCDE approach to trauma patients); 4. perform Trauma Secondary Survey (the head-to-toe trauma exam); 5. recognize life-threatening injuries; 6. perform critical interventions for high-risk conditions. Essential skills • Cervical spine immobilization • Spine immobilization and log-roll manoeuvre • Jaw-thrust manoeuvre • Airway suctioning • Insertion of oropharyngeal and nasopharyngeal airway • Recovery Position • Oxygen delivery • Bag-valve-mask ventilation • Needle decompression for tension pneumothorax • Three-sided dressing for a sucking chest wound • Direct pressure for haemorrhage control, including deep wound packing • Tourniquet for haemorrhage control • IV line insertion • IV flluid resuscitation • AVPU and GCS assessment • Pelvic binding • Basic fracture immobilization • Trauma secondary survey • Basic wound management, including irrigation (washing) • Burn management KEY TERMS Write the definition using the Glossary at the back of the workbook. AVPU: Bradycardia: Circumferential burn: Crepitus: Compartment syndrome: Module 2: Approach to trauma 38 Cyanosis: Decontamination: Deep wound packing: Diaphoresis: Direct pressure: Disposition: Escharotomy: Flail chest: Fracture: Glasgow Coma Scale: Guarding: Haemorrhage: Haemorrhagic shock: Haematoma: Haemothorax: Hyperresonance: Hypothermia: Hypovolaemic shock: Hypoxia: Laceration: Large bore IV: INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 39 Log-roll manoeuvre: Needle decompression: Parkland Formula: Percussion: Pericardial tamponade: Pneumothorax: Priapism: Rebound tenderness: SAMPLE history: Shock: Sprain: Sucking chest wound: Tension pneumothorax: Trauma primary survey: Trauma secondary survey: Module 2: Approach to trauma 40 Overview GENERAL PRINCIPLES OF TRAUMA CARE Early priorities for an injured person include managing airway and breathing emergencies, controlling bleeding, treating shock and immobilizing the spine if needed. The goal of INITIAL ASSESSMENT is to identify life-threatening injuries. The goal of ACUTE MANAGEMENT is to ensure oxygenation and perfusion, to control pain and to plan ongoing care. This module will guide you through the: Approach to trauma ABCDE: Trauma primary survey DO: Important conditions to recognize and manage in the primary survey (signs, symptoms and management) ASK: Key history findings (SAMPLE history) CHECK: Trauma secondary survey DO: Important conditions to recognize and manage based on the history and secondary survey (Signs, symptoms and management) Special populations – Trauma in pregnancy – Special considerations in children Disposition considerations APPROACH TO TRAUMA Approach to the trauma patient consists of three phases: Trauma primary survey: The ABCDE approach for injured patients SAMPLE history: Signs and Symptoms, Allergies, Medications, Past medical history, Last oral intake, and Events surrounding the injury Trauma secondary survey: A complete head-to-toe examination to look for injuries not identified by the primary survey During primary and secondary surveys, if life-threatening problems are identified, STOP AND MANAGE them. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 41 ABCDE: TRAUMA PRIMARY SURVEY The ABCDE approach in injured patients is often also called the trauma primary survey. As for all patients this should be conducted within the first 5 minutes and repeated whenever the patient’s condition worsens. This trauma-specific ABCDE approach includes the initial assessment and management for all immediately life-threatening injuries. Always suspect head and spine injury in a trauma patient with altered mental status. ASSESSMENT IMMEDIATE MANAGEMENT Airway with cervical spine immobilization A Look for: • blood, vomit, tongue or objects obstructing the airway • burned nasal hairs or soot around the nose or mouth • head or neck trauma • neck haematoma (bleeding under the skin) • altered mental status, as this can affect the ability to protect the airway Listen for abnormal airway sounds (such as gurgling, snoring, stridor, noisy breathing). • Stabilize the cervical spine. [See SKILLS] • Open airway using jaw thrust, NOT head-tilt chin-lift if suspected spine injury. [See SKILLS] • Suction airway secretions, blood and/ or vomit. Remove any visible foreign objects from the airway. [See SKILLS] • Place oral airway (avoid nasal airway if facial trauma). [See SKILLS] • If the patient has an expanding neck haematoma or evidence of airway burns or trauma, plan for rapid handover/transfer to a provider capable of advanced airway management. If the airway is open, move onto “Breathing”. Breathing B Look for: • increased work of breathing • abnormal chest wall movement which may indicate flail chest • tracheal shift • sucking chest wound • cyanosis (blue-grey color of the skin) around the lips and fingertips • abrasion, bruising or other signs of injury to chest • circumferential burns (burns that go all the way around a body part) to chest or abdomen • absent or decreased breath sounds Listen for dull sounds or hyperresonance with percussion. Feel for crepitus (cracking and popping when pressing on the skin). • Give oxygen. [See SKILLS] • Perform needle decompression immediately and give oxygen and IV fluids for tension pneumothorax. [See SKILLS] • Place three-sided dressing for sucking chest wound. [See SKILLS] • If breathing not adequate or patient remains hypoxic on oxygen, assist breathing with bag-valve-mask ventilation. [See SKILLS] • For chest or abdominal burns that restrict breathing, handover for escharotomy (a surgical procedure to cut and release burned tissue that may restrict breathing or blood supply to a limb). If breathing is adequate, move onto “Circulation”. Module 2: Approach to trauma 42 ASSESSMENT IMMEDIATE MANAGEMENT Circulation C Look for: • capillary refill longer than 3 seconds • pale extremities • distended neck veins • external AND internal bleeding Common sources of serious bleeding are: • chest injuries • abdominal injuries • pelvic fractures • femur fractures • amputations or large external wounds • burns, noting size and depth Feel for: • cold extremities • weak pulse or tachycardia • Apply direct pressure to control active bleeding, or deep wound packing if large or gaping. [See SKILLS] • If amputated limbs or any other source of uncontrolled bleeding are present, apply tourniquet (document time of application), start IV fluids and plan for urgent transfer to a surgical unit. [See SKILLS] • If ongoing blood loss or evidence of poor perfusion, place two large bore IVs, give IV fluids and re-assess. [See SKILLS] • If burn injury, start IV fluids according to burn size. • Splint suspected femur fracture. [See SKILLS] • Bind pelvic fracture. [See SKILLS] • Leave any penetrating objects in place and stabilize object for transfer to a surgical team. • Position pregnant patients on their left side while maintaining spinal immobilization. If circulation is adequate, move onto “Disability”. Disability D Look for: • confusion, lethargy or agitation • seizures/convulsions • unequal or poorly reactive pupils • deformities of skull • blood or fluid from ear or nose Check: • AVPU or GCS • movement and sensation in all extremities • blood glucose level if confused or unconscious • If GCS <9 (or for children, AVPU score of P or U), plan for rapid handover/ transfer to a provider capable of advanced airway management. • If patient is lethargic or unconscious, re-assess the airway frequently as above. • Suspect spine injury or closed head injury with any trauma and altered mental status. • Give oxygen if concern for hypoxia as a cause of altered mental status. [See SKILLS] • Give glucose if altered mental status and: measured low blood glucose, unable to check blood glucose, or history of diabetes. [See SKILLS] • If seizing, give a benzodiazepine. [See SKILLS] INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 43 ASSESSMENT IMMEDIATE MANAGEMENT Exposure E Remove all clothing. Examine entire body for evidence of injury (including the back, spine, groin and underarms) using the log-roll manoeuvre. • If spinal injury is suspected, perform log-roll manoeuvre to examine the back. [See SKILLS] • Remove restrictive clothing and all jewellery. • Remove any wet clothes and dry patient thoroughly. • Cover the patient as soon as possible to prevent hypothermia. Acutely injured patients have difficulty regulating body temperature. • Respect the patient and protect modesty during exposure. Workbook question 1: Approach to trauma A middle-aged man is brought in after being hit by a car. Using the workbook section above, list the immediate management for the assessment findings below. PRIMARY SURVEY FINDINGS IMMEDIATE MANAGEMENT On airway assessment: • Gurgling airway sounds • Obvious head trauma 1. ������������������������������������������������ 2. ������������������������������������������������ 3. ������������������������������������������������ 4. ������������������������������������������������ On circulation assessment: • Weak pulses • Capillary refill of <3 seconds • Unstable pelvis on exam 1. ������������������������������������������������ 2. ������������������������������������������������ 3. ������������������������������������������������ Module 2: Approach to trauma 44 DO: IMPORTANT CONDITIONS TO RECOGNIZE AND MANAGE IN THE PRIMARY SURVEY A Airway conditions CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Airway obstruction • Visible blood, secretions, vomit, tongue or foreign bodies in the airway • Changes in voice • Abnormal sounds from the airway (such as stridor, snoring, gurgling) • Neck haematoma or burns to head and neck • Mental status changes leading to airway obstruction • Poor chest rise • Injury causing swelling of the airway (such as anaphylaxis or airway burn) Head and neck injuries may result in obstruction of the airway by blood, secretions, vomit, foreign bodies, or swelling. Penetrating wounds to the neck can cause expanding haematomas. Inhalational injuries due to burns can cause swelling. • Patients with a decreased level of consciousness may not be able to protect their airways and need to be watched for vomiting and aspiration. – Suction the airway and remove foreign bodies. – Open the airway using a jaw thrust manoeuvre (NOT head-tilt/chin-lift) and place an oral airway as needed. [See: SKILLS] • Maintain cervical spine immobilization throughout, if needed. • Plan for rapid handover/transfer to a provider capable of advanced airway management. B Breathing conditions CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Tension pneumothorax • Hypotension WITH: – difficulty breathing – distended neck veins – absent breath sounds on affected side – hyperresonance with percussion on affected side – may have tracheal shift away from affected side Any pneumothorax can become a tension pneumothorax. Air in the cavity between the lungs and the chest wall can collapse the lung (simple pneumothorax). Building pressure (tension) from a large pneumothorax can displace and block flow from the great vessels to the heart, causing shock as the heart cannot receive and pump enough blood to the rest of the body (tension pneumothorax). In tension pneumothorax, perfusion is compromised. • Treat tension pneumothorax immediately with needle depression. [See: SKILLS] • Give oxygen and IV fluids. [See: SKILLS] • Plan for rapid handover/transfer to an advanced provider capable of placing a chest tube. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 45 CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Sucking chest wound (open pneumothorax) • Open wound in the chest wall with air passing through causing bubbling or “sucking” noises • Difficulty in breathing • Chest pain Sucking chest wounds are important to recognize because they can rapidly cause a tension pneumothorax. Air enters the chest cavity (into the space between the chest wall and the lungs) through the wound in the chest wall when the patient takes a breath. Pressure on the lung builds if the air cannot escape. • Give oxygen. [See SKILLS] • Place a three-sided dressing that allows air to leave with exhalation but prevents air from entering when the person inhales. [See SKILLS] – There is a danger of the dressing becoming stuck to the chest wall with clotted blood and causing a tension pneumothorax. – After applying a three-sided dressing the patient should be observed continuously. – Remove the dressing if worsening respiratory status or evidence of worsening perfusion. Plan for rapid handover/transfer to an advanced provider capable of placing a chest tube. Flail chest • Difficulty in breathing • Chest pain • Part of chest wall moving in the opposite direction of the rest of the chest when breathing Flail chest segments occur when ribs are broken in multiple places, freeing an entire section of ribs from the chest wall. Without the connection to the chest wall, this section will move abnormally with breathing and prevent part of the lung from expanding. Flail chest is also usually associated with damage to underlying lung tissue. • Give oxygen and pain control. [See SKILLS] • There is a very high risk of developing difficulty in breathing and hypoxia. • Plan for rapid handover/transfer to a provider capable of chest tube placement, advanced airway placement and ventilation. Haemothorax • Difficulty in breathing • Decreased breath sounds on affected side • Dull sounds with percussion on affected side • Large haemothorax may cause shock Haemothorax (blood in the space between the lungs and the chest wall) can present with decreased or absent breath sounds and dull sounds with percussion on the affected side. • Give oxygen and IV fluids. • Plan for rapid handover/transfer to a centre with surgical capacity. Module 2: Approach to trauma 46 C Circulation conditions CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Hypovolaemic shock • Tachycardia, tachypnoea, pale skin, cold extremities, slow capillary refill • May have dizziness, confusion or altered mental status • May have hypotension • External bleeding or internal bleeding (chest, abdomen, pelvis, femur, blood vessels) Hypovolaemic shock can result from rapid loss of blood (haemorrhagic shock) or from the fluid loss associated with burns. An adult patient in shock may have only tachycardia (elevated heart rate) and/or tachypnoea (high respiratory rate) and may not have low blood pressure until the condition is immediately life-threatening. Even with a systolic blood pressure greater than 90 mmHg, suspect hypovolaemic shock if there is severe bleeding or any sign of poor perfusion (such as cool, moist, or pale skin, slow capillary refill, fast breathing, confusion, restlessness, anxiety). • Stop bleeding with direct pressure, deep wound packing if wound is gaping, a tourniquet, splinting of fractures and binding the pelvis as needed. [See SKILLS] • Start two large-bore IV lines and give IV fluids. [See SKILLS] • Patients with suspected large haemothorax or other internal haemorrhage will need rapid handover/transfer to a unit with surgical care and blood transfusion capabilities. REMEMBER... Children and young people are able to maintain a normal blood pressure until they have lost up to a quarter of their blood. Always check for other signs of shock. [See “Special considerations in children” section] Pericardial tamponade • Signs of poor perfusion (such as tachycardia, tachypnoea, hypotension, pale skin, cold extremities, capillary refill greater than 3 seconds) • Distended neck veins • Muffled heart sounds • May have dizziness, confusion, altered mental status Pericardial tamponade occurs when fluid builds up in the sac around the heart. The pressure from this fluid can collapse the chambers of the heart and prevent them from filling, limiting the amount of blood the heart can pump. • Give IV fluid to improve heart filling. [See SKILLS] • Patients need immediate handover/transfer to an advanced provider for drainage of the fluid. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 47 D Disability conditions CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Severe head injury • Visual changes, loss of memory, seizures/ convulsions, vomiting, headache • Altered mental status or other neurologic deficit • Scalp wound and/or skull deformity • Bruising to head (particularly around eyes or behind ears) • Blood or fluid from the ears or nose • Unequal pupils • Weakness on one side of the body Brain injuries can range from mild bruising to severe bleeding in or around the brain. Because the skull is rigid, the bleeding cannot expand and causes increased pressure on the brain. If the pressure becomes too high, it will prevent blood from entering into the skull and perfusing the brain, and can squeeze part of the brain through the base of the skull, causing death. Any trauma to the brain can cause significant impact on function. • Always remember that head injuries can be associated with spinal injuries. Immobilize the spine and use the log-roll technique to examine the back of the body. • Use the Glasgow Coma Scale (or AVPU in children) to assess and monitor patients with head injury. • Be sure to frequently re-assess ABCDE. • If concern for open skull fracture, give IV antibiotics as per local protocol. • Always check glucose and administer as needed. • Do not give food or drink by mouth. • Plan for early handover/transfer to a facility with specialist care. REMEMBER… People who initially appear well may have hidden life-threatening injuries, such as internal bleeding. It is very important to re-assess trauma patients frequently using the primary survey. Once you find a primary survey problem and manage it, go back and repeat the primary survey to identify any new problems and make sure that the management worked. Ideally, the ABCDE approach should be rechecked every 15 minutes and with any change in condition. Vital signs should be checked at the end of the primary survey A full set of vital signs (blood pressure, heart rate, respiratory rate and oxygen saturation if available) should be performed after the primary survey. Do not delay primary survey interventions for vital signs. Module 2: Approach to trauma 48 Workbook question 2: Approach to trauma Using the workbook section above, list five important conditions to recognize in the primary survey 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ ASK: KEY HISTORY FINDINGS FOR TRAUMA PATIENTS Information about an injured person and the injury event can be critical to planning management. Children, older adults and people with chronic disease have an increased risk of complications from trauma. They may need to be watched for several hours even when they appear well. Certain mechanisms are often associated with multiple injuries, some of which may not be obvious right away. High-risk mechanisms include: pedestrian being hit by a vehicle; motorcycle crashes or any vehicle crash with unrestrained occupants; falls from heights greater than 3 metres (or in children, twice the child’s height); gunshot or stab wounds; and explosion or fire in an enclosed space. Use the SAMPLE approach to obtain a history. Remember that you may be able to obtain information from bystanders, family, police, fire service or other health-care workers. If the history identifies a primary survey condition, STOP AND RETURN IMMEDIATELY TO PRIMARY SURVEY to manage it. S: SIGNS AND SYMPTOMS Is there a history of hoarse or raspy voice, or other voice changes? Changes in voice in the setting of injury to the head, neck or with burns may suggest that the airway is swelling and that it may obstruct. Is there any difficulty in breathing? Problems with breathing may develop over time and might not be present in the initial primary survey. Difficulty in breathing may suggest that the person has an injury to the lungs, ribs, muscles, chest wall or spine. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 49 Is there reported bleeding? It is usually quite difficult for patients to estimate the volume of blood loss, but it may be helpful to know how long there has been bleeding, how many bandages have been soaked and if the bleeding is getting lighter or heavier. Is there confusion or unusual sleepiness? Confusion after injury may be a sign of head injury, lack of oxygen or shock (with decreased blood flow to the brain). A head injury can cause bleeding or increased pressure on the brain leading to confusion, lethargy (increased sleepiness) and coma. Is there pain? Where is the pain, what does it feel like and how severe is it? Pain is a sign of underlying injury. Headache may suggest that the person has an injury to the skull or the brain. Pain along the spine can suggest an injury that may progress to cause damage to the spinal cord. Pain in the chest or abdomen may suggest damage to the heart, lungs or other organs. Pain in the pelvis or hips may suggest a fracture in the pelvis which can cause serious bleeding and shock. Pain may be the first sign of an internal injury in the chest, abdomen or pelvis. Is there nausea or vomiting? This may indicate an abdominal or head injury. Is there reported numbness or weakness? This may indicate a spinal injury. Are there reported vision changes? Direct trauma to the eye, fractures of bones around the eye, and head injuries can all cause vision changes. A: ALLERGIES Any allergies to medications? M: MEDICATIONS Currently taking any medications? Medications that affect blood clotting (e.g. aspirin, warfarin, clopidogrel) can make bleeding more difficult to control and increase the risk of delayed bleeding. Blood pressure medications can make it hard to manage shock. Obtain a full list of medications if possible or ask family members to bring in medications. Module 2: Approach to trauma 50 P: PAST MEDICAL HISTORY Is the person pregnant? Pregnancy causes some of the organs to be moved out of their usual position and causes changes in the body that need to be considered when managing trauma. Always ask women of childbearing age about the date of last menstrual period. Tetanus status? A person who has not had a tetanus vaccination within the past 5 years and who has an injury that damages the skin needs a tetanus vaccination. Are other conditions present that put the person at higher risk for serious injury? RISK FACTORS FOR POOR OUTCOMES FROM INJURY: – Age less than 5 years or greater than 55 years – Heart or lung disease – Diabetes – Liver failure (cirrhosis) – Severely overweight – Pregnancy – Immunosuppression (including HIV) – Bleeding disorder or taking blood-thinning medications (medications that prevent clotting) L: LAST ORAL INTAKE When did the person last eat or drink? E: EVENTS SURROUNDING INJURY Certain mechanisms of injury are so high risk that patients should be observed closely, even if they do not appear to be significantly injured. Was there a fall from 3 metres or more (or twice the height in children)? Falls are a common cause of injury for both adults and children. A greater distance fallen increases the chance of serious injury. Falls in adults are often associated with older age, alcohol intoxication, or the failure of workplace equipment, including scaffolding and ladders. Children often fall from trees, windows or balconies. Was a pedestrian or a cyclist hit by a vehicle? Adults and children who are hit by a vehicle while walking or using non-motorized forms of transport (such as bicycles) are always at high risk of serious injury. Young children may be less able than adults to report events, even major events like being hit by a vehicle. Always consider the possibility of unwitnessed trauma in young children. Children and adults can sustain multiple injuries when hit by a vehicle – both from direct impact to the body, especially the lower extremities, and from secondary impact if they are thrown against the windscreen or road, which may cause injuries anywhere in the body, including to head, neck, chest or limbs. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 51 In a motorcycle (or powered 3-wheeler) crash, was the rider thrown? Motorcycles collisions often result in a rider being thrown. Ask if the motorcyclist was wearing a helmet and how far away from the vehicle the rider was found. Common injury sites include head (especially when no helmet was worn), spine, chest, abdomen and pelvis (as the rider hits the handlebars), as well as limbs and skin (as the rider hits the road). Was there a road traffic crash at high speed? Was the person thrown from or trapped inside a vehicle? Did any vehicle occupants die in this crash? With higher-speed crashes, greater force is transmitted to vehicle occupants increasing the risk of serious injury. Vehicle occupants may be injured by impact with the windscreen or steering wheel, or by the forces that result from the sudden stopping of the vehicle. A person thrown from a vehicle is at very high risk of serious injury. If a person was trapped within a vehicle it is important to find out what part of the body was trapped (arm/leg, etc.) and for how long. Consider crush injury in a person who has been trapped. A death at the scene of a road traffic crash suggests that there was significant force exerted on the vehicle and its passengers. All passengers involved in the crash, even if they appear unhurt, are at high risk for serious injury. In a motor vehicle crash, was the patient wearing a seatbelt? Some types of injuries are more common in patients who were not wearing a seat-belt (being thrown from the vehicle, head strike on the windscreen, chest strike on the steering column). However, in very high-speed crashes, seat belts can also cause certain types of injuries (cervical spine injury, abdominal injury). Was a weapon used? Any time there is a history of a stab or gunshot wound, there may be multiple wounds. Always check the full body for wounds. After a bullet enters the body it may not follow a direct path and can twist throughout the body. Many internal organs can be injured by a single bullet. A stab wound creates a direct path (it is important to know the length of the blade that was used). Remember that blunt injuries from objects such as sticks and bats can cause damage to internal organs in addition to obvious injuries such as fractures, bruises and lacerations. Was there a burn? If so, what type of burn was it? Burns from fires (flame burns) are the most common. A history of flame burn in an enclosed space can also suggest an inhalation or airway injury. Scald burns (due to hot liquids) are common in children. Electrical injuries often come from high-voltage sources such as overhead electrical wires coming in contact with the body. On the surface, these electrical injuries may look small but they can cause extensive tissue and muscle damage. The electrical current often crosses the body, taking the shortest path from the point of contact with the skin to the ground, often leaving entry and exit burn marks. In the case of chemical burns, information about the specific chemical may be needed to remove it properly. For burns, was first aid provided at the scene? It is important to know if the burning process was stopped, and in the event of a chemical exposure, if decontamination was performed. If the burn is less than 3 hours old and no first aid was provided, the wound will need to be washed with clean water to stop the burning process. If there is a history of chemical exposure, protect yourself from the chemical and ensure that it is properly removed from the skin. Module 2: Approach to trauma 52 Did the person sustain a crush injury? Is there severe pain or numbness? Is there dark urine? Crush injuries may damage skin, muscle, blood vessels and bone. Damaged muscle can release a muscle by-product (called myoglobin) that can build up and damage the kidneys. It is important to know how long a body part was crushed. Even a small crushed area can cause the release of a dangerous amount of myoglobin (for example when a limb is caught under falling debris for an extended time). If a person with a crush injury has dark urine, this may be a sign of build-up of myoglobin in the kidneys. Tissue damage and swelling from crush injury can also cause a build-up of pressure (particularly in limb-crush injuries) that can limit blood flow to the muscles and nerves (compartment syndrome). Did the person sustain a blast injury? Blast injuries (from explosions) can involve all systems of the body, especially the hollow organs. Common blast injuries include damage to the lungs, intestines and ears. Patients involved in explosions need to be checked carefully and repeatedly because these injuries are easily missed. Blasts may also be associated with foreign bodies in the skin and eyes, burns or chemical injury, and toxin or radiation exposure. Workbook question 3: Approach to trauma Using the workbook section above, list five questions you would ask when taking a SAMPLE history from a person injured in a road traffic crash: 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ CHECK: TRAUMA SECONDARY SURVEY Following the primary survey and SAMPLE history, the secondary survey is a detailed head-to- toe examination designed to identify any additional injuries or issues requiring intervention. The secondary survey gives the provider an organized way to assess the entire body for signs of trauma that may not have been obvious on the primary survey. Remember that very painful or frightening injuries may distract both patients and providers from recognising other injuries. Always examine the entire body. If the secondary survey identifies a primary survey condition, STOP AND RETURN IMMEDIATELY TO THE PRIMARY SURVEY to manage it. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 53 Head, ears, eyes, nose, and throat (HEENT) Look for: • Scalp wounds or bruising • Skull deformities • Blood in mouth or throat • Unequal or unresponsive pupils indicating head injury • Vision loss or changes and eye injuries • Any problems with eye movements • Blood or fluid from ear or nose, which can indicate tissue injury or skull fracture • Tooth injury or poor alignment of teeth • Signs of airway burns: ash, singed nasal hairs, new or worsening lip/ mouth swelling Listen for: • Stridor which could indicate that the airway will obstruct soon • Gurgling indicating fluid in the airway • Changes in voice, which can indicate airway or vocal cord injury Feel for: • Tenderness or abnormal movement of facial bones, suggesting fracture • Loose teeth that may accidentally be inhaled • Defects or crepitus in the skull or facial bones concerning for fracture Neck Look for: • Reduced ability to move neck or pain on movement • Bruising, bleeding or swelling • Haematoma (bruising/bleeding under the skin) – this may eventually cause airway obstruction • Penetrating neck wounds • Distended neck veins (which may indicate tension pneumothorax or tamponade) Feel for: • Air in the skin or soft tissue – concerning for airway injury or pneumothorax • Tenderness or deformity along the spine – concerning for fracture Chest Look for: • Bruising, deformity, wounds • Uneven chest wall movement–concerning for pneumothorax or flail chest • Burns around the entire chest (circumferential) which can cause difficulty in breathing Listen for: • Breath sounds (decreased, unequal or absent, wheeze, crepitations) • Muffled heart sounds – concerning for pericardial tamponade Feel for: • Tenderness • Crepitus – concerning for fracture or pneumothorax Module 2: Approach to trauma 54 Abdomen Look for: • Abdominal distension • Visible abdominal wounds, bruising or abrasions • Bruising on back or abdomen, which may indicate internal bleeding • Circumferential burns to the abdomen (may cause severe problems with breathing) Feel for: • Abdominal rebound tenderness (pain when releasing pressure on the abdomen) or guarding (sudden contraction of the abdominal wall muscles when the abdomen is pressed), suggesting serious injury • Abdominal tenderness, which can indicate organ or blood vessel injury Pelvis and genitals (always protect patient privacy during exam) Look for: • Bruising/lacerations to pelvis • Blood at the opening of the penis or rectum. May be a sign of sexual assault. • Vaginal lacerations or bleeding – these could indicate open pelvic fracture, injury to the uterus, or may be a source of significant blood loss. May be a sign of sexual assault. • Penile lacerations • Priapism (prolonged erection) can indicate spinal injury • Urine colour changes (dark urine or obvious blood) that might indicate muscle breakdown or kidney injury Feel for: • Tenderness or abnormal movement in pelvis Extremities Look for: • Swelling or bruising • Deformity, which could indicate fracture • Open fractures • Amputation • Circumferential burns • Pale skin that could indicate limited blood flow Feel for: • Absent or weak pulses • Cold skin that could indicate limited blood flow • Tenderness • Abnormally firm, painful muscular compartments in the extremities can indicate compartment syndrome INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 55 Spine/back Log roll the person with assistance, then: Look for: • Bruising • Deformity Feel for: • Tenderness, crepitus and misalignment along the entire spine (upper neck to lower back) • Tenderness, crepitus or misalignment over any other areas with visible evidence of trauma Skin Look for: • Bruising • Abrasions • Lacerations • Feel for peripheral pulses in all extremities • Burns – Look for circumferential burns: depending on the location, these can cause difficulty in breathing (if on the chest) or compartment syndrome (if on the extremities) Neurologic Check for: • Decreased level of consciousness (using AVPU or GCS) and seizures/ convulsions, which may be signs of serious head injury • Movement and strength in each limb • Sensation on face, chest, abdomen, limbs; if there is a sensory deficit, identify where it begins • Priapism (persistent penile erection) • Decreased sensation, decreased strength or priapism can indicate spinal cord injury Module 2: Approach to trauma 56 Workbook question 4: Approach to trauma Using the workbook section above, list one way that you would ASSESS the following systems. Head, ears, eyes, nose, throat: Listen for: _______________________________________________________________ Look for: ________________________________________________________________ Feel for: _________________________________________________________________ Chest: Look for: ________________________________________________________________ Listen for: _______________________________________________________________ Feel for: _________________________________________________________________ Pelvis and genitals: Look for: ________________________________________________________________ Feel for: _________________________________________________________________ INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 57 DO: IMPORTANT CONDITIONS TO RECOGNIZE AND MANAGE BASED ON HISTORY AND SECONDARY SURVEY Management of specific injuries found during secondary survey CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Head injury • Headache • Altered mental status • Abnormal pupils • Scalp lacerations and/or skull fractures • Bruising to head (particularly around eyes or behind ears) • Blood or clear fluid coming from nose or ears • Weakness on one side of the body • Seizures/convulsions • Visual change • Loss of memory • Vomiting Because the brain is encased in the rigid skull, any swelling or bleeding caused by brain injury can rapidly become life-threatening. • Monitor level of consciousness (a marker of brain function) using the Glasgow Coma Scale (GCS) or AVPU scale in children. [See SKILLS] • Any patient who has significant head injuries is at risk of having spine injuries as well. [See SKILLS] • Always monitor immobilized patients for vomiting to avoid choking. • If there is concern for an open skull fracture, give IV antibiotics. • Check blood glucose and give glucose if less than 3.5 mmol/L or unable to measure. • Any patient with GCS less than 9 should be transferred for a CT scan within 2 hours of injury, if possible. Facial fractures • Deformities or unusual movement in the facial bones • Patient reports jaw not closing normally or teeth not aligned • Problems with eye movements • Give antibiotics for open facial fractures (laceration over a broken bone). • Update tetanus vaccination. • Suspect cervical spine injury and immobilize the cervical spine if needed. [See SKILLS] • Remember to position patient to keep blood from flowing into airway. • Avoid nasopharyngeal airways and nasogastric tubes when facial fracture is suspected. Penetrating eye injury • Any visible object in the eye • Painful red eye or a reported feeling of something in the eye; it may be difficult to see small objects that have penetrated the eye • Problems with vision • An abnormally shaped pupil or clear liquid draining from the eye may indicate a puncture wound • Evidence of facial trauma • Avoid any pressure on the injured eye – this could worsen the injury • Do not remove objects penetrating the eye. • Give antibiotics. • Update tetanus vaccination if needed. • Keep the head elevated and place a loose patch over both eyes (do NOT put pressure on the eye). • Plan for handover/transfer to an advanced provider. Module 2: Approach to trauma 58 Management of specific injuries found during secondary survey CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Penetrating neck wound • Small lacerations or puncture wounds may be the only sign of serious injury • Swelling (suggesting haematoma) • Look carefully for penetrating objects Patients with penetrating neck wounds are at risk of airway obstruction, so monitor the airway closely. Neck wounds may also have significant haemorrhage. • Maintain cervical spine precautions. [See SKILLS] • Stabilize, but do not remove penetrating objects. • Apply firm pressure to bleeding site, being careful not to block the airway. • Do not insert anything into wound to check the depth – this can cause further damage. • Initiate rapid handover/transfer to a unit with surgical care and advanced airway management capabilities. Chest injury • Difficulty in breathing • Crepitus or tenderness to palpation over the ribs • Uneven chest wall movement or unequal breath sounds Monitor closely for difficulty in breathing due to lung injury which can develop over time. Tension pneumothorax is treated in the primary survey; however, chest injury may also be associated with simple pneumothorax which can progress to a tension pneumothorax. • Any patient with a pneumothorax should be placed on oxygen and monitored closely for development of a tension pneumothorax. • Crepitus or tenderness may be signs of rib fractures which are often associated with underlying chest or abdominal injury. • Plan for handover/transfer for chest tube (pneumothorax) or advanced airway and breathing management. Abdominal injury • Abdominal pain or vomiting • Tender, firm or distended abdomen on examination • Sudden abdominal wall muscle contractions when the abdomen is touched (guarding) • Very few or no bowel sounds on examination • Rectal bleeding • Visible wound in the abdominal wall • Bruising around the umbilicus or over the flanks can be a sign of internal bleeding Severe pain or bruising to the abdomen is concerning for organ injury or internal bleeding. • If you suspect abdominal injuries, give IV fluids. • Do not give the patient anything to eat or drink. • If bowel is visible: – leave it outside the body; – cover it with sterile gauze soaked in sterile saline; – give antibiotics. • If there is any concern for abdominal injury, plan for rapid handover/transfer to a unit with surgical capabilities. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 59 Management of specific injuries found during secondary survey CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Spinal cord injury • Midline spinal pain/tenderness • Movement problems: paralysis, weakness, abnormal reflexes • Sensation problems: tingling (“pins and needles” sensation), loss of sensation • Loss of control of urine or stool • Priapism • May have hypotension, bradycardia • Crepitus when you touch the spinal bones • Spinal bones that are not properly aligned • Difficulty in breathing (upper cervical spine injury) • Provide spinal immobilization to any person with a history of trauma who is unconscious; or who is conscious and has neck pain, cervical spine tenderness, numbness or weakness. – Use a rolled sheet or neck collar to immobilize the cervical spine. [See SKILLS] Keep the patient lying flat in bed to immobilize the rest of the spine. [See SKILLS] When examining or moving the trauma patient, the spine should be protected by using the log-roll manoeuvre. [See SKILLS] • Give IV fluids. [See SKILLS] • Any patient with possible spinal trauma needs handover/transfer to a specialist unit. NOTES: • Spinal trauma is not always obvious. Fractured spinal bones can injure the spinal cord, causing paralysis. If the spinal cord injury is in the cervical spine, paralysis could involve the muscles that control respiration and could lead to death. Examination findings should be carefully documented so that future providers can evaluate if the patient’s condition has changed. • Spinal injuries can also cause shock. This can occur when nerves that control the contraction of the blood vessels in the body are damaged. When the walls of a blood vessel relax, the vessel dilates and pressure drops, leading to poor perfusion and shock. Risk is higher if there is also blood loss, so patients must be monitored closely. Always consider spinal injury in a patient with shock that does not improve with treatment. • Spine boards should only be used to move patients. Leaving patients on spine boards for long periods of time can cause pressure sores. Remove patients from boards as soon as they arrive at the facility and can be laid flat. Internal bleeding (not seen on primary survey) • Bruising around the umbilicus or over the flanks can be a sign of internal bleeding • Pelvic fracture • Femur fracture • Decreased breath sounds on one side in the chest (haemothorax) • Signs of poor perfusion (hypotension, tachycardia, pale skin, diaphoresis) A large quantity of blood can be lost into the chest, pelvis, thigh, and into the abdomen before bleeding is recognized. • Stop the bleeding if possible – bind pelvis or splint femur. [See SKILLS] • Give IV fluid. [See SKILLS] • Refer for blood transfusion and ongoing surgical management if needed. Module 2: Approach to trauma 60 Management of specific injuries found during secondary survey CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Pelvic fracture • Pain with palpation of the pelvis • Instability or abnormal movement of the pelvic bones • Blood at opening of the penis or rectum • Give IV fluids and pain control. [See SKILLS] • Compress pelvis gently to check for stability. • Do not open and rock pelvis or perform repeat exams as this can worsen internal bleeding. • Stabilize the pelvis with a sheet or pelvic binder. [See SKILLS] • Plan for early handover/transfer to a unit with blood transfusion capabilities. Extremity fracture with poor perfusion • Deformity or crepitus of the bone • Absent pulses beyond the fracture • Capillary refill time of greater than 3 seconds beyond the fracture • Cold extremities beyond the fracture with blue or grey skin colour Fractures can displace blood vessels and limit blood supply to the limb beyond the fracture. • Look for signs of poor perfusion beyond the fracture. Feel the pulse. Check capillary refill. Look for pale skin. [See SKILLS] If a fracture is found with weak pulses or poor perfusion, re-establish perfusion by reducing (manually re-aligning bone ends to put limb back to its normal position) and splinting the fracture. [See SKILLS] Always check and document pulses, capillary refill and sensation before and after any reduction. • Plan for urgent handover/transfer to a specialist unit. Open fracture • Deformity or crepitus of the bone with overlying laceration Consider any patient to have an open fracture if there is a wound (more than just a skin abrasion) near a fracture site. Open fractures are emergencies because they can lead to severe bone infections. • Control haemorrhage with direct pressure. [See SKILLS] • Reduce the fracture immediately if there is poor perfusion. [See SKILLS] • Irrigate the wound well. [See SKILLS] • Dress wound. • Give antibiotics and tetanus vaccination. • Splint the wound. • Plan for handover/transfer to a specialist unit. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 61 Management of specific injuries found during secondary survey CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Open wound • Laceration • Abrasion • Wounds in the underarm area, genital area, buttocks or back are easily missed • Pumping or squirting blood can indicate arterial bleeding The goal of wound care is to stop bleeding, prevent infection, assess damage to underlying structures and promote healing. • Stop bleeding. [See SKILLS] • Clean wounds thoroughly with soap and clean water or antiseptic to remove any dirt, foreign bodies or dead/dying tissue. (Give local anaesthetic before cleaning the wound if available.) • Dress wounds with sterile gauze, if available. • Check perfusion beyond the wound (capillary refill and/or distal pulses) before and after dressing wounds. • Splint extremities with large lacerations to help with wound healing and pain control. [See SKILLS] • Stabilize but do not remove penetrating objects. • For snake bite, immobilize the extremity. [See WOUND MANAGEMENT in SKILLS] • For animal bites, consult advanced provider to assess for risk of infection and rabies exposure. Depending on vaccination status, management can be extremely time-sensitive. • Give tetanus vaccination if needed. REMEMBER… Always assess, treat and monitor pain. Applying direct pressure to a wound Applying direct pressure to a wound page 15 Module 2: Approach to trauma 62 SPECIAL CONSIDERATIONS Management by injury mechanism CONDITION CONCERNING SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Crush injury • Fractures, bruising, soft tissue damage • Evidence of compartment syndrome (pain, firm muscle compartments, numbness, decreased pulses or pale skin) • Small amounts of red-brown urine Crush injuries can have serious complications. Look for compartment syndrome (a build-up of pressure within the muscle compartments that can limit blood supply to muscles and nerves) and kidney damage due to by-products of muscle injury. • It is important to monitor urine output and look for red- brown urine (a concern for possible kidney damage). • Give IV fluids to help the kidneys maintain urine output. • Splint fractures to keep bone ends from causing further damage. • Plan for early surgical referral to release the pressure if compartment syndrome develops. • Patients may have many systemic problems related to muscle damage and should always be handed over to an advanced provider. Blast injury • Injury to air-filled organs (such as lung, stomach and bowel) • Delayed symptoms of tachypnoea, hypoxia, chest pain, cough with or without blood • Abdominal pain, nausea, vomiting with or without blood • Tympanic membrane (ear drum) rupture: hearing loss, ringing in the ears, pain, ear bleeding • Other injuries, burns, exposure to chemicals or toxins An explosive blast can cause injuries in three ways: 1. Visible injuries from shrapnel (fragments of metal released by an explosive device) or burns from heat or chemicals released; 2. Internal (often hidden) injuries from the change in pressure caused by the blast. The stomach and bowel, lungs, and ears are commonly injured; and 3. Additional blunt injuries that result when the body is thrown by the blast. • Examine carefully for pneumothorax. • Give oxygen if there is difficulty in breathing. [See SKILLS] • Update tetanus. • Burns should be dressed and fluid needs calculated based on burn area. [See SKILLS] • If the patient has abdominal pain, consider bowel perforation, give IV fluids [See SKILLS] • Prepare for rapid surgical referral. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 63 Management by injury mechanism CONDITION CONCERNING SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Burn injury • Skin colour can range from pink, red, pale, or black, depending on the burn depth. The burn may or may not have blisters. • The following may suggest inhalation or airway injury. – Soot (ash) around nose or mouth, or singed (burned) nasal hairs – Swelling to lips or mouth – Voice changes Burns can affect the whole body and cause soft tissue injury, swelling and shock resulting from fluid loss due to the burn. The goal of burn management is to stop the burning process, watch for swelling and compensate for fluid loss. In significant burn injury, fluid leaks into the skin and surrounding tissue causing swelling and shock. • Burns involving the airway can rapidly cause airway obstruction. • It is crucial to replace fluid loss and anticipate ongoing losses. – In order to calculate the IV fluid requirements, it is important to determine the depth of the burn and the percentage of body surface area (BSA) that is burned. [See SKILLS] • Do not forget to give tetanus vaccination and pain relief for burn injuries. • Remove all jewelry and elevate the burned limb if possible. • Burns are at high risk for infection, even with good care. Clean and dress the wound carefully. [See SKILLS] BURNS REQUIRING RAPID HANDOVER/TRANSFER: • Serious burns to >15% of body [See SKILLS] • Burns involving the hands, face, groin area, joints, or circumferential burns • Inhalation injury • Burns with other associated trauma • Any burn in very young or elderly people • Significant pre-burn illness (such as diabetes) Module 2: Approach to trauma 64 Workbook question 5: Approach to Trauma Using the workbook section above, list what you would DO to manage the following injuries. INJURY MANAGEMENT Pelvic fracture 1. ______________________________________________________ 2. ______________________________________________________ 3. ______________________________________________________ 4. ______________________________________________________ Burn injury in an adult 1. ______________________________________________________ 2. ______________________________________________________ 3. ______________________________________________________ 4. ______________________________________________________ Abdominal injury 1. ______________________________________________________ 2. ______________________________________________________ 3. ______________________________________________________ 4. ______________________________________________________ INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 65 SPECIAL POPULATIONS TRAUMA IN PREGNANCY Any female patient aged 10–50 years should have a pregnancy test. Pregnancy causes many changes in physiology and there are added considerations for fetal well-being. Even minor trauma may cause harm to the mother and fetus. Women suffering trauma in the third trimester are at risk for placental abruption (where the placenta can separate from the uterus wall, resulting in bleeding), uterine rupture, and premature labour. Remember resuscitation of the mother resuscitates the fetus. KEY ELEMENTS OF PATIENT HISTORY Gestational age (age of the fetus or number of weeks since last menstrual period). Any pregnancy complications. PRIMARY SURVEY Airway: swelling in pregnancy can make airway obstruction more likely, so monitor closely. Breathing: the diaphragm is pushed up by the pregnant uterus, leaving less lung space for breathing. Circulation: check for vaginal bleeding; a pregnant uterus can also compress large blood vessels, causing hypotension. Place on left side with cervical spine precautions. [See SKILLS] Disability: always consider eclampsia if seizures/convulsions occur. Exposure: keep patient warm. COMMON CONDITIONS CAUSED BY TRAUMA Preterm (early) labour with or without premature rupture of membranes (loss of the fluid surrounding the baby). Placental abruption or uterine rupture: causing blood loss and shock. Seizures/convulsions. SPECIAL MANAGEMENT CONSIDERATIONS Plan early for handover/transfer to a specialist unit with obstetric care. If the uterus can be felt at the level of the umbilicus (belly button), this generally indicates that the patient is at least 20 weeks pregnant. If the woman is more than 20 weeks (5 months) pregnant, the pregnant uterus can compress the inferior vena cava, the large vessel that brings blood back to her heart, and can cause shock. When lying the pregnant patient flat, always place on the left side (on a spine board if immobilization necessary). [See SKILLS] Trauma in late pregnancy may trigger early labour. Prepare for neonatal resuscitation as well when trauma occurs in late pregnancy. Module 2: Approach to trauma 66 Workbook question 6: Approach to Trauma Using the workbook section above, list the common conditions in a pregnant woman that can be caused by trauma. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 67 SPECIAL CONSIDERATIONS IN CHILDREN Children can appear well after an injury, and yet deteriorate quickly. They have different injury patterns, and serious internal organ injuries may occur without overlying skull or rib fractures (paediatric bones are more flexible). Common management problems include over- or under-resuscitation, medication errors and failure to recognize hypothermia and hypoglycaemia. Below are special considerations for injured children. Refer also to the ABCDE module for normal paediatric vital signs and additional details. AIRWAY • When neck trauma or cervical spine injury is suspected, use jaw thrust to manually open airway while maintaining cervical spine immobilization. Children have big heads and large tongues that may easily obstruct their airways. Young children and infants may require a pad under the shoulders to align the airway. [See SKILLS] BREATHING • If the child is not breathing adequately after opening the airway, assist breathing with a bag-valve-mask, ideally with oxygen. • Give a breath every 4 seconds (15 breaths per minute) for older children and a breath every 3 seconds (20 breaths per minute) for infants. [See SKILLS] Neutral position in infants page 2 Module 2: Approach to trauma 68 CIRCULATION • For ongoing blood loss or evidence of poor perfusion in children with normal nutritional status (see also SKILLS): – place IV; – give IV fluids and re-assess. [See SKILLS] • For malnourished children, fluids MUST be adjusted. [See SKILLS] • For severe burn injury, initial bolus is with dextrose- containing fluids. [See SKILLS] • If significant haemorrhage, arrange for blood transfusion or rapid handover/transfer to a centre capable of blood transfusion. DISABILITY • Monitor child’s level of consciousness with the AVPU scale (Alert, responsive to Verbal stimuli, responsive to Painful stimuli, Unresponsive). AVPU is preferred to GCS in young children. • Assess for and manage seizures/convulsions. • Assess for and manage hypoglycaemia. EXPOSURE • Expose the entire body but watch for hypothermia. • Protect the child’s modesty at all times. • Use log-roll to assess remainder of child’s back and head. Estimate weight in children based on age Weight in kilograms = [age in years + 4] × 2 or use weight-estimation tools such as PAWPER tape, Mercy TAPE, or Broselow tape, etc. GENERAL Young children may be less able than adults to report events, even major events like being hit by a vehicle. Always consider the possibility of unwitnessed trauma in young children. Location of brachial pulse in a child page 35 Location of brachial pulse in a child INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 69 HEAD INJURIES Head injuries are a common cause of death in children, and children frequently suffer from acute brain swelling after a severe head injury. If a paediatric patient has signs of traumatic brain injury, transport urgently to a facility with critical care and/or surgical capacity. CHEST INJURIES Chest injuries can be life-threatening, and children require less force for more serious internal injuries. The ribs are more flexible than in adults, and there may be extensive chest injuries without rib fractures. ABDOMINAL INJURIES Children’s abdomens are relatively larger than adults, and the abdomen is a common site of injury in children. Injuries to the spleen and liver are especially common. Abdominal injuries should be considered in all paediatric trauma patients as they can be life- threatening and can cause severe internal bleeding. BURN INJURIES Burns in children can be difficult to manage. They require careful fluid resuscitation, close observation for airway swelling, and pain medications for dressing changes. In children who are burned, plan for rapid handover/transfer to a burn unit. Workbook question 7: Approach to Trauma Using the workbook section above, list the circulation considerations in children who suffer trauma. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ List the disability considerations in children who suffer trauma. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ Module 2: Approach to trauma 70 DISPOSITION CONSIDERATIONS Trauma patients can have complex injuries that may be hidden, and can worsen and die very quickly. Always refer seriously injured patients to a higher level of care for specialized treatment. The following high-risk conditions always require handover/transfer to a specialist unit for ongoing care: Airway problem requiring intervention. Signs of shock: – Tension pneumothorax: perform needle decompression prior to transfer (will need urgent chest tube placement). – Pericardial tamponade: ensure IV fluids started and continued on transfer. Altered mental status (drowsy, lethargic, confused or unconscious). Trauma in pregnancy: place on left side for transport (needs specialist obstetric care). Child with ABCDE problem, burn, or any head, chest or abdominal injury. Any serious burn injury: assess the burn depth and total burn surface area, commence fluid resuscitation (transfer preferably to a specialist burns unit). [See SKILLS] Other considerations for transfer: If a patient has required oxygen, arrange to continue it during transport and after handover. If an injured person is displaying signs of shock, ensure IV fluid started and continued during transfer. Ensure any external bleeding is controlled and monitored during transport. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 71 FACILITATOR-LED CASE SCENARIOS These case scenarios will be presented in small groups. The following cases WILL NOT be assessed and are for practice only. It is important that you practise these scenarios as you will be assessed on how you lead a case in the following modules. For each case scenario the group must identify the critical findings and management needed and formulate a one- line summary for handover, including assessment findings and interventions. You should use the Quick Cards for these scenarios. CASE #1: ADULT TRAUMA A taxi driver brings in a man that was severely injured. You come outside to find a 30-year-old male lying in the back seat of the taxi in severe pain. He was in a car crash a few kilometers away. His jeans are soaked with blood, with bone sticking out of the right thigh. 1. What do you need to do in your initial approach? 2. Use the primary survey to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate a short summary of this patient for handover. CASE #2: PAEDIATRIC TRAUMA A 5-year-old boy pulled a pan of boiling water off the stove at 8pm tonight. The boiling water spilled on him, burning his right side. His mother used a container of cool water to wash him down and then brought him in for evaluation. The child is crying and tells you he is in pain. He has burns to his right palm, and right inner arm up to the elbow, and the front of his chest and abdomen and the front of his right thigh. The mother does not know how much the child weighs. Module 2: Approach to trauma 72 1. What do you need to do in your initial approach? 2. Use the primary survey to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. Use the table below for your notes. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO A. Calculate the total burn surface area in this child. Try to shade in the children’s burn diagram for burn area estimation. B. Explain how you will decide if this child needs IV fluids? C. Calculate how much fluid is needed, explaining your method. D. What fluid would you use? 3. Formulate a short summary of this patient for handover. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 73 MULTIPLE CHOICE QUESTIONS Answer the questions below. Questions and answers will be discussed in the session. 1. Which of the following is a component of the trauma primary survey? A. Examine the arms for any fractures B. Check the skin color and temperature C. Examine the ears for any drainage of blood or clear liquid D. Check skin pinch 2. You are assessing a man who was in a car crash. He is very confused, but the remainder of his primary survey is normal. How do you perform a SAMPLE history if the patient is too confused to answer your questions? A. You do not need to do a SAMPLE history in a trauma patient B. Ask the patient repeatedly until he is able to answer C. Ask bystanders or family member for the information D. Assume that there is no important information 3. A 23-year-old man is carried in after diving head first into a river. He is speaking and his airway is open but he cannot walk or move his arms or legs. What is the first thing you must do? A. Place an IV line B. Examine him for other injuries C. Immobilize the cervical spine D. Give him a tetanus vaccination 4. You are evaluating a 21-year-old male who was in a motorcycle crash. He was thrown from the motorcycle and suffered injuries to his face, chest and legs. When you compress his pelvis, he screams in pain. His vital signs are: blood pressure 90/40 mmHg, heart rate 120 bpm, respiratory rate 25/min. What should be your next step? A. Place in a pelvic binder B. Administer tetanus vaccine C. Provide antibiotics D. Clean the abrasions with soap and water 5. A young woman has been brought in after an explosion. She has an open airway, a respiratory rate of 30/min, heart rate 125 bpm, blood pressure of 85/50 mmHg, has moist pale skin and she complains of abdominal pain. She has small wounds to her skin but there is no obvious bleeding. What would you do to manage this patient? A. Place two large-bore cannulae and give 1 litre of fluid B. Offer her a drink of water C. Check her temperature D. Provide antibiotics 74 Notes ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS 75 PARTICIPANT WORKBOOK Module 3: Approach to difficulty in breathing Objectives On completing this module you should be able to: 1. recognize signs of difficulty in breathing (DIB); 2. list the high-risk causes of difficulty in breathing; 3. perform critical actions for high-risk causes of difficulty in breathing. Essential skills Basic airway manoeuvres Basic airway device insertion Management of choking Oxygen administration Bag-valve-mask ventilation Needle decompression for tension pneumothorax Three-sided dressing for sucking chest wound KEY TERMS Write the definition using the Glossary at the back of the workbook. Accessory muscle use: Anaemia: Asthma: Chronic obstructive pulmonary disease (COPD): Circumferential burns: Crepitus: Module 3: Approach to difficulty in breathing 76 Cyanosis: Diabetic ketoacidosis (DKA): Diaphoresis: Difficulty in breathing (DIB): Disposition: Drowning: Haemothorax: Heart attack: Heart failure: Hives: Hyperventilation: Inflammation: Ischaemia: Large-bore IV: Needle decompression: Pericardial effusion: Pleural effusion: Pleuritic: Pneumonia: Pulmonary embolism: TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 77 Stridor: Tachycardia: Tachypnoea: Tracheal shift: Tripod position: Wheezing: Overview Difficulty in breathing (DIB) is a term used to describe a range of conditions from a feeling of shortness of breath to abnormal breathing movements, or any increased effort required to breathe. DIB can result from problems in the upper or lower airways, the lungs, the heart or the muscles used for breathing; or from conditions that may cause faster breathing (such as anaemia or chemical imbalance). DIB can be caused by: upper or lower airway obstruction (blockage by an object; by spasm of the airways, such as with asthma; by swelling due to allergy; infection or injury); fluid in the airspaces of the lung (such as from pneumonia or pulmonary oedema); air or fluid outside the lung causing lung collapse or compression (such as pneumothorax or effusion); blood clots in the vessels supplying the lungs; any other cause of decreased oxygen carried in the blood (such as anaemia); conditions that increase respiratory rate such as toxic ingestion, chemical imbalance (for example in diabetic ketoacidosis) or anxiety. The goal of INITIAL ASSESSMENT is to identify reversible causes of difficulty in breathing, and to recognize conditions that require urgent intervention or rapid transfer. The goal of ACUTE MANAGEMENT is to ensure the airway stays open and breathing is adequate to deliver oxygen to the organs. Module 3: Approach to difficulty in breathing 78 This module will guide you through: ABCDE key elements ASK: key history findings (SAMPLE history) CHECK: secondary exam findings Possible causes DO: management Special considerations in children Disposition considerations REMEMBER... • ALWAYS START WITH THE ABCDE APPROACH, intervening as needed. • Then do a SAMPLE history. • Then do a secondary exam. ABCDE: KEY ELEMENTS FOR PATIENTS WITH DIFFICULTY IN BREATHING For the patient with difficulty in breathing, the following are key elements that should be considered in the ABCDE approach. AIRWAY A person with difficulty in breathing may have airway swelling caused by a severe allergic reaction (anaphylaxis) or choking (obstruction from a foreign body). Stridor suggests serious airway narrowing. BREATHING Hypotension with absent breath sounds on one side – especially with distended (swollen or enlarged) neck veins or tracheal shift – may indicate tension pneumothorax. Wheezing may indicate asthma or severe allergic reaction. CIRCULATION Shock, heart attack, heart failure and severe infection can all present with poor perfusion and difficulty in breathing. Poor perfusion sends signals to the brain to increase the rate of breathing, which can feel and look like difficulty in breathing. Check for signs of shock by checking capillary refill, heart rate and blood pressure. Swelling in the legs or crackles in the lungs can indicate heart failure and fluid overload as a cause of difficulty in breathing. A B C TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 79 DISABILITY Patients with decreased level of consciousness may not be able to protect their airways. Drugs, infection or injury can directly affect the part of the brain that controls breathing. Assess for paralyzing conditions affecting the breathing muscles. Check level of consciousness with the AVPU scale: A: Alert V: Responds to Voice P: Responds to Pain U: Unresponsive EXPOSURE Expose the patient fully to assess for abnormal chest wall movement and any signs of trauma. Penetrating trauma to the back, chest, underarms or abdomen may cause lung injury and is often missed. ASK: KEY HISTORY FINDINGS FOR PATIENTS WITH DIFFICULTY IN BREATHING Use the SAMPLE approach to obtain a history from the patient and/or family. If the history identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it. S: SIGNS AND SYMPTOMS When did the symptoms start and was onset sudden? Do they come and go and how long do they last? Have they changed over time and has there been a similar episode previously? Sudden difficulty in breathing can suggest airway obstruction such as by a foreign body; swelling of the airway from allergic reaction or infection; trauma to the airway, lungs, heart or chest wall; or inhalation of hot gases or smoke. Acute heart problems such as heart attack, abnormal heart rhythm or valve problems can cause rapid onset DIB. A history of rapid or deep breathing may suggest poisoning, high acid levels in the blood (infection or diabetic ketoacidosis) or anxiety. DIB that starts slowly is more common with infection and chronic conditions such as a gradual build-up of fluid around the lungs (as occurs in TB and heart failure), fluid around the heart (from TB or kidney disease), lung cancer or diseases affecting the function of the chest wall. Recurrent difficulty in breathing associated with wheeze may suggest asthma or COPD. Did anything trigger the difficulty in breathing and what makes it better or worse? A history of allergies may suggest that the airway is blocked by swelling due to a severe allergic reaction. Inhaling smoke or hot gas (such as in fires) or some chemicals may cause E D Module 3: Approach to difficulty in breathing 80 DIB through upper airway injury and swelling. Exposure to some chemicals (such as certain pesticides) can cause fluid to build up in the airways and can cause weakness in the muscles involved in breathing. Difficulty in breathing that gets worse when the person lies flat can be due to fluid in the lungs. Is there any tongue or lip swelling, or voice changes? Swelling to the mouth, lips, tongue or upper throat, or a change in voice can suggest a severe allergic reaction or other inflammation of the airway. Are there abnormal sounds with breathing? High-pitched or ‘squeaking’ sounds when breathing IN may be stridor, which is caused by narrowing of the upper airway and may suggest severe allergic reaction or other airway obstruction. Wheezing – a high-pitched sound with breathing OUT – is caused by narrowing or spasm of the lower airways in the lungs and can suggest asthma, COPD, heart failure or allergic reactions. Gurgling sounds with breathing suggest that there is mucus, blood or other fluid in the airway. Is there pain associated with the difficulty in breathing? Difficulty in breathing with chest pain can suggest heart attack, pneumothorax, pneumonia or trauma to the lungs, ribs or ribcage muscles. In particular, pain that is worse with deep breaths (pleuritic pain) may suggest infection or blood clot in the lung (pulmonary embolism). Is there fever or cough? Fever suggests infection. Lung infection and any severe infection may cause fluid in the lungs. A cough may indicate fluid in the lungs from pneumonia or oedema. Cough and wheezing may suggest asthma or COPD. Is there foot or leg swelling or recent pregnancy? Difficulty in breathing with oedema of both feet or legs can suggest heart failure with fluid back-up to the lungs and body. Difficulty in breathing with swelling and pain in one leg may suggest a clot in a leg vein that has travelled to the lung (pulmonary embolism). Pregnancy is a risk factor for both pulmonary embolism and heart failure. A: ALLERGIES Any allergies to medications or other substances? Any recent insect bites or stings? Severe allergic reactions may cause difficulty in breathing due to airway swelling. People can have severe allergic reactions to almost anything, but food, plants, medications and insect bites/stings are the most common. M: MEDICATIONS Currently taking any medications? Ask about new medications and changes in doses. New medications can cause allergies with associated difficulty in breathing. Accidental overdose of some medications can stop or slow breathing. TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 81 P: PAST MEDICAL HISTORY Is there a history of asthma or chronic obstructive pulmonary disease (COPD)? Asthma and COPD often cause episodes of difficulty in breathing. A history of prior hospitalization or intubation for these conditions suggests a high-risk patient. Is there a history of heart disease or kidney disease? People with a history of heart or kidney failure may have fluid in the lungs. Heart attack may present with difficulty in breathing. Is there a history of tuberculosis (TB) or cancer? Conditions such as tuberculosis and cancer can cause build up of fluid in the sac around the heart (pericardial effusion) or build-up of fluid outside the lung (pleural effusion), both of which can cause a feeling of difficulty in breathing. Is there a history of diabetes? Diabetes can cause diabetic crisis (diabetic ketoacidosis or DKA). DKA causes fast breathing that may be reported as difficulty in breathing. Is there a history of smoking? Smoking increases the risk of asthma, COPD, lung cancer and heart attack. Is there a history of HIV? HIV infection increases the risk of other infections. L: LAST ORAL INTAKE When did the person last eat or drink? A full stomach puts the patient at risk of vomiting and possible choking. E: EVENTS SURROUNDING ILLNESS What was the person doing when the difficulty in breathing started? Always consider choking if DIB started while eating or drinking. DIB with exercise might be due to heart attack, especially when there is also chest pain. Was the patient found in or near water? Always consider drowning (inhalation of water) in a person found in or near water. Even a small amount of inhaled water can cause serious lung damage, which can worsen over time. Has there been exposure to pesticides or other chemicals? Inhaled chemicals can cause DIB by irritating the airways and lungs. Some pesticides used in farming can be absorbed through the skin, causing fluid buildup in the airways and lungs. Exposure to gases from a fire is often associated with chemical inhalation. Has there been any recent trauma? DIB with trauma is concerning for rib fractures, pneumothorax, haemothorax, and heart or lung bruising. Module 3: Approach to difficulty in breathing 82 Workbook question 1: Difficulty in breathing Using the workbook section above, list five questions about past medical history you would ask when taking a SAMPLE history. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ CHECK: SECONDARY EXAMINATION FINDINGS FOR PATIENTS WITH DIFFICULTY IN BREATHING DIB may present with changes in respiratory rate, respiratory effort, or low oxygen saturation. Always assess ABCDE first. The initial ABCDE approach identifies and manages life-threatening conditions. The secondary exam looks for changes in the patient’s condition or less obvious causes which may have been missed during ABCDE. If the secondary examination identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it. LOOK Look for signs of respiratory failure: Accessory muscle use and increased work of breathing. Difficulty speaking in full sentences. Inability to lie down or lean back. Diaphoresis (excessive sweating) and mottled skin. Confusion, irritability, agitation. Poor chest wall movement. Cyanosis (blue skin colour, especially lips and fingertips). Look at the pupils for size and reactivity: Very small pupils suggest possible opioid overdose or exposure to chemicals (including pesticides). Unequal or abnormally shaped pupils suggest head injury which can cause abnormal breathing. TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 83 Look at the face, nose and mouth: Cyanosis around the lips or nose suggests low oxygen levels in the blood. Pale inner surface of lower eyelids suggests severe anaemia. Swelling of the lips, tongue and mouth suggests an allergic reaction. Soot around the mouth or nose, burned facial hair or facial burns suggest smoke inhalation and airway burns. Bleeding or swelling of the airway may be due to trauma. Look at the neck and chest: Distended neck veins can be due to a back-up of blood due to heart failure, tension pneumothorax or pericardial tamponade. Excessive muscle use in the neck and chest (between the ribs) suggests significant respiratory difficulty. If the trachea is shifted to one side, think about tension pneumothorax or tumour. Swelling or redness of the neck suggests infection or trauma. Examine the entire neck and chest carefully for bruising, wounds or other signs of trauma. Look at the rate and pattern of breathing: People with wheeze may take longer to breathe out because of narrowing of the lower airways in the lung. Fast breathing can be due to dehydration, severe infection, chemical imbalance in the blood, poisoning or anxiety. Slow and shallow breathing might be due to opioid overdose. Look for very small pupils and altered mental status. Chest wall injury is often associated with pain that limits the ability to take deep breaths. A flail chest occurs when multiple rib fractures cause a segment of the rib cage to be separated from the rest of the chest wall. The segment may appear to be moving in the opposite direction from the rest of chest wall during breathing. Look at the legs: Swelling to the both lower legs suggests heart failure as a cause of difficulty in breathing. Swelling to one leg may be due to a blood clot in the leg. If there is also difficulty in breathing, this may mean that part of the clot has traveled to the lung. Look at the skin: Bites can be a source of allergic reaction. Rashes, such as hives, can indicate allergic reaction. When associated with difficulty in breathing, rashes can indicate widespread (systemic) infection. Pallor (pale skin) can indicate anaemia as a cause of DIB. Circumferential burns (a burn that goes entirely around a body part) to the chest can restrict chest wall expansion and limit breathing. Module 3: Approach to difficulty in breathing 84 LISTEN Listen to the breath sounds: Stridor suggests partial upper airway obstruction, which may be due to a foreign object, mass, or swelling from trauma or infection. Decreased or absent breath sounds suggest abnormal air movement in the lungs. This can be due to air or fluid around the lung (pneumothorax, haemothorax, effusion), narrowing or foreign body blockage of the airways, and infection or tumour in or around the lung. Wheezing, in particular, suggests lower airway obstruction such as from asthma, COPD, allergic reaction, foreign body or tumour. Crackles or crepitations suggest fluid in the airspaces of the lung. Listen to the heart sounds: Abnormal heart rhythms can cause the heart to pump blood abnormally, leading to poor perfusion and a feeling of difficulty in breathing. Difficulty in breathing accompanied by heart murmurs can suggest damage to the heart valves. Muffled or distant heart sounds accompanying low blood pressure, fast heart rate and distended neck veins suggest pericardial tamponade. FEEL Feel the ribs and chest wall: Deformities and abnormal movement when pressing on the chest wall suggest rib fracture. Crepitus (crackling or popping when pressing on the skin of the chest wall) may suggest underlying fracture or air under the skin (associated with pneumothorax). Unequal expansion of the chest wall suggests pneumothorax, haemothorax, or flail chest. Percuss the chest wall [See SKILLS]: Hollow sounds (hyperresonance) on one side when tapping the chest wall suggest pneumothorax. Dull sounds when tapping the chest wall may indicate fluid or blood either inside the airspaces of the lungs or between the lungs and the chest wall. TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 85 Workbook question 2: Difficulty in breathing Using the workbook section above, list three signs you should LOOK for in a patient with difficulty in breathing. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ List four things you should LISTEN for in a patient with difficulty in breathing. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ List three things you should FEEL the chest wall for in a patient with difficulty in breathing. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ POSSIBLE CAUSES OF DIFFICULTY IN BREATHING The causes of difficulty in breathing can be organized by body area: airway, lung, heart, or whole body. Key airway causes CONDITION SIGNS AND SYMPTOMS Foreign body in the airway • Acute difficulty in breathing • Visible secretions, vomit or foreign body in the airway • Abnormal sounds from the airway (such as stridor, snoring, gurgling) • Coughing • Drooling Severe allergic reaction • Swelling of lips, tongue and mouth • Stridor and/or wheezing • Rash or hives • May have tachycardia and hypotension • Exposure to known allergen Module 3: Approach to difficulty in breathing 86 CONDITION SIGNS AND SYMPTOMS Airway swelling (due to inflammation/ infection) • Stridor • Hoarse voice • Drooling or difficulty swallowing (indicates severe swelling) • Unable to lie down • May have fever (with infection) Airway burns • History of exposure to chemical or fire • Burns to head and neck (or singed facial hair or soot around nose or mouth) • Stridor • Change in voice Key lung causes CONDITION SIGNS AND SYMPTOMS Pneumonia • Fever and cough • Gradually more laboured breathing • Pain worse with breathing (pleuritic) • Abnormal lung examination (crackles) Asthma/COPD • Wheezing • Cough • Accessory muscle use • Tripod position (see figure) • May have history of smoking or allergies Pneumothorax • Decreased breath sounds on one side • Sudden onset • Hollow sounds (hyperresonance) to percussion on affected side [See SKILLS] • May have pain that worsens with breathing • May have history of trauma or evidence of rib fracture • Hypotension with distended neck veins and decreased breath sounds on one side indicate tension pneumothorax. Haemothorax • Decreased breath sounds on affected side • Dull sounds with percussion [See SKILLS] • May have a history of trauma, cancer or tuberculosis Shock (if large haemothorax) Pleural effusion • Decreased breath sounds on one or both sides • Dull sounds with percussion [See SKILLS] • May have history of cancer, tuberculosis, heart disease or kidney disease • Acute or chronic difficulty in breathing Acute chest syndrome in a patient with sickle dell disease • History of sickle cell disease • Chest pain • Fever • Hypoxia TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 87 Tripod position page 32 Key heart causes CONDITION SIGNS AND SYMPTOMS Heart attack • Pressure, tightness or crushing feeling in the chest • Diaphoresis and mottled skin • Nausea or vomiting • Signs of heart failure • History of smoking, heart disease, hypertension, diabetes, high cholesterol, family history of heart problems Heart failure • Worse with exertion • Worse when lying flat • Swelling to both legs • Distended neck veins • Crackles may be heard in the lungs • May have chest pain Pericardial tamponade • Signs of poor perfusion (tachycardia, tachypnoea, hypotension, pale skin, cold extremities, capillary refill greater than 3 seconds) • Distended neck veins • Muffled heart sounds • May have dizziness, confusion, altered mental status • History of tuberculosis, trauma, malignancy, kidney failure Tripod position Module 3: Approach to difficulty in breathing 88 Key systemic causes CONDITION SIGNS AND SYMPTOMS Anaemia • Pale skin and inner lower eyelids • Tachycardia • Tachypnoea • History of haemorrhage, malnourishment, cancer, pregnancy, malaria, sickle cell disease, renal failure Opioid overdose • Clinical or recreational opioid use • Altered mental status • Very small pupils • Slow, shallow breathing Diabetic ketoacidosis • May have known history of diabetes • Deep or rapid breathing • Frequent urination • Sweet smelling breath • High glucose in blood or urine • Dehydrated Workbook question 3: Difficulty in breathing Using the workbook section above, list the possible cause of difficulty in breathing next to the history and physical findings below. HISTORY AND PHYSICAL FINDINGS LIKELY CAUSE A 20-year-old man presents with difficulty in breathing, wheezing and: • swelling of lips, tongue and mouth • rash or hives (patches of pale or red, itchy, warm, swollen skin) • tachycardia and hypotension • history of allergies • exposure to known allergen A 50-year-old woman presents with difficulty in breathing, signs of poor perfusion (tachycardia, tachypnoea, hypotension, pale skin, cold extremities, capillary refill >3 seconds) and: • distended neck veins • muffled heart sounds • history of tuberculosis TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 89 DO: MANAGEMENT FIRST PERFORM ABCDE ASSESSMENT AND INTERVENE FOR LIFE-THREATENING CONDITIONS. Assess and manage airway and provide bag-mask-ventilation (BVM) for any patient who is not breathing or not breathing adequately (too slow for age or too shallow); any unconscious patient with abnormal (slow, shallow, gasping or noisy) breathing; or any patient with a pulse who is not breathing. For patients without a pulse, follow relevant CPR protocols. CONDITION MANAGEMENT CONSIDERATIONS Airway inflammation or burns Keep patients calm. Give oxygen if you can do this without upsetting the patient. [See SKILLS] If the patient is fully alert and no spinal injury suspected, the seated position may be more comfortable. Patients with airway burns may require early intubation as the airway can swell and block quickly; delays may make intubation more difficult. A person with airway inflammation or burns requires urgent handover/ transfer. Choking Use age-appropriate chest thrusts/abdominal thrusts/back blows. [See SKILLS] Allergic reaction Remove the allergen, if possible. For severe allergic reaction with difficulty breathing give intramuscular adrenaline as soon as possible. Give oxygen for severe cases. [See SKILLS] Asthma/COPD Administer salbutamol as soon as possible. Give oxygen if indicated. [See SKILLS] Fever Give antibiotics as soon as possible if infection might be the cause of difficulty in breathing. If the patient has signs of poor perfusion, give IV fluids with caution to avoid fluid overload. [See SKILLS] Heart attack Give aspirin. While oxygen is no longer recommended in all patients with heart attack, it should initially be given to patients with shock or difficulty in breathing. [See SKILLS] For those patients who already have nitroglycerin, you can assist them in taking it if perfusion is adequate. Chronic, severe anaemia Give IV fluids more slowly and check the lungs for crackles (fluid overload) frequently. [See SKILLS] These patients may need handover/transfer for blood transfusion. Diabetic ketoacidosis Give IV fluids. [See SKILLS] A person with diabetic ketoacidosis is extremely ill and requires urgent transfer to an advanced provider. Opioid overdose Support breathing with a bag-valve-mask as needed. Give naloxone. [See SKILLS] Pleural effusion or haemothorax Give oxygen. [See SKILLS] Arrange for handover/transfer immediately. Many of these patients will need a chest tube or other drainage. Trauma All trauma patients with difficulty in breathing should be given oxygen. IV fluid should be given to help fill the heart if either pericardial tamponade or tension pneumothorax is suspected. Needle decompression should be performed if tension pneumothorax is suspected. Treat sucking chest wounds with a 3-sided dressing. [See SKILLS] The patient will need urgent handover/transfer for a chest tube if needle decompression is performed or a 3-sided dressing is applied. Acute chest syndrome Give oxygen, IV fluids, antibiotics. May need transfer for advanced management. Module 3: Approach to difficulty in breathing 90 Workbook question 4: Difficulty in breathing Using the workbook section above, list what you would DO to manage a person who presents with: DIB, coughing. You suspect choking. 1. ���������������������������������������� 2. ���������������������������������������� DIB, high fever, cough. You suspect serious infection. 1. ���������������������������������������� 2. ���������������������������������������� DIB, hoarse voice and stridor on breathing in. You to suspect airway inflammation. 1. ���������������������������������������� 2. ���������������������������������������� 3. ���������������������������������������� SPECIAL CONSIDERATIONS IN CHILDREN The following are danger signs in children: • Signs of airway obstruction (unable to swallow saliva/drooling or stridor). • Increased breathing effort (fast breathing, nasal flaring, grunting, chest indrawing or retractions). • Cyanosis (blue colour of the skin, especially at the lips and fingertips). • Altered mental status (lethargy or unusual sleepiness, agitation). • Poor feeding or drinking. • Vomiting everything. • Seizures/convulsions. • Low temperature (hypothermia). REMEMBER... • Wheezing in children can be caused by viral infection, asthma or an inhaled object blocking the airway. • Stridor in children can be caused by an object stuck in the upper airway OR airway swelling. • Children may present with rapid breathing as the only sign of pneumonia. • Rapid breathing can also indicate diabetic crisis (DKA), which may be the first sign of diabetes in a child. TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 91 Workbook question 5: difficulty in breathing Using the workbook section above, list the paediatric danger signs. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ 6. ______________________________________________________________________ 7. ______________________________________________________________________ 8. ______________________________________________________________________ DISPOSITION CONSIDERATIONS Keep in mind that the effects of inhaled medications such as salbutamol last for only approximately 3 hours. Patients need to be monitored closely. If a patient with a severe allergic reaction is given adrenaline, the reaction can return when the adrenaline wears off. Patients need to be monitored closely. Naloxone only lasts about 1 hour. Most opioid medications last longer than this, so patients may need repeat naloxone doses. Following immersion in water (drowning), a person may develop late signs of breathing problems after several hours and should be observed closely. Never leave patients who might need definitive airway placement unmonitored during handover/transfer. Ensure that a new provider is monitoring the patient before leaving. Make transfer arrangements as early as possible for any patient who may require assisted ventilation. Module 3: Approach to difficulty in breathing 92 FACILITATOR-LED CASE SCENARIOS These case scenarios will be presented in small groups. One participant will be identified as the lead and will be assessed while the rest of the group writes the responses in the workbook. To complete a case scenario, the group must identify the critical findings and management needed and formulate a one-line summary for handover, which includes assessment findings and interventions. You should use the Quick Cards for these scenarios while being assessed. CASE #1: ADULT WITH DIFFICULTY IN BREATHING A 22-year-old man arrives by taxi. He was robbed on the street, and was stabbed in the left chest with a knife. He is now having severe difficulty in breathing. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Cards for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate one sentence to summarize this patient for handover. TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 93 CASE #2: PAEDIATRIC PATIENT WITH DIFFICULTY IN BREATHING A mother brings in her 6-year-old son for difficulty in breathing. The mother states that her son has been having difficulty breathing for the past 3 days. She says he makes funny noises when he breathes. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate one sentence to summarize this patient for handover. Module 3: Approach to difficulty in breathing 94 MULTIPLE CHOICE QUESTIONS Answer the questions below. Questions and answers will be discussed in the session 1. You are evaluating a 34-year-old female complaining of difficulty in breathing, coughing, and fever for 3 days. Which of the following actions should you do first? A. Check blood pressure B. Administer antibiotics C. Start an IV D. Check the lung sounds 2. A 67-year-old man with a history of a heart attack is complaining of difficulty in breathing that is worse whenever he lies flat. His legs are both swollen, which has become worse in the past 2 weeks. What is the most likely cause of his difficulty in breathing? A. Heart failure B. Asthma C. Pneumothorax D. Pneumonia 3. There was a fire in a nearby house and a patient is brought to you with burned nasal hairs and shortness of breath. What should you do first? A. Give oxygen B. Give intramuscular adrenaline C. Start an IV line D. Perform needle decompression 4. A 30-year-old woman was stung by a bee and now has difficulty in breathing, facial swelling, and a rash. She has a history of severe allergic reactions to bee stings. What medication should you give her? A. Naloxone B. Benzodiazepine C. Adrenaline D. Aspirin 5. You are assessing a 10-year-old boy for difficulty in breathing. You notice that the skin on his fingertips and around his mouth has a blue color. What is this finding called? A. Retractions B. Nasal flaring C. Crepitus D. Cyanosis BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 95 Module 4: Approach to shock Objectives On completing this module you should be able to: 1. recognize signs of shock/poor perfusion; 2. perform critical actions for patients with shock; 3. assess fluid status; 4. select appropriate fluid administration based on patient age, weight and condition; 5. recognize malnourishment, anaemia and burns and adjust fluid resuscitation. Essential skills Oxygen administration IV line placement Fluid status assessment IV fluid resuscitation Burn management Needle decompression Three-sided dressing Direct pressure for bleeding control Uterine massage for bleeding control Trauma secondary survey KEY TERMS Write the definition using the Glossary at the back of the workbook. Bolus: Bradycardia: Capillary refill: Cholera: Module 4: Approach to shock 96 Diaphoresis: Dehydration: Diabetic ketoacidosis (DKA): Dilation (of blood vessels): Disposition: Ectopic pregnancy: Fluid status: Fontanelle: Gastroenteritis: Large-bore IV: Lethargy: Oral rehydration solution (ORS): Perfusion: Pericardial tamponade: Resuscitation: Shock: Skin pinch testing: BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 97 Overview Poor perfusion is when the body is not able to get enough oxygen-carrying blood to vital organs. When organ function is affected, this is called shock and can lead rapidly to death. Infants, children and older adults are more likely to be affected by shock. Causes of poor perfusion which may lead to shock include: loss of blood (haemorrhage); loss of fluid due to diarrhoea, vomiting, extensive burns or excess urination (such as caused by high blood sugar); poor fluid intake. Small children, the elderly and the very ill may be unable to drink enough fluids without assistance and are at risk of dehydration; abnormal relaxation and enlargement (dilation) of the blood vessels (with the same amount of blood inside the vessel) can lower blood pressure. This can occur in severe infection, spinal cord injury and severe allergic reaction; poor filling of the heart can result from blood or other fluid in the sac around the heart (pericardial tamponade), or increased pressure in the chest that can shift and block the vessels returning blood to the heart (tension pneumothorax); failure of the heart muscle to pump effectively can be due to a heart attack (vessel blockage that causes acute heart muscle damage); inflammation or other disease of the heart muscle itself; an abnormal rhythm or valve problems. (Shock due to failure of the heart to pump effectively is sometimes called cardiogenic shock.) The goal of INITIAL ASSESSMENT is to identify shock and any reversible causes of shock. The goal of ACUTE MANAGEMENT is to restore perfusion (oxygen delivery to the organs) and address ongoing fluid loss where possible. This module will guide you through: ABCDE key elements ASK: key history findings (SAMPLE history) CHECK: secondary examination findings Possible causes DO: management Special considerations in children Disposition considerations REMEMBER... ALWAYS START WITH THE ABCDE APPROACH, intervening as needed. Then do a SAMPLE history. Then do a secondary examination. Module 4: Approach to shock 98 ABCDE: KEY ELEMENTS IN SHOCK For the person in shock, the following are key elements that should be considered in the ABCDE approach. AIRWAY Face/mouth swelling or voice changes can indicate an allergic reaction. A severe allergic reaction can cause shock. BREATHING Wheezing can indicate a severe allergic reaction which can cause shock. Shock, difficulty in breathing and absent breath sounds on one side can indicate a tension pneumothorax. Poor perfusion itself can sometimes cause rapid breathing when vital organs do not receive enough oxygen. Severe heart failure can cause poor perfusion with difficulty in breathing when fluid backs up into the lungs. Any infection severe enough to cause shock may be associated with lung inflammation that causes difficulty in breathing. CIRCULATION Shock can be caused by many types of bleeding (from the stomach or intestines, pregnancy-related, and internal and external haemorrhage from trauma). Shock can also result from the fluid loss associated with diarrhoea, vomiting, extensive burns, or excess urination (such as caused by high blood sugar). DISABILITY Confusion in a person with poor perfusion suggests severe shock. Paralysis may indicate a spinal cord injury causing shock. EXPOSURE Look for signs of bleeding, trauma, and excessive sweating (diaphoresis). Hives can indicate allergic reaction, and other rashes can indicate systemic infection. ASK: KEY HISTORY FINDINGS IN SHOCK Use the SAMPLE approach to obtain a history from the patient and/or family. If the history identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it. A B C D E BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 99 S: SIGNS AND SYMPTOMS Has there been vomiting and/or diarrhoea? For how long? Fluid losses through vomiting and diarrhoea can be severe and can lead to shock. The amount of vomiting or diarrhoea can help give a rough estimate of the risk for shock, so always ask about frequency of episodes. Has the person had blood in stool or vomit? Bleeding in the stomach and/or intestines can be severe before it is recognized. A person can lose a significant portion of his or her blood volume in the intestines. Blood may appear black in both vomit and stools. Has there been any vaginal bleeding? Vaginal bleeding may be related to pregnancy in women of childbearing years. Always ask about pregnancy status, last menstrual period, any missed periods, or known recent pregnancy. Blood loss from normal delivery or miscarriage can cause shock. A pregnancy developing outside the uterus (ectopic pregnancy) can also be life-threatening if it ruptures. Ectopic pregnancy rupture can occur before a woman even knows she is pregnant. Other causes of vaginal bleeding are masses in the cervix or uterus. Has the person had any chest pain? Chest pain may suggest the person has had a heart attack. The muscle damage to the heart from a heart attack can reduce its ability to pump blood around the body, which can cause shock. Has there been fever? Fever may suggest infection as the cause of shock. Severe infection causes both dilation of the blood vessels (which lowers blood pressure) and fluid leakage from the blood vessels (with fluid loss into the tissues). Has there been any exposure to toxins, medications, insect stings or other substances? Severe allergic reactions can lead to shock. Additionally, many medications, including blood pressure and seizure/convulsion medications, can cause shock. Has there been altered mental status or unusual sleepiness? The brain is one of the last organs to be affected by poor perfusion, so altered mental status may be a sign of severe shock. A: ALLERGIES Does the person have any known allergies? Allergic reactions can lead to shock by causing abnormal relaxation of the blood vessels. Module 4: Approach to shock 100 M: MEDICATIONS Currently taking any medications? Obtain a full medication list from the person or the family. Knowing the patient’s medication list can help understand why the patient is in shock (such as heart medications). Overdose of blood pressure or seizure/convulsion medications can cause shock, and it may be more difficult to treat shock from any cause in patients taking these medications. Medications that thin the blood can worsen bleeding. Always ask about new medications in particular and recent dose changes to evaluate for allergic reaction or unexpected side effects. P: PAST MEDICAL HISTORY History of pregnancy or recent miscarriage or delivery? Blood loss following delivery can be severe if the uterus does not contract well. Hidden blood loss leading to shock can occur with ruptured ectopic pregnancy, even in women who do not know they are pregnant. Any woman of childbearing age with shock should be evaluated for pregnancy. History of recent surgery or induced abortion? Internal bleeding or infection after surgery can lead to shock. History of heart disease (heart attack or heart valve problems)? Patients with heart disease are at risk for worsening heart function that may lead to shock or worsen shock from other causes. Is there a history of HIV? HIV increases the risk of infection. L: LAST ORAL INTAKE When did the person last eat or drink? A person who is not eating or drinking well can develop severe dehydration, leading to shock. E: EVENTS SURROUNDING ILLNESS Has there been any recent trauma? Trauma can cause hidden internal bleeding, tension pneumothorax, and bruising or bleeding around the heart, all of which may reduce blood flow and cause shock. In addition, trauma to the neck or back causing spinal cord injury can interfere with the blood vessels’ ability to maintain blood pressure. Has there been any recent illness? Any infection can cause a blood infection that can spread throughout the body and lead to shock. BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 101 Workbook question 1: Shock Using the workbook section above, list six questions about signs and symptoms you would ask when taking a SAMPLE history. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ 6. ______________________________________________________________________ CHECK: SECONDARY EXAMINATION FINDINGS IN SHOCK A person with shock will have signs of poor perfusion, which may include a fast heart rate, a low systolic blood pressure, fast breathing, pale and cool skin, slow capillary refill, dizziness, confusion, altered mental status, decreased urine output or excessive sweating. REMEMBER: Perfusion can be limited even before blood pressure falls, especially in the young. Low blood pressure with poor perfusion is a very serious sign. Always assess ABCDE first. The initial ABCDE approach identifies and manages life-threatening conditions. The secondary exam looks for changes in the patient’s condition or less obvious causes that may have been missed during ABCDE. If the secondary examination identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it. REMEMBER: Children have different normal vital signs ranges, and children with shock may not have changes in vital signs until they are very ill. Always do a careful exam for any signs of shock. Check breath sounds and respiratory rate: – Abnormal or noisy breathing can indicate pneumonia as a source for system-wide infection causing shock. – High sugar levels can result in chemical imbalance (diabetic ketoacidosis) that the body tries to address by faster or deeper breathing. This condition may also result in sweet or ‘fruity’ smelling breath. Since elevated blood glucose levels cause increased urination, severe dehydration and shock can result. Check for bleeding: – All external bleeding should be controlled with direct pressure. [See SKILLS] Arterial bleeding may appear as pulsing or high pressure bleeding, and significant blood volume can be lost in minutes. Module 4: Approach to shock 102 – Vaginal bleeding may be an important source of blood loss from pregnancy-related bleeding (even in those who think they are not pregnant) or from masses in the cervix or uterus. Check fluid status: In dehydration states, the patient may feel thirsty or may have dry lips and mouth, abnormal skin pinch, lethargy, and delayed capillary refill. Patients with heart failure can be in shock with fluid overload, and may have lower body swelling (usually in both legs), crackles on lung examination, and distended neck veins. Check for pale conjunctiva (the inside of the lower eyelid): No matter the person’s skin color, the inside of the eyelid should appear pink and moist. If the inner portion of the eyelid (conjunctiva) is pale, it may indicate significant blood loss. You can compare the patient’s conjunctiva to another healthy person or look at your own in a mirror. Check mental status: Confusion in a patient with other signs of poor perfusion suggests severe shock. Check for fever: Fever in a patient with shock suggests severe infection. Check blood sugar: Low blood glucose can sometimes look like shock. If you cannot check blood glucose, but the person has altered mental status, a history of diabetes or another reason to have low sugar (for example, is taking quinine for malaria, is very ill, or is very malnourished), give glucose. [See SKILLS] Check for severe abdominal pain or a very firm abdomen: If the person has severe abdominal pain, this can be a sign of bleeding or infection in the abdomen. In a patient who might be pregnant, this can be a sign of an ectopic pregnancy. Check urine: Check the urine colour and volume. Small amounts of darker urine may indicate substantial dehydration. Check stool: Any significant diarrhoea can cause dehydration. A large amount of watery, “rice-water” stool suggests cholera, which can rapidly cause severe dehydration and shock. Black, dark, or reddish colored stool can suggest stomach or intestinal bleeding. BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 103 Check for malnourishment [see SKILLS]: If the person appears malnourished, fluid must be adjusted [see SKILLS]. Be sure to ask about recent changes in weight. Check for swelling, rash or excessive sweating: Swelling of mouth or body can indicate an allergic reaction. Rashes can indicate allergic reaction (hives) or systemic infection. Swelling of both legs can indicate heart failure. Sweating may occur with moderate to severe shock. Workbook question 2: Shock Using the workbook section above, list what you need to check for in a person with shock. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ 6. ______________________________________________________________________ 7. ______________________________________________________________________ 8. ______________________________________________________________________ 9. ______________________________________________________________________ 10. _____________________________________________________________________ Visible severe wasting in a child page 23 Visible severe wasting in a child Assessing for pitting edema in children with malnutrition page 22 Assessing for pitt ng edema in children with malnutri ion page 2 Asse ing for pitting ed ma in children with malnutrition page 22 Assessing for pitting edema in children with malnutrition Module 4: Approach to shock 104 POSSIBLE CAUSES OF SHOCK POOR PERFUSION DUE TO DILATED BLOOD VESSELS CONDITION SIGNS AND SYMPTOMS Severe infection • Fever • Tachycardia • Tachypnoea • May have hypotension • May or may not have obvious infectious source: visible skin infection, cough and crackles in one area of the lungs (often with tachypnoea), burning with urination, urine that is cloudy or foul smelling, or any focal pain in association with fever Spinal cord injury • History or signs of trauma • May have spinal pain/tenderness, vertebrae not in line, or crepitus (crunching) when you touch the spinal bones • Movement problems: paralysis, weakness, abnormal reflexes • Sensation problems: tingling (“pins and needles” sensation), loss of sensation • Unable to control urine and stools • Priapism • May have hypotension or bradycardia • Difficulty in breathing with an upper cervical spine injury Severe allergic reaction • Swelling of the mouth • Difficulty breathing with stridor and/or wheezing • Skin rash • Tachycardia • Hypotension POOR PERFUSION DUE TO FLUID LOSS CONDITION SIGNS AND SYMPTOMS Diabetic ketoacidosis (DKA) • May have known history of diabetes • Rapid or deep breathing • Frequent urination • Sweet-smelling breath • High glucose in blood or urine • Dehydration Severe dehydration • Abnormal skin pinch • Decreased fluid consumption or increased fluid loss (vomiting, diarrhoea, excessive urination) • Dry mucous membranes • Tachycardia Burn injury • Red, white or black areas of skin depending on depth of burn • May have blistering • May have signs of inhalational injury BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 105 POOR PERFUSION DUE TO BLOOD LOSS CONDITION SIGNS AND SYMPTOMS External bleeding • History of trauma • Visible bleeding • Use of blood-thinning medications Large bone fracture • History of trauma • Pain or abnormal movement of the pelvis, blood at opening of penis or rectum (pelvic fracture) • Deformity or crepitus of the femur, shortening of the leg with the injury (femur fracture) Abdominal bleeding • Bruising around the umbilicus or over the flanks can be a sign of internal bleeding • Abdominal pain • Very firm abdomen Bleeding in the stomach or intestines • Blood in vomit or stool • Black vomit or stool • History of alcohol use Haemothorax • Difficulty in breathing • Decreased breath sounds on affected side • Dull sounds with percussion on affected side • Shock (if large amount of blood) Ectopic pregnancy • History of pregnancy, missed menstrual cycle or any woman of childbearing age • Abdominal pain • Vaginal bleeding Postpartum haemorrhage • Recent delivery • Heavy vaginal bleeding: – Pad or cloth soaked in <5 minutes – Constant trickling blood – Bleeding >250 ml – Soft uterus/lower abdomen Module 4: Approach to shock 106 POOR PERFUSION DUE TO PROBLEMS WITH THE HEART CONDITION SIGNS AND SYMPTOMS Heart failure • Difficulty breathing with exertion or when lying flat • Swelling to both legs • Distended neck veins • Crackles may be heard in the lungs • May have chest pain Heart attack • Pressure, tightness, pain or crushing feeling in the chest • Diaphoresis and mottled skin • Difficulty in breathing • Nausea or vomiting • Pain moving to jaw or arms • Signs of heart failure • History of smoking, heart disease, hypertension, diabetes, high cholesterol, family history of heart problems Abnormal heart rhythm • Very fast or very slow pulse • Irregular pulse Heart valve problem • History of rheumatic fever or heart disease • Murmur Pericardial tamponade • Signs of poor perfusion (tachycardia, tachypnoea, hypotension, pale skin, cold extremities, capillary refill greater than 3 seconds) • Distended neck veins • Muffled heart sounds • May have dizziness, confusion, altered mental status • History of tuberculosis, trauma, cancer, kidney failure Tension pneumothorax • Hypotension WITH the following: – Difficulty breathing – Absent breath sounds on affected side – Hyperresonance with percussion on affected side – Distended neck veins – May have tracheal shift away from affected side REMEMBER... hypoglycaemia can look like shock. Signs and symptoms include: • Sweating (diaphoresis) • Seizure/convulsion • Blood glucose <3.5 mmol/L • Altered mental status (ranging from confusion to unconsciousness) • History of diabetes, malaria, or a severe illness, especially in children BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 107 Workbook Question 3: Shock Using the workbook section above, list the possible cause of shock next to the history and physical findings below. HISTORY AND PHYSICAL FINDINGS LIKELY CAUSE A 35-year-old woman presents with shock, fever and: • burning with urination • cloudy urine A 20-year-old woman presents with shock, abdominal pain and: • missed menstrual cycle • vaginal bleeding A 17-year-old man presents after a motor vehicle crash with shock, bruising to the pelvis and: • a femur fracture DO: MANAGEMENT FIRST PERFORM ABCDE ASSESSMENT AND INTERVENE FOR LIFE- THREATENING CONDITIONS. Start by giving IV fluid (normal saline or Ringer’s Lactate in adults and children with normal nutritional status). Then work to address underlying causes. Place IV access rapidly (two large-bore IVs) and start IV fluids. Place IV access rapidly (two large-bore IVs), start IV fluids and assess response. Repeat with additional boluses if needed. [See SKILLS] If you cannot place an IV, immediately call for a provider who can place a nasogastric tube (a tube that goes from the nose into the stomach) or intraosseous line (a needle that is placed directly into the bone). See if the patient can safely take oral fluids in the meantime. CAUTION! For severely malnourished or severely anaemic people, or anyone with signs of volume overload, do NOT follow the fluid protocol below. Use adjusted protocol. [See SKILLS] Module 4: Approach to shock 108 Uterine massage for postpartum hemorrhage page 17 If vaginal bleeding after delivery (postpartum haemorrhage) is suspected as a cause of shock: ALL patients need rapid handover/transfer to an advanced obstetric provider. While arranging for transport and during transport, it is important to try to stop the bleeding. Give BOTH intramuscular and IV oxytocin. This is a loading dose. After these doses, continue oxytocin IV until one hour after the bleeding stops. [See SKILLS] Bleeding frequently happens if the uterus is not fully contracted (does not feel hard on palpation). Perform uterine massage [See SKILLS] until the uterus is hard. You should use BOTH oxytocin and uterine massage to stop the bleeding. If the placenta delivers, collect it in a leak-proof container and keep with the patient to allow the advanced obstetric provider to examine it. Visually check externally for a perineal or vaginal tear. If found, apply direct pressure with sterile gauze and put legs together. Even if the bleeding stops, these patients still need rapid handover/transfer to an advanced obstetric provider (see figure). IV FLUID IMMEDIATELY AVAILABLE? IV FLUID AVAILABLE NEARBY? START ORS via NG NASOGASTRIC TUBE REASSESS IMMEDIATELY AFTER BOLUS DID PERFUSION IMPROVE? TRANSFER IMMEDIATELY CONTINUE ORS VIA NG YES YES YES YES No No No No DID PERFUSION IMPROVE? IV FLUIDS REASSESS IMMEDIATELY AFTER BOLUS CONTINUE E <30 MINUTES <30 MINUTES START IV FLUIDS RE-BOLUS GIVING FLUID IN SHOCK NO malnutrition, overload or severe anaemia Uterine massage for postpartum hemorrhage BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 109 REMEMBER... fluid only addresses the immediate problem of perfusion. Patients with shock need rapid handover/transfer to a unit capable of addressing the causes of shock and providing advanced management, including transfusion. REMEMBER... fluid status assessment is critical. Patients who have signs of poor perfusion but overall volume overload can be particularly difficult to manage. Patients with malnutrition, severe anaemia, and excess fluid in the lungs due to heart, liver, or kidney failure can present this way. These patients still need fluids, but the fluids must be given cautiously and, especially in malnourished children, according to a specific protocol. [See SKILLS] Postpartum Haemorrhage 1. Arrange immediate transfer to qualifi ed obstetric provider! 2. Attempt to control bleeding while arranging and during transfer. 3. Check: 4. Transfer immediately Heavy bleeding after delivery? Has the placenta delivered? Still bleeding? Is there a perineal or lower vaginal tear? Massage uterus until it is hard. Give oxytocin IM. Give IV uids and IV oxytocin. Empty bladder. Continue uterine massage. When uterus is hard, the placenta will likely deliver. Collect placenta and keep with patient. Continue oxytocin. Continue oxytocin for at least 1 hour after bleeding stops. Apply pressure with sterile gauze, put legs together. Continue to massage uterus until hard. Continue oxytocin. Continue IV uids with oxytocin. Insert second IV line. YES YES NO NO YES Module 4: Approach to shock 110 DO: MANAGEMENT OF SPECIFIC CONDITIONS • Always perform ABCDE first. Patients in shock need oxygen. • In all forms of shock, the primary management is administration of IV fluids appropriate for age and condition. • The specific conditions below require additional considerations. CONDITION MANAGEMENT CONSIDERATIONS Burns • Burns disrupt the skin barrier and can cause significant fluid losses that can lead to shock. These patients have different fluid replacement needs. [See SKILLS] Hyperglycaemia • If concern for diabetic ketoacidosis, treat with IV fluids. [See SKILLS] A person with diabetic ketoacidosis is extremely ill and requires rapid transfer to a unit where IV infusion and close monitoring are available. Fever • Give fluids and start antibiotics. [See SKILLS] If infectious diarrhoea (like cholera) is suspected, use gloves, aprons and relevant isolation precautions and report it to the local public health agency. If signs of poor perfusion do not improve with fluids, consider rapid handover/transfer. Spinal cause • Give IV fluids and refer for ongoing management at a unit that can provide spinal care. [See SKILLS] Stomach or intestinal bleeding • Start IV fluids and refer for blood transfusion. [See SKILLS] Ectopic pregnancy • Give IV fluids and refer for blood transfusion and obstetric care. [See SKILLS] Postpartum haemorrhage • Give oxytocin and IV fluids and plan for rapid transfer to facility with blood transfusion and obstetric care capabilities. • Give IV fluids and massage uterus until it is hard. [See SKILLS] • Give oxytocin. [See SKILLS] • If the placenta has delivered, collect it in a leak-proof container and keep with patient for inspection by advanced provider. • Check for perineal and vaginal tears and apply direct pressure. Tension pneumothorax • Perform needle decompression immediately to relieve the pressure, give oxygen and IV fluids. [See SKILLS] Any patient who has had a needle decompression will need rapid handover/ transfer to a unit that can place a chest tube. Pericardial tamponade • Give IV fluids to help fill the heart against the building pressure in the heart sac. [See SKILLS] Plan for rapid handover/transfer to a provider who can drain the pericardial fluid. BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 111 CONDITION MANAGEMENT CONSIDERATIONS Suspected heart attack • Give aspirin if indicated. Place an IV and give fluids, re-assessing the patient frequently. [See SKILLS] • While oxygen is no longer recommended in all patients with heart attack, it should initially be given in patients with shock or difficulty in breathing, even when heart attack is the suspected cause. • Plan for rapid handover/transfer to advanced provider. Heart failure • Give IV fluids more slowly, checking the lungs for crackles (fluid overload) frequently. Stop IV fluids if fluid overload develops (difficulty in breathing, crackles in the lungs, increased respiratory rate, increased heart rate). [See SKILLS] • Plan for rapid handover/transfer to an advanced provider. Severe allergic reaction • Give intramuscular adrenaline [See SKILLS]. These patients will also need IV access and fluids as their condition can rapidly worsen once the adrenaline wears off. You may give a second dose if the effects wear off. [See SKILLS] If the airway is swollen or there is difficulty in breathing, patients may need rapid transfer. Traumatic injury or rapid blood loss suspected • Stop the bleeding, give IV fluids, and conduct a thorough trauma assessment. [See SKILLS] Refer for blood transfusion and ongoing surgical management. Workbook question 4: Shock Using the workbook section above, list what you would do to manage this patient. A 6-year-old boy is brought in with fever. He is in shock and does not appear malnourished. Your facility has supplies to put in an IV. 1. ________________________________________ 2. ________________________________________ 3. ________________________________________ A young man is brought in after a motorcycle crash. He has a large cut to his arm that is bleeding and there is a large pool of blood under him. He is in shock when you examine him. 1. ________________________________________ 2. ________________________________________ 3. ________________________________________ A 30-year-old woman is brought in after accidentally eating prawns. She has a known shellfish allergy, her body is covered in a red, itchy rash and she is in shock. 1. ________________________________________ 2. ________________________________________ 3. ________________________________________ Module 4: Approach to shock 112 SPECIAL CONSIDERATIONS IN CHILDREN Shock can occur quite rapidly in children and is life-threatening. Children have a relatively larger surface area (compared to their body volume) and are thus likely to become dehydrated more rapidly. Infants and young children are particularly at risk as they are unable to say when they are thirsty and cannot drink more on their own. Assessing shock in children: The clinical definition of shock in children varies. The 2016 WHO guidelines for the care of critically ill children use the presence of three clinical features: cold extremities, capillary refill greater than 3 seconds, and weak and fast pulse. There are also other important signs of poor perfusion, including low blood pressure, fast breathing, altered mental status, and decreased urination (always ask parents how much urine the child is passing). [See SKILLS] Signs of dehydration in children • Very dry mouth and lips • Lethargy (excessive drowsiness and slowness to respond), child not interactive • Sunken eyes • Small amounts of dark urine (ask about number of nappies for infants) • Sunken fontanelles in infants under 1 year • Delayed capillary refill (normal capillary refill is less than 3 seconds) • Abnormal skin pinch [See SKILLS] • Pallor (anaemia makes dehydration even more difficult to treat [See SKILLS]) Abnormal skin pinch in a child page 34 Abnormal skin pinch in a child Common causes of shock and dehydration in children include: • Vomiting and diarrhoea: Gastroenteritis causes sudden onset of vomiting and diarrhoea with some abdominal pain and fever. Large amount of watery diarrhoea may suggest cholera, and needs to be reported to public health authorities. • Vomiting without diarrhoea: Vomiting without diarrhoea or fever may suggest raised pressure on the brain (trauma, tumour, brain swelling), or intestinal blockage. It is important to examine the child for signs of trauma. Vomiting associated with fever may suggest infection. • Overwhelming infection: Fever can cause children to become dehydrated quickly. In addition, overwhelming infection can cause blood vessels to dilate, worsening shock. BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 113 Special management considerations: • Malnourishment: Malnourished children are at high risk for hypoglycaemia and will need sugar in addition to fluids. Give specialized fluids if available. [See SKILLS] Give less IV fluid more slowly, and check the lungs for crackles (fluid overload) every 5 minutes. Stop IV fluids if fluid overload develops (crackles in the lungs, increased respiratory rate, increased heart rate). Switch to oral fluids as soon as signs of poor perfusion improve. These patients need rapid handover/transfer over to an advanced provider at a centre with blood transfusion capabilities. Workbook question 5: Shock Using the workbook section above, list signs of severe dehydration in children. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ 6. ______________________________________________________________________ 7. ______________________________________________________________________ 8. ______________________________________________________________________ DISPOSITION CONSIDERATIONS People with shock can worsen and die quickly. They must be monitored very closely. Additionally, the same illnesses that cause shock interfere with the body’s ability to manage fluids, so these patients must be monitored very closely for signs of difficulty in breathing. Patients with shock may be confused and anxious. Ensure they are safe and contained during transfer. Patients with shock are often transferred for transfusion or general or obstetric surgery. Always communicate directly with the receiving facility to make sure that these resources are actually available at the time of transfer. Module 4: Approach to shock 114 FACILITATOR-LED CASE SCENARIOS These case scenarios will be presented in small groups. One participant will be identified as the lead and will be assessed while the rest of the group writes the responses in the workbook. To complete a case scenario, participants must identify the critical findings and management needed, and formulate a one-line summary for handover, including assessment findings and interventions. You should use the Quick Card for these scenarios while being assessed. CASE #1: ADULT SHOCK A 48-year-old male with a history of alcohol abuse is brought in by his wife to be evaluated for weakness. His wife states that he has been having very dark stools for the past 2 days and now cannot stand up. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 115 3. Formulate one sentence to summarize this patient for handover. CASE #2: PAEDIATRIC SHOCK The patient is a 4-year-old girl brought in by her mother. She has been having almost constant diarrhoea for the past 3 days and vomiting every time she tries to drink anything. The mother thinks she may have had a fever as well. She has no signs of malnutrition. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate one sentence to summarize this patient for handover. Module 4: Approach to shock 116 MULTIPLE CHOICE QUESTIONS Answer the questions below. Questions and answers will be discussed in the session. 1. A 7-year-old boy has had lethargy, vomiting and diarrhoea for the past 4 days. His vital signs are: blood pressure 80/40 mmHg, heart rate 140 beats per minute, respiratory rate 18 breaths per minute. The patient vomits when you try to give anything by mouth. What is your most immediate management? A. Start an IV line and give fluids B. Continue to attempt oral rehydration C. Place a nasogastric (NG) tube and hydrate through it D. Rapidly transfer to a referral hospital 2. You are taking care of a 28-year-old man who was shot in the abdomen. He is lethargic and the vital signs are as follows: blood pressure 80/40 mmHg, heart rate 130 beats per minute, respiratory rate 20 breaths per minute. There is heavy bleeding from the gunshot wound and the abdomen is rigid and tender. What is the first intervention you should give this patient? A. IV fluids B. Intraosseous line C. Surgery D. Adrenaline 3. A child that presents with sunken eyes, small amounts of dark urine, dry mucous membranes and abnormal skin pinch testing is most likely suffering from: A. Pneumonia B. Head injury C. Dehydration D. Hypoglycaemia 4. A 60-year-old man states he has been weak and dizzy for the past week. His vital signs are: blood pressure 90/50 mmHg, heart rate 125 beats per minute, respiratory rate 16 breaths per minute. His skin is cool and pale. He states that his stools have been black for the past 2 days. What is the most likely cause of his shock? A. Stomach bleeding B. Abdominal trauma C. Dehydration D. Severe infection BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 117 5. You are assessing a 23-year-old man who was stabbed in the chest. You expose the chest to find one stab wound in the right chest with minor bleeding. He is complaining of severe difficulty in breathing and there are no lung sounds on the right side. His neck veins are distended and his skin is cool and sweaty. His vital signs are: blood pressure 86/56 mmHg, heart rate 136 beats per minute, respiratory rate 28 breaths per minute. What is your next step? A. Chest tube placement B. Needle decompression C. Blood transfusion D. Start IV fluids 118 Notes ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS 119 PARTICIPANT WORKBOOK Module 5: Approach to altered mental status Objectives On completing this module you should be able to: 1. recognize key history findings suggestive of different causes of altered mental status; 2. recognize key physical findings suggestive of different causes of altered mental status; 3. list high-risk causes of altered mental status in adults and children; 4. perform critical actions for high-risk causes of altered mental status. Essential skills Glasgow Coma Scale AVPU assessment Recovery position Oxygen administration IV cannula insertion IV fluid resuscitation Snake-bite management Spinal immobilization KEY TERMS Write the definition using the Glossary at the back of the workbook. Altered mental status: Coma: Confusion: Convulsion: Cyanosis: Module 5: Approach to altered mental status 120 Delirium: Dementia: Diabetic ketoacidosis (DKA): Eclampsia: Envenomation: Human Immunodeficiency Virus (HIV): Hypoglycaemia: Hypoxia: Ingestion: Kangaroo care: Large-bore IV: Level of consciousness: Orientation: Psychosis: Rabies: Seizure: Stroke: SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 121 Overview Altered mental status (AMS) is a term used for a range of presentations, from sudden or gradual changes in behaviour to disorientation, confusion and coma. Changes in mental status and/or level of consciousness may be due to conditions that affect the brain (such as lack of oxygen or glucose; or shock causing lack of perfusion) or problems with the brain itself (such as infection, inflammation or injury). While chronic psychiatric problems and dementia can cause changes in mental status, altered mental status is often an indication of severe disease, and other life- threatening causes must always be considered. The presence of delirium – a rapidly changing state of confusion with agitation, loss of focus and inability to interact appropriately – always requires a full assessment. Always ask family/friends about baseline mental status when possible. The goal of INITIAL ASSESSMENT is to identify rapidly reversible causes of altered mental status, and to recognize dangerous conditions requiring transfer. The goal of ACUTE MANAGEMENT is to ensure that blood, oxygen and glucose reach the brain; and to protect the brain from additional injury. This module will guide you through: ABCDE key elements ASK: key history findings (SAMPLE history) CHECK: secondary exam findings Possible causes DO: Management Special considerations in children Disposition considerations REMEMBER... ALWAYS START WITH THE ABCDE APPROACH, intervening as needed. Then do a SAMPLE history. Then do a secondary exam. Module 5: Approach to altered mental status 122 ABCDE: KEY ELEMENTS FOR ALTERED MENTAL STATUS For the person with altered mental status, the following are key elements that should be considered in the ABCDE approach. AIRWAY People with altered mental status may not be able to protect their airways and may be at risk of choking on vomit. BREATHING Hypoxia (lack of oxygen) can be a cause of altered mental status. Search for any signs of difficulty breathing, or cyanosis (blue colouring of the skin). Abnormal breathing can reflect diabetic ketoacidosis or poisoning. CIRCULATION Lack of perfusion to the brain can cause altered mental status. Look for and manage signs of shock (low blood pressure, elevated heart rate, delayed capillary refill). DISABILITY Check AVPU or GCS (in trauma). Look for abnormal glucose (hypoglycaemia or hyperglycaemia can cause altered mental status). Very small pupils suggest opioid overdose or poisoning (consider pesticides). Very dilated pupils suggest stimulant drug use. Unequal pupils suggest an increased pressure on the brain. If the patient can follow commands, test for strength and sensation in face, arms and legs. Weakness or loss of sensation on one side suggests a mass, bleeding, or blocked blood vessels in the brain (stroke), though hypoglycemia can also present this way. Altered mental status with general muscle weakness may suggest salt (electrolyte) imbalance in the blood. Look for abnormal repetitive movements or shaking on one or both sides of the body (seizure/ convulsion) – this may be due to a tumour, bleeding, brain infection, hypoglycaemia, or salt (electrolyte) imbalance. EXPOSURE Remember that patients with altered mental status may not report their history accurately. Examine the entire body for infections, rashes, and any evidence of trauma, bites or stings. Needle marks on the arms may suggest drugs as a cause. ASK: KEY HISTORY FINDINGS FOR PATIENTS WITH ALTERED MENTAL STATUS Use the SAMPLE approach to obtain a history from the patient and/or family. It is important to obtain a history from bystanders, friends or family as it may be difficult to obtain accurate history from a confused patient. For example, a person with hypoglycaemia may be too confused to relate a history of diabetes. If the history identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it. A B C D E SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 123 S: SIGNS AND SYMPTOMS How does the current condition compare to baseline mental status? Always ask family/friends about baseline mental status when possible. Is there difficulty breathing? Altered mental status associated with difficulty in breathing may indicate lack of oxygen to the brain. Is there headache? Headache with altered mental status can indicate infection, tumour or bleeding. Is there vomiting/diarrhoea? Vomiting without diarrhoea can be a sign of increased pressure in the brain. Any source of dehydration, including vomiting and diarrhoea, may cause altered mental status from poor perfusion. Vomiting and diarrhoea can also cause hypoglycaemia leading to altered mental status. Has there been any dizziness or fainting? These may be signs of poor perfusion (lack of oxygenated blood) to the brain. When did the symptoms start? Do they come and go? How long do they last? Have they changed over time? Rapid onset of altered mental status may suggest infection, inflamation, bleeding or drugs/ toxic exposures. A more gradual onset (over weeks or months) may indicate a space- occupying lesion in the brain, such as a tumour or slow bleeding in the brain. Altered mental status that comes and goes with normal intervals between episodes may suggest other causes, such as seizures/convulsions or psychiatric disease. Has there been any recent fever? Any person with altered mental status and fever may have an infection. Brain infections often present with altered mental status and fever. In small children and the elderly, any serious infection, such as urine, lung, or blood infection can cause altered mental status. Also consider prolonged outdoor exposure, poisonings, medications and drugs as these may present with fever as well. Very high fever itself from any source may cause altered mental status. Is there any weakness, clumsiness or difficulty walking? Change in mental status with weakness or sensory loss in one area of the body, or problems with walking and balance, suggest that the altered mental status comes from a cause in the brain itself, such as a stroke or tumour. Is there neck pain or stiffness? Fluid that circulates around the brain also circulates around the spinal cord, meaning any bleeding, inflammation or infection in the brain (meningitis, encephalitis) can also cause neck pain and stiffness. Module 5: Approach to altered mental status 124 Is there a recent history of trauma or falls? Bleeding in or around the brain can cause altered mental status some days after an injury. Remember that chronic alcohol drinkers and the elderly are more prone to brain bleeding and may not remember falls. Always consider slow bleeding around the brain as a cause, even several days after a fall, and consider unwitnessed trauma in a patient who is found altered with no known cause. Has there been any recent depression or changes in behaviour? Drug and alcohol use or psychiatric problems can present as altered mental status. Always consider the possibility of a suicide attempt by poisoning. Does anyone else from the same family or location have symptoms? Gaseous poisoning, like carbon monoxide poisoning, can cause altered mental status in multiple people. Carbon monoxide poisoning is usually seen in cold climates when people use indoor heating. A: ALLERGIES Any allergies or recent exposure to a known allergen? Severe allergic reactions (anaphylaxis) may present with altered mental status due to low blood oxygen levels or poor blood circulation to the brain as a result of shock. M: MEDICATIONS Currently taking any medications? Many common medications can cause altered mental status as a side effect, including those for seizures/convulsions, pain and sleeping. Ask about new medications and changed doses, and consider medication interactions. A medication list should be collected and can provide clues for underlying disease (such as convulsions, liver disease, diabetes) if the person cannot communicate. Opioid medications (such as morphine, pethidine and heroin) can cause altered mental status. P: PAST MEDICAL HISTORY History of diabetes? In any patient with diabetes and altered mental status, suspect diabetic crisis, or low blood sugar caused by medications. Recent increase in urine output, increased thirst, and fast or deep breathing suggest diabetic crisis (diabetic ketoacidosis). History of heart disease? Heart attack can cause decreased blood flow and oxygen to the brain leading to confusion. Those with heart disease are also at an increased risk of stroke. SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 125 History of stroke? Altered mental status in a patient with a history of stroke may suggest an additional stroke or bleeding in the brain. Be sure to ask people who know the patient about his or her usual mental and neurological status. Symptoms of old stroke may return with severe illness of any kind. History of high blood pressure? High blood pressure increases the risk for bleeding in and around the brain (such as stroke). History of seizure/convulsion? Altered mental status in a patient with a history of seizures/convulsions may suggest that the patient is having or recovering from a convulsion. If there is a history of epilepsy (primary seizure/convulsion disorder), ask about regular medication and any recent dose changes or missed doses. With a witnessed convulsion, ask about fall or head trauma. Always ask if the convulsion was the same or different compared to prior. Remember that recovery of normal mental status after convulsions usually takes only a half hour to several hours at most, though patients may feel tired for longer. Longer altered mental status suggests another cause. History of HIV infection? Altered mental status in a person with HIV may suggest infection in or around the brain (meningitis, encephalitis). History of tuberculosis? Tuberculosis can infect the brain and cause altered mental status. History of liver or kidney failure? Liver or kidney failure can cause problems with the clearing of toxins and waste from the blood, which can lead to altered mental status. History of heavy alcohol use? Alcohol intoxication and alcohol withdrawal can present with altered mental status. People with a history of heavy alcohol use also have a high risk for head injury (and may not remember falls) and hypoglycaemia, both of which can cause altered mental status. Use of drugs of abuse? Several drugs of abuse cause altered mental status, including stimulants, sedatives and opioids. History of pregnancy? High blood pressure during pregnancy can lead to eclampsia (or seizures/convulsions and high blood pressure) during pregnancy. L: LAST ORAL INTAKE When did the person last eat or drink? Low blood glucose levels and dehydration can cause altered mental status. Module 5: Approach to altered mental status 126 E: EVENTS SURROUNDING ILLNESS Recent trauma? Both head injury and poor perfusion resulting from blood loss can cause altered mental status. Recent travel to areas where certain types of infections might be more common? Specific infections that can cause altered mental status may be more common in certain areas. Malaria is a key consideration in many areas. Recent exposures: contact with a sick person, recent bites, chemical exposures, hot or cold environments etc.? Sick contacts may suggest infectious cause. Chemical exposures (such as pesticides) or bites may suggest intoxication or envenomation. Altered mental status can be caused by both very low and very high body temperatures. Recent alcohol or drug use? Both alcohol intoxication and alcohol withdrawal can cause altered mental status. Methamphetamines and cocaine may cause severe agitation, while heroin (and other opioids) may cause lethargy and coma. See also “Past medical history” section above. Workbook question 1: Altered mental status Using the workbook section above, list seven questions about signs and symptoms you would ask about when taking a SAMPLE history. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ 6. ______________________________________________________________________ 7. ______________________________________________________________________ CHECK: SECONDARY EXAMINATION FINDINGS IN ALTERED MENTAL STATUS A person with altered mental status may be unable to answer questions, and clues to the cause may only be found during the physical examination. Always assess ABCDE first. The initial ABCDE approach identifies and manages life-threatening conditions. The secondary SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 127 examination looks for changes in the patient’s condition or less obvious causes that may have been missed during ABCDE. If the secondary examination identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it. Check for safety: Agitated and violent behaviour is a common presentation. It is very important to identify and treat the underlying cause if possible, while prioritizing the safety of the patient and providers. Keep calm and work as a team. Ensure that the space is safe from possible weapons and make sure that the patient is not between you and the door. Avoid making the patient feel threatened. Do not sit too close and speak with a calm, soft and sympathetic voice. Continually explain what is happening. Many aggressive patients will cooperate when faced with a team, so call for help and approach a patient as a group if necessary. Check vital signs, including temperature and glucose, and treat abnormalities. Call for help early and arrange handover/transfer to an advanced provider. Check and monitor level of consciousness with the AVPU scale: – A: Alert – V: Responds to Voice – P: Responds to Pain – U: Unresponsive AVPU tests the person’s ability to respond to stimuli. A person who is not intoxicated and who has no illness or injury affecting the brain will usually be alert without being prompted. Patients who only respond when prompted by voice or pain require further assessment of the neurological system. [See SKILLS] In trauma, check Glasgow Coma Scale: Check and monitor the Glasgow Coma Scale. [See SKILLS] Check the blood glucose level: Hypoglycaemia can cause altered mental status. Diabetic ketoacidosis can present with hyperglycaemia and altered mental status. Check the pupils: Very small pupils and slow breathing suggests opioid overdose. Very large (dilated) pupils suggest stimulant drug use. Unequal pupils suggest increased pressure on the brain. Check for orientation: If the patient is alert and responds to voice, ask simple questions (for example: What is your name? Where are you? What time is it? What day of the week is it?). Check for trauma: Any patient with altered mental status and history or evidence of trauma should be considered to have a possible head injury – even if the trauma occurred several days before. Bruising around the eyes, behind the ears, or leaking of clear fluid from the nose or ears suggests head injury with skull fracture. Check temperature: Fever should raise concerns about an infectious cause, and fever with stiff neck suggests an infection in or around the brain. Poisonings, medication overdoses, alcohol withdrawal Module 5: Approach to altered mental status 128 and changes in body hormones can also present with fever. Hypothermia may indicate infection, low body hormone levels (e.g., thyroid) or exposure to wet or cold environments. Check for stiff neck (Remember, if you suspect trauma, do not move the neck): Stiff neck is suggestive of infection (meningitis) or bleeding around the brain. If you suspect infection, anyone who comes in contact with the patient should wear a mask. Check strength and sensation: If the patient can follow commands, test for strength and sensation in face, arms and legs. Weakness or loss of sensation on one side suggests a mass, bleeding or blocked blood vessels in the brain (stroke), though hypoglycaemia can also present this way. Altered mental status with general muscle weakness may suggest salt (electrolyte) imbalance in the blood. Check for signs of dehydration: Dehydration can cause altered mental status. Check for dry mouth and abnormal skin pinch. Dehydration may also suggest diabetic ketoacidosis. Check the abdomen: Feel if the liver is enlarged or tender. A palpable or tender liver suggests liver disease. Check the skin: Cool, pale, and moist skin suggests shock or hypoglycaemia. Yellow skin (jaundice) suggests liver disease. Bruising suggests trauma. Rashes can indicate systemic infection. Check for bites and stings. Monitor for changes in mental status: People who are initially confused and rapidly return to normal without treatment may have had a seizure/convulsion or head trauma. People with altered mental status require close monitoring to make sure they do not worsen again. (This can happen in patients who have low blood sugar or head trauma). Workbook question 2: Altered mental status Using the workbook section above, list five secondary examination findings you would check for in a patient with altered mental status. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 129 POSSIBLE CAUSES OF ALTERED MENTAL STATUS RAPIDLY REVERSIBLE CAUSES CONDITION SIGNS AND SYMPTOMS Hypoglycaemia • Sweating (diaphoresis) • Seizures/convulsions • Blood glucose <3.5 mmol/L • History of diabetes, malaria, or severe illness, especially in children • Mental status improves quickly with glucose Severe dehydration • Signs of poor perfusion • Abnormal skin pinch • Decreased ability to drink fluids, or fluid loss • Dry mucous membranes Heat stroke • Prolonged exposure to heat and sun • High body temperature, very warm skin • May or may not be sweating (diaphoretic) Hypoxia • Shortness of breath • Low blood oxygen levels • Cyanosis INFECTION CONDITION SIGNS AND SYMPTOMS Cerebral malaria • Fever • Rapid malaria test or smear positive • In or from an area with malaria Inflammation/infection around the brain (meningitis, encephalitis, brain abscess, bleeding) • Fever • Neck stiffness • Rash • Eye pain with looking at light/sensitivity to light • Headache • Known infectious epidemic or exposure • History of HIV or TB infection Severe infection • Fever • Tachycardia • Tachypnoea • May have hypotension • Signs of infection: visible infection in the skin, cough and crackles in one area of the lungs (often with tachypnoea), burning with urination or urine that is cloudy (not clear), or any focal pain in association with fever CONDITION SIGNS AND SYMPTOMS Rabies • Agitation • Fear of drinking (hydrophobia) • Drooling • Weakness • History of animal bite Module 5: Approach to altered mental status 130 METABOLIC CONDITION SIGNS AND SYMPTOMS Diabetic ketoacidosis (DKA) • History of diabetes • Rapid or deep breathing • Frequent urination • Sweet smelling breath • High glucose in blood or urine • Dehydration TOXIC CONDITION SIGNS AND SYMPTOMS Alcohol or drug intoxication or withdrawal • Known alcohol or drug use • Injection marks, drugs found on patients • Alcohol – breath smells of alcohol, reddened face – Acutely intoxicated (drunk) – Withdrawal (convulsions, confusion, tachycardia) – Chronic use (balance problems, confusion) • Opioids: – Acutely intoxicated (lethargy, very small pupils and slow breathing) – Withdrawal (agitation, sweating, diarrhoea, vomiting) • Other drugs may cause large pupils, agitation, sweating, fever Pesticide poisoning • History of exposure • Very small pupils • Diarrhoea • Vomiting • Diaphoresis Snake bite • Snake bite history • Bite marks in a setting with venomous snakes • Oedema • Blistering of the skin • Bruising • Hypotension • Paralysis • Seizures • Bleeding from wounds Medication reaction or dosing issue • New medications or recent change in dose Gaseous poisoning • History consistent with possible exposure • Multiple people with symptoms • Headache SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 131 OTHER CAUSES CONDITION SIGNS AND SYMPTOMS Seizures/convulsions • Known history of seizures/convulsions • Bitten tongue • Urinated on self • Gradual improvement over minutes or hours • If pregnant, consider eclampsia Increased pressure on the brain (trauma, tumour, bleeding or brain swelling) • Headache • Seizures/convulsions • Nausea, vomiting • Unequal pupils • Weakness on one side of the body or speech problems Liver disease • History of alcohol abuse or liver disease • Enlarged abdomen with thin arms, yellow coloring to the skin and eyes (jaundice), or hypoglycaemia Kidney disease • High blood pressure • Oedema or swelling in the legs • Decreased or no urine if severe Head trauma • Visual changes, loss of memory, vomiting, headache • History of recent trauma • Scalp lacerations and/or skull deformity • Bruising to head (particularly around eyes or behind ears) • Blood or clear fluid coming from nose or ears • Unequal pupils or weakness on one side of the body • Seizures/convulsions ADDITIONAL CONSIDERATIONS IN CHILDREN CONDITION SIGNS AND SYMPTOMS Ingestions of chemicals or toxins • Common in younger children • History of medications or substances found around child Module 5: Approach to altered mental status 132 Workbook question 3: Altered mental status Using the workbook section above, list the possible cause of altered mental status from the history and physical findings below. HISTORY AND PHYSICAL FINDINGS LIKELY CAUSE A 15-year-old girl presents with altered mental status, fever and: • neck stiffness • eye pain when looking at light • headache A 45-year-old man presents with altered mental status, and deep, rapid breathing and: • frequent urination • sweet-smelling breath • high glucose in blood or urine • dehydration DO: MANAGEMENT FIRST PERFORM ABCDE ASSESSMENT AND INTERVENE FOR LIFE-THREATENING CONDITIONS. NOTE: If the airway is clear, and there is no evidence of trauma, place the patient in the recovery position to avoid getting fluid or vomit in the lungs. [See SKILLS] CONDITION MANAGEMENT CONSIDERATIONS Hypoxia Give oxygen. Look for underlying cause. [See SKILLS] Hypoglycaemia Treat with glucose. [See SKILLS] Hyperglycaemia If concern for diabetic ketoacidosis, treat with IV fluids. [See SKILLS] A person with diabetic ketoacidosis is extremely ill and requires rapid transfer to a unit where IV infusion and close monitoring are available. Fever (hyperthermia) with altered mental status Start antibiotics. Severe infections may require treatment by an advanced provider. Include malaria testing and treatment in endemic areas. Also consider poisoning and envenomation. Treat high fever with paracetamol. [See SKILLS] For severe temperature elevation, spray with cool water mist, fan and give IV fluids. Avoid shivering. Hypothermia Move to warm environment, remove wet clothing, warm with blankets and warm IV fluid. SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 133 CONDITION MANAGEMENT CONSIDERATIONS Bleeding or other cause of increased pressure on the brain If no trauma, raise the head of the bed to 30 degrees. If trauma is suspected ensure spinal immobilization. [See SKILLS] Opioid overdose Administer naloxone. [See SKILLS] Naloxone effects last approximately 1 hour. Most opioids last longer and patients may need repeat naloxone dosing. Consider this when planning ongoing care and re-assess the person frequently. Active seizure/convulsion Treat with benzodiazepine and monitor the person closely to check for slow breathing. Check glucose or give glucose if you are unable to check. Place patient in recovery position if no trauma suspected. [See SKILLS] If the patient continues to seize or does not wake up between seizures, arrange for rapid transfer to an advanced provider and monitor the airway. Pregnant with active seizure/convulsion This could be eclampsia. Arrange rapid handover/transfer to a specialist unit and give magnesium sulphate. Monitor the patient closely for signs of toxicity. [See SKILLS] If any of these occur, do not give additional doses of magnesium. Alcohol withdrawal Always check glucose and give as needed. Treat withdrawal with a benzodiazepine. [See SKILLS] Monitor the airway closely. Poisoning or envenomation Try to identify the poison and refer to an advanced provider for specific treatments. If pesticide poisoning, make sure the patient has been decontaminated, and monitor the airway closely as the secretions can cause obstruction. Snake bites should be treated as described in the “Wound Management” section [see SKILLS] and referred as soon as possible for antivenom. Rabies There is no specific treatment for rabies. Symptomatic rabies is almost always fatal. See TRAUMA for management of suspected exposure from animal bite. Violent or very agitated patient Protect the patient from harming self or others. Ensure that staff have a clear exit path (do not place the patient between staff and the door). Remove potential weapons and unsafe objects. Call for help from colleagues, family members, and security if needed. Speak in a calm, soft, non-threatening tone. Explain what is happening at each stage of care. Do not confront or judge. Consider other causes: check glucose and vital signs including temperature and oxygen saturation. Treat abnormalities. Arrange for safe handover/transport to advanced provider. Trauma Assess GCS, immobilize the spine and evaluate for signs of increased pressure on the brain. [See SKILLS] Module 5: Approach to altered mental status 134 SPECIAL CONSIDERATIONS MANAGEMENT OF ACTIVE CONVULSIONS • Check ABCDE. • Maintain the airway – do not put anything in the mouth. • Give oxygen if concern for hypoxia or prolonged seizure/convulsion. • Place patient on his/her side, if possible. • Protect the patient from harm or further injury. • Check glucose or give glucose (if unable to check). • Give a benzodiazepine. • If pregnant and seizing, give magnesium sulphate. • If no response, give another dose of benzodiazepine (repeat three times if needed) and monitor for low blood pressure and slow breathing. • If the patient does not wake between seizure/convulsions, consider this a life-threatening condition. Arrange for rapid handover/transfer to an advanced provider. • If the seizures/convulsions stop, place patient in recovery position and monitor closely. Workbook question 4: Altered mental status Using the workbook section above, list what you would do to manage these patients. CONDITION MANAGEMENT A 3-year-old child presents with altered mental status and a blood glucose of 2 mmol/L. 1. ____________________________________________ A 25-year-old woman is brought in with jerky movements and you suspect an active seizure/ convulsion. 1. ____________________________________________ 2. ____________________________________________ 3. ____________________________________________ A 50-year-old man is brought in following a fall from a roof. He has a headache and altered mental status. 1. ____________________________________________ 2. ____________________________________________ SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 135 SPECIAL CONSIDERATIONS IN CHILDREN Children with altered mental status may have seemingly mild signs such as sleeping more than usual or being less interactive. Manage ABCDE first, and then look for and manage causes of altered mental status. Remember that very ill or injured children may have normal vital signs until they rapidly deteriorate. Hypoglycaemia occurs frequently in severely ill children and is a common cause of altered mental status in children. Check blood glucose (or give glucose if you are unable to check) in any child with altered mental status. Hypoxia can occur as a result of many conditions, including respiratory infections and shock; birth hypoxia is a consideration in newborns. Hyperthermia with altered mental status suggests infection, but can also be seen with excessive heat exposure, exercise, seizure/convulsion, hormonal imbalance and some medications and poisons. Hypothermia with altered mental status can also suggest infection, particularly in infants, but can be due to drug intoxication, exposure to cold or hormonal imbalance. Young infants are more affected by variation in temperature. Keep the child warm by using blankets and a hat to prevent heat loss and using skin-to-skin contact (also called “kangaroo care”) with a family member 24-hours per day while ill. Seizures/convulsions can be due to fever alone but (as in adults) can also suggest infection, hypoglycaemia or hyponatremia (low sodium). Do not delay antibiotics in patients with suspected serious bacterial infection. Always consider trauma. Infection in or around the brain can cause altered mental status. Look for a bulging or swollen fontanelle (in a child under 1 year) and/or rash to the legs and lower abdomen, which can indicate infection or increased pressure on the brain. Do not delay antibiotics in children with suspected serious bacterial infection. Flat fontanelle Bulging fontanelle page 31 Flat fontanelle Bulging fontanelle Poor perfusion can cause altered mental status. Children can become dehydrated very quickly. Check for signs of dehydration: abnormal skin pinch, dry mucous membranes (the inner, pink part of the mouth), irritability, sunken or depressed fontanelle (in a child under 1 year), slow capillary refill (greater than 3 seconds), cold extremities, tachycardia, and hypotension. Give IV fluids and re-assess frequently. [See SKILLS] Module 5: Approach to altered mental status 136 Malaria may be more severe in children than adults. Children with severe malaria may present with severe anaemia, seizure/convulsions, coma, and hypoglycaemia. Ingestion of chemicals or drugs is common in children. Try to identify the poison (talk to parents) and try to get a photograph of the package. Consult advanced provider immediately for management. Consider unwitnessed ingestions in children aged under 6 years (especially aged 1–3): • Ask about signs and symptoms depending on the substance ingested. • Take a thorough history from the family. • Examine the bottles of the ingested substance or medicine. • Determine what time it took place. • Ensure that no other children were involved. • Check for signs of burns in or around the mouth • Check for stridor (high-pitched noises) suggesting ingestion of chemicals that burned or damaged the airway and are causing swelling. • Children with ingestion of drugs or chemicals need to be monitored closely and may require handover/transfer to a referral unit for further management. Workbook question 5: Altered mental status Using the workbook section above, answer the following questions about altered mental status in children: How would you assess for brain infection in a child? ________________________________________________________________________ ________________________________________________________________________ Why does hypoglycaemia occur frequently in severely ill children? ________________________________________________________________________ Seizures/convulsions in young children can be a sign of what? ________________________________________________________________________ SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 137 DISPOSITION CONSIDERATIONS Disposition depends on the cause of altered mental status. Causes of altered mental status that cannot be rapidly corrected or which might return after medications wear off need management in a hospital setting. Any patient with altered mental status must be closely monitored for airway problems. Consider handover/transfer to a provider with advanced airway capabilities. If the underlying cause of the low blood glucose is not identified and treated, patients with hypoglycaemia who improved with glucose may develop low blood glucose again and may require repeat treatments. These patients need to be monitored closely. Naloxone (opioid reversal agent) effects only last approximately 1 hour. Many opioid medications are longer-acting and may need more doses of naloxone to reverse the opioid effects. Any patient treated with naloxone must be monitored closely. Make sure the new provider knows the patient has been given naloxone and may need additional doses. FACILITATOR-LED CASE SCENARIOS These case scenarios will be presented in small groups. One participant will be identified as the lead and will be assessed, while the rest of the group writes the responses in the workbook. To complete a case scenario, the group must identify the critical findings and management needed, and formulate a one-line summary for handover, including assessment findings and interventions. You should use the Quick Card for these scenarios while being assessed. CASE #1: ADULT WITH ALTERED MENTAL STATUS A 42-year-old man is brought in after he was found slumped over at a bus stop. When the bystanders went to him he was awake but very confused. They do not know him, but because he is so confused they brought him to you for care. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTION TO PERFORM: AIRWAY YES NO BREATHING YES NO Module 5: Approach to altered mental status 138 ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTION TO PERFORM: CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate one sentence to summarize this patient for handover. CASE #2: PAEDIATRIC PATIENT WITH ALTERED MENTAL STATUS A mother brings her 3-year-old child to you for evaluation after she had two seizures/ convulsions today. The child is wrapped in multiple blankets. The mother states that the child has been increasingly confused over the past 2 days and has had high fevers. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTION TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate one sentence to summarize this patient for handover. SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 139 MULTIPLE CHOICE QUESTIONS Answer the questions below. Questions and answers will be discussed in the session. 1. You are evaluating ABCDE on a 4-year-old boy who has a fever and a cough. He is not responding to you calling his name, but if you pinch the sole of his foot, he moans. What is his level on the AVPU scale? A. Alert B. Verbal C. Pain D. Unresponsive 2. A 37-year-old male is brought in by his wife with fever and confusion. She says since the fever began 3 days ago he has become increasingly confused. There has been no trauma. On examination you notice that his neck is stiff. What is the most likely cause of his altered mental status? A. Pneumonia B. Infection around the brain C. Stroke D. Drug use 3. A 46-year-old man comes in to check his blood pressure. His vital signs are: blood pressure 160/90, heart rate 120, respiratory rate 18, and blood glucose is 5 mmol/L. While you are examining him he has a seizure/convulsion. What treatment should you give? A. Benzodiazepine B. Glucose C. Antibiotics D. Naloxone 4. A 36-week pregnant woman is having a seizure/convulsion. She has a recent history of high blood pressure as well. What treatment should you give? A. Magnesium sulphate B. Glucose C. Nitroglycerin D. Nothing, the seizure/convulsion will stop on its own 5. You are assessing a 6-month-old infant and find a depressed fontanelle. What does this physical examination finding suggest? A. Infection in the brain B. Dehydration C. Pneumonia D. Hypoglycaemia 140 Notes ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS 141 PARTICIPANT WORKBOOK WHO BASIC EMERGENCY CARE [SKILLS]
AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 143 TABLE OF CONTENTS: SKILLS 1. AIRWAY SKILL STATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 BASIC AIRWAY MANOEUVRES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 • Adult head-tilt and chin-lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 • Paediatric head-tilt and chin-lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 • Adult and paediatric jaw thrust . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 MANAGEMENT OF CHOKING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 AIRWAY SUCTIONING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 BASIC AIRWAY DEVICE INSERTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Airway skill station assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 2. BREATHING SKILL STATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 BREATHING EXAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 GIVING SUPPLEMENTAL OXYGEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 BAG-VALVE-MASK VENTILATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 EMERGENCY NEEDLE DECOMPRESSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 MANAGEMENT OF OPEN PNEUMOTHORAX (SUCKING CHEST WOUND) . . . . . . . . . . . . . . . . . 157 HOW TO MAKE A SPACER FROM A PLASTIC BOTTLE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 Breathing skill station assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 3. CIRCULATION SKILL STATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 CIRCULATION EXAM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 EXTERNAL BLEEDING CONTROL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 • Direct pressure for external bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 • Deep wound packing for external bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 • Tourniquet technique for uncontrolled external bleeding . . . . . . . . . . . . . . . . . . . . . . . . 162 UTERINE MASSAGE FOR POSTPARTUM HAEMORRHAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 IV CANNULATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 • ADJUSTING FLUID VOLUME FOR SPECIAL CONDITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . 167 • IV FLUID ADMINISTRATION FOR SHOCK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 Circulation skill station assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 TABLE OF CONTENTS: SKILLS 144 4. EXTENDED PHYSICAL EXAMINATION SKILL STATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . 176 NEUROLOGIC EXAM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 • Glasgow Coma Scale (GCS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 • AVPU Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 SECONDARY SURVEY TRAUMA ASSESSMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 Extended physical examination skill station assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . 177 5. IMMOBILIZATION SKILL STATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 CERVICAL SPINE IMMOBILIZATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 LOG ROLL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 FULL SPINAL IMMOBILIZATION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 POSITIONING OF THE PREGNANT PATIENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 RECOVERY POSITION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 FRACTURE IMMOBILIZATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 • FRACTURE IMMOBILIZATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 • FRACTURE IMMOBILIZATION: OPEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 APPLYING A PELVIC BINDER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 Immobilization skill station assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 6. WOUND MANAGEMENT SKILL STATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 GENERAL WOUND MANAGEMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 BURN MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 • DETERMINE TOTAL BODY SURFACE AREA (TBSA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 • ESTIMATE DEPTH OF BURN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190 • FLUID RESUSCITATION IN BURN INJURY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 SNAKE BITE BANDAGING AND IMMOBILIZATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192 Wound management skill station assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192 7. Medication administration skill discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194 AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 145 SKILLS SKILL STATIONS are designed to allow you to practise new skills and demonstrate life- saving techniques. REMEMBER...ALWAYS WEAR PROPER PPE PRIOR TO CARING FOR A PATIENT AND PERFORMING ANY SKILL. 1. AIRWAY SKILL STATIONS AIRWAY SKILL STATION: BASIC AIRWAY MANOEUVRES Opening the airway: adult head-tilt and chin-lift To be used for patients with altered mental status who may not be able to protect the airway, with NO history of trauma: • Place person face up on flat, firm surface. • Tilt the head back with one hand and lift the chin with your fingers. – To do this, place one hand on the patient’s forehead and then place two fingers of the other hand on the chin. Rotate your hands, tilting the chin up away from the chest. • Remove foreign bodies if visible. • Use suction to remove any liquids or secretions from the airway if needed. • Hold the airway open – do not let the head drop back as this will close the airway. Opening the airway: paediatric head-tilt and chin-lift To be used with patients with altered mental status who may not be able to protect the airway, with NO history of trauma: • Remember, children’s heads are bigger than adults’ heads compared to body size, and their airways are softer and easier to block when the neck is bent. In older children, the airway can be opened by tilting the head backwards slightly (see figure). • Babies have the largest heads relative to their body size. Their heads should be placed in neutral (sniffing) position (see figure). • Inspect the mouth and remove visible foreign bodies. Take care not to push the foreign body deeper into the airway. Adult head-tilt and chin-lift page 1 Adult head-tilt and chin lift SKILLS 146 • Use suction to remove any liquids or secretions from the airway. • Hold the head as below in position to keep the airway open. Neutral position in infants Head-tilt and chin-lift in children (no trauma) Opening the airway: adult and paediatric jaw thrust Use when the patient has altered mental status and may not be able to protect the airway and there IS a history of trauma (cervical spine fracture is possible): • Ask an assistant to immobilize the cervical spine while you perform the jaw thrust. [See SKILLS] • Place fingers behind the angle of mandible (the curve on the jaw bone) on both sides of the jaw and push up so that the lower jaw moves. The head and neck should NOT move. • Inspect the mouth and remove foreign bodies if visible. • Use suction to remove any liquids or secretions from the airway if needed. • Hold the jaw in place to keep the airway open – do not let the jaw drop back as this will close the airway. Jaw thrust in children Jaw thrust in adults Head-tilt and chin-lift in children (no trauma) page 3 N utral position in infants page 2 Modified _02 Pediatric jaw thrust page 4_A AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 147 AIRWAY SKILL STATION: MANAGEMENT OF CHOKING Managing choking in an adult or larger child If respiratory distress occurs suddenly while eating, a person is clutching the throat, or there is silent coughing, cyanosis (skin turns blue in colour), stridor or noisy breathing, suspect a foreign body obstructing the airway. Encourage the person to speak or cough if possible and observe if the obstruction is removed. Do not perform the manoeuvres described below if the person is audibly coughing and/or able to make sounds. A person who is unable to speak or cough has complete airway obstruction and needs immediate help: • Tell the person that you are going to provide help. • Deliver five abdominal thrusts (see below for modifications for pregnant women). – Stand behind the person and lean the person forward. – Form a fist with one hand and place it in the centre of the abdomen between the umbilicus (belly button) and the bottom portion of breastbone. – Place your other hand over your fist. – NOTE: If the patient is pregnant, place the side of your fist in the center of the chest and pull sharply inward. – Pull in and up five times using hard, quick thrusts. This forces the air out of the patient’s lungs to try to “blow out” the obstruction. – If the obstruction persists, have the person bend at the waist and give five back blows (with the heel of your hand, strike the back between the shoulder blades in the direction towards the head). – Re-assess. – Repeat abdominal thrusts followed by back blows until patient speaks, coughs or becomes unconscious. – If the choking person becomes unconscious, lie him/her face up on a firm surface. Performing chest thrusts may relieve the obstruction. If a series of chest thrusts is not successful, continue with rescue breaths and chest compressions based on relevant CPR protocols. Chest thrusts for choking in late pregnancy page 6 Abdominal thrusts for choking adult page 5 Abdominal thrusts for choking adult Chest thrusts for choking in late pregnancy SKILLS 148 Managing choking in an infant or small child • Lay the infant on your arm or thigh in face down position with the head lower than the abdomen. • Give five back blows (with the heel of your hand, striking the back sharply between the shoulder blades in the direction towards the head). • If obstruction persists, turn the infant over. • Give five chest thrust with two fingers, just below the nipple line in the midline of the chest. • If obstruction persists, check infant’s mouth for any visible obstruction that can be removed. (Caution for biting.) • If necessary, repeat entire process until the foreign body is removed. Chest thrusts for choking in infants page 7 Back blows for choking in infants page 8 Chest thrusts for choking in infants Back blows for choking in infants AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 149 AIRWAY SKILL STATION: AIRWAY SUCTIONING The purpose of suctioning is to remove any liquids or secretions from the upper airway. Suctioning may be necessary to maintain an open airway if a person cannot clear secretions without help. • Check to see if your suction canister or handheld device is working. • Attach a rigid or soft suction catheter to the end of the suction tubing. • Explain what you are doing. • Insert the suction catheter into the back of the mouth (only as far back as you can see), cover the side hole on the catheter (NOT the tip of the catheter) to create suction. Suction only while pulling the catheter out and release suction when advancing the catheter forward (advancing the catheter further into the mouth while suctioning can cause injury). Repeat to suction all of the fluid in the back of the mouth. • Do not suction for more than 10 seconds at a time unless the airway is completely blocked with fluid. • To avoid trauma to the mouth, do not place the end of the suction tip directly against the soft tissue or hold it in just one place. Suction only in the oral cavity, do not suction up the nose. AIRWAY SKILL STATION: BASIC AIRWAY DEVICE INSERTION Oropharyngeal airway (OPA) insertion • An oropharyngeal airway (OPA) should only be inserted when the person is unconscious. A conscious person will not tolerate an OPA and will push it out. If the person resists, gags or vomits, remove the device immediately. • Always protect the cervical spine when there is a history of trauma. • Measure the appropriate size of the OPA by measuring from the tip of the earlobe to the corner of the mouth. • Open the person’s mouth using care not to insert your fingers between the teeth (to avoid accidentally being bitten). • Insert the OPA with the curved portion sideways and the tip pointing towards the cheek. • Push the OPA gently into the mouth and, when you can push no further, rotate the OPA 90 degrees, so that the tip now points down the throat and follows the curve of the tongue (see figure). • Push the OPA the remainder of the way in if necessary so that the flange (the wide, flat end) rests on the person’s lips. If you have to do this, be sure that the tip of the OPA does not push the tongue down to obstruct the back of the throat. • Check again to make sure the OPA did not push the tongue down and obstruct the airway. • Give oxygen if available. Oropharyngeal airway (OPA) insertion page 10 Oropharyngeal airway (OPA) insertion SKILLS 150 Nasopharyngeal airway (NPA) insertion Nasopharyngeal airways (NPA) are better tolerated in people who are semi-conscious or when there is a possibility of gagging with oropharyngeal airways. DO NOT use an NPA in people with head and facial trauma. • Assess the nasal passage for any obvious airway obstruction. • Determine the appropriate size NPA to insert. Measure from the base of the nostrils to the earlobe. The diameter of the NPA itself needs to be smaller than the person’s nasal passage. • Lubricate the NPA well and insert it into the nostril, directing it along the floor of the nose posteriorly towards the throat until the wide, flat portion (flange) of the tube rests against the nostril. • Give oxygen if available. Nasopharyngeal airway (NPA) insertion page 9 Nasopharyngeal airway (NPA) insertion Airway skill station assessments Skills station marking criteria 1st pass 2nd pass 3rd pass Safety: Personal protective equipment used or verbalized. BASIC AIRWAY MANOEUVRES Skill 1 – Open the airway: head-tilt and chin-lift List the indications for use – non-trauma cases only. Tilt the head with one hand on the forehead and lift chin with fingers. State that a baby must be placed in a neutral (sniffing) position. Remove foreign bodies if visible. Suction airway if required. Hold the airway open. Do not let the head drop back as this will close the airway. Comments: Skill 2– Open the airway: jaw thrust List the indications for using jaw thrust versus head-tilt and chin-lift (trauma with possible cervical spine injury). Ask for an assistant to immobilize the cervical spine. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 151 Place fingers behind the angle of mandible (the curve on the jaw bone) on both sides of the jaw and push up so that the lower jaw moves. Note that the head and neck should NOT move. Remove any visible foreign bodies. Hold the airway open – do not let the jaw drop back as this will close the airway. Comments: MANAGEMENT OF CHOKING Skill 3 – Choking: adult and larger child Be able to give the indication for abdominal thrusts (the person is unable to speak or cough). Tell the person what you are going to do. Stand behind the person and lean the person forward. Form a fist with one hand and place it in the centre of the abdomen between the umbilicus and the bottom portion of breastbone. Cover one fist with your other hand. Pull in and up five times using hard quick thrusts. This forces the air out of the patient’s lungs to try to “blow out” the obstruction. Assume the victim is still choking: have the person bend at the waist. Deliver five back blows with the heel of one hand between the shoulder blades, striking the back in the direction towards the head. State that you will re-assess the patient Repeat abdominal thrust then back blows until patient speaks or coughs or becomes unconscious. State how this would be modified for a pregnant woman: • Rather than abdominal thrust, place the side of fist in the centre of the chest, cover fist with other hand, and pull sharply inward. Comments: Skill 4 – Management of the choking infant and small child Lay the infant over your arm or thigh in the face down position with the head lower than the abdomen. Give five back blows to the infant’s back between the shoulder blades with the heel of one hand. If obstruction persists, turn the infant over. SKILLS 152 Give five chest thrusts with two fingers placed just below the nipple line in the middle of the chest. If obstruction persists, check infant’s mouth for any obstruction that can be removed. Repeat until obstruction is removed. Comments: Skill 5 – Suctioning the airway Check your suction canister or handheld device to make sure it is working. Attach a hard (yankauer) or soft suction catheter to the end of the suction tubing. Tell the person what you are doing. Insert the suction catheter into the back of the mouth (ONLY as far back as you can see) and cover the side hole on the catheter (NOT the tip of the catheter). Do not suction while inserting the catheter into the mouth. Suction only while pulling catheter out. State how long the patient should be suctioned for (no more than 10 seconds at a time unless the airway is completely covered with fluid). State the need to constantly move the suction catheter and not put the suction tip against the soft tissue. Comments: BASIC AIRWAY DEVICE INSERTION Skill 6 – Oropharyngeal airway (OPA) List the indication for using an oropharyngeal airway (person is unconscious with no gag reflex). Determine the appropriate size OPA to insert: (participant should explain how to do this out loud). • Measure from the earlobe to the corner of the mouth on that side. Open the mouth using care not to insert your fingers between the teeth (to avoid accidentally being bitten). Insert the OPA with the curved portion sideways and the tip pointing to the cheek. Once the OPA is in as a far as it will go, rotate the oropharyngeal 90 degrees so that the tip now points down the throat and the curve follows the tongue. Push the OPA the remainder of the way in so that the flange (the flat end) rests on the person’s lips. Check to make sure the OPA did not push the tongue down to obstruct the airway. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 153 State that oxygen will be given if available. Comments: Skill 7 – Nasopharyngeal Airway (NPA) List the indications for an NPA. (Better tolerated in a person who is semi-conscious or who may still have a gag reflex). State that NPAs should not be used in people with head and facial trauma. Assess the nasal passage for any obvious airway obstruction. Explain how to determine the appropriate size NPA to insert: • Measure from the external portion of the nostril to the bottom of the earlobe. • The diameter of the tube should not be bigger than the nostril (nasal passage). Lubricate the NPA. Lift up the tip of the nose. Insert the lubricated NPA into the nostril and gently push it along the floor of the nose until the flared-out base (flange) rests against the nostril. State that oxygen will be given if available. Comments: Competency demonstrated YES NO Remediation required YES NO Signature of facilitator: SKILLS 154 2. BREATHING SKILL STATIONS BREATHING SKILL STATION: BREATHING EXAM • Assess and count the rate of breathing (normal is between 10–20 breaths per minute in an adult. See ABCDE module for normal paediatric values). • Look for increased work of breathing (nasal flaring, retractions or chest in-drawing). • Feel for chest rise and chest wall tenderness. • Percuss the chest wall: – Place one hand on the chest with fingers separated (the middle finger should lie between the ribs). – With the other hand, tap on the middle finger of the first hand and listen for changes in tone (hollow or dull). • Listen to the chest: – Always expose the chest. Never listen through clothes. – Make sure your stethoscope is not too cold. – Place your stethoscope lightly on the chest wall. Ask the patient to open his or her mouth and take a complete deep breath in and out. Listen to the sounds of the breathing and compare the left side to the right. Listen in the upper zone, middle zone and lower zones and listen to the front of the chest and the back. – Normal breath sounds like wind moving in and out, while abnormal breathing sounds like air going through water, crumpling paper bags, or no air moving at all. [See DIB] – Respect modesty and avoid placing the stethoscope directly on the breasts when possible. BREATHING SKILL STATION: GIVING SUPPLEMENTAL OXYGEN Supplemental oxygen should be given when the patient has signs and symptoms of hypoxia – fast breathing, anxiety, excessive sweating, cyanosis or chest pain. Where available, a pulse oximeter should be used to measure oxygen saturation. • If hypoxia does not appear severe, lower levels of oxygen (24–40% oxygen) can be provided to children and adults through nasal cannula (nasal prongs), but monitor closely in case a mask is needed. (Remember, regular air is approximately 21% oxygen) – Nasal cannula should be about half the size of the nostril. – Position the cannula in each nostril, making sure that it does not extend too far back or press on the tissues. – Secure the tubing to the cheeks or loop the tubing over the ears so that the nasal prongs and the tubing are both on the front side of the patient’s body (never put the head through the loop in the tubing – if patients become confused and hypoxic, they can accidentally strangle themselves). – Oxygen is delivered at a low rate: max 5 L/min. • If hypoxia appears more severe (or if signs of hypoxia continue with maximum oxygen flow via nasal cannula), a simple facemask may be used. Simple facemask is usually used with oxygen flow rates of 6–10 L/min and can deliver approximately 40–60% oxygen. – The facemask is applied to the face, ensuring the bridge of the nose is covered and as little as possible leaks along the side. The mask should rest below the lower lip, but not past the chin. The elastic strap should be placed over the head to secure the mask. • For patients who appear extremely hypoxic or who still have signs of hypoxia with a simple facemask, oxygen can be delivered through a non-rebreather facemask. This provides close to 100% oxygen if the reservoir bag is full. – To prepare the non-rebreather facemask, put one finger over the valve at the top of the reservoir bag inside the mask to inflate the bag. Then apply the non-rebreather facemask in the same way as the simple facemask, ensuring as little leakage as possible. – Make sure that the oxygen is attached to the wall or cannister and that the flow rate is between 10–15 L/min depending on the pressure in your oxygen system and how fast and deep the patient breathes. If the patient is still hypoxic or the non-rebreather facemask bag does not fill, increase the oxygen flow rate. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 155 – NEVER put a non-rebreather facemask on before it is connected to oxygen. A true non- rebreather mask will not allow outside air in and can worsen difficulty in breathing and hypoxia if there is no oxygen flowing through the tubing. Nasal cannula/prongs Simple facemask Non-rebreather BREATHING SKILL STATION: BAG-VALVE-MASK VENTILATION Assess and manage airway and provide bag-mask-ventilation (BVM) for any patient who is not breathing or not breathing adequately (too slow for age or too shallow), any unconscious patient with abnormal breathing (slow, shallow, gasping or noisy), or any patient with a pulse who is not breathing (for patients without a pulse, follow relevant CPR protocols). CAUTION! Avoid over-aggressive ventilation (using bag-valve-mask too fast or with too much pressure) as this will damage the lungs. Children have smaller lungs that are especially fragile. When ventilating a child, be particularly careful to only give enough pressure to make the chest rise and be sure to allow enough time between breaths for exhalation (for the air to escape). Large volumes of air or high pressures may result in pneumothorax or irreversible lung damage. Bag-mask-ventilation steps: • If you have oxygen available, attach the BVM tubing and set the flow to the highest rate available. DO NOT DELAY bag-mask-ventilation to prepare oxygen. (Oxygen can be attached later.) • Place the mask over the patient’s mouth and nose (if you have two people available one person squeezes the bag and other holds the mask on the patient’s face and keeps the airway open). • Create a seal so that air does not leak out. Put your hand or hands in the “EC” position – your thumb and first finger should make a “C” around the top of the mask and push down evenly, your last three fingers should reach just under the bony part of the jaw (looking like an “E”) and pull the jaw upward to open the airway. – Think about pulling the face up to the mask (thus opening the airway) and pushing the mask down onto the face (creating a seal). – If you push down too hard without pulling the face up to the mask, you will block the airway and the patient will be difficult to bag. If you have problems ventilating, reposition your hands and the mask and try again. • If the patient is breathing on his or her own, deliver breaths when the patient takes a breath (during inspiration). Do not attempt to deliver a breath as the patient exhales. • If you are still unable to ventilate the person after repositioning the mask, consider the possibility of foreign body obstruction or air leak. Insert an oral or nasopharyngeal airway device if not already in place (See SKILLS). Nasal cannula/prongs Simple facemask Non-rebreather page 11 SKILLS 156 • Hold the bag in one hand and depress the bag enough to make the chest rise (to about one third of its volume for an adult – make sure you are using the appropriate-sized bag: an adult bag should have a volume of about 2 litres). • Squeeze bag over 1–2 seconds to provide chest rise (giving the breath faster can cause lung damage). • Give one breath every 6 seconds (10 breaths per minute) in an adult; one breath every 4 seconds (15 breaths per minute) in older children; or one breath every 3 seconds (20 breaths per minute) in infants. CAUTION with volume of breaths given in small children (see SKILLS). Giving large volume breaths can cause pneumothorax. • After each breath allow the chest to fall before giving another breath. • Watch the chest rising and falling evenly with each breath. BVM: One provider BVM: Two providers BVM: Child BREATHING SKILL STATION: EMERGENCY NEEDLE DECOMPRESSION Needle decompression of the chest is a life-saving emergency procedure for suspected tension pneumothorax (presence of air or gas in the cavity between the lungs and the chest wall causing excessive pressure on the opposite lung, the great vessels, and the heart). Patients can die very quickly from a tension pneumothorax. These patients need an emergent chest tube, but emergency needle decompression will relieve the immediate pressure and allow time for handover/transfer for chest tube. Emergency needle decompression should only be performed for tension pneumothorax. • Expose the chest and assess breathing. • A tension pneumothorax is identified if shock and the following are present: – Difficulty in breathing – Absence of lung sounds on the affected side – Hypotension – Distended neck veins – Hyperresonance with percussion on the affected side – Tracheal shift away from affected side • Insert a large-bore (14–16G preferred) IV cannula along the upper edge of the third rib through the second rib (intercostal) space in line with the midpoint of the clavicle on the affected side. – In tension pneumothorax, there will be a gush of expelled air • Give oxygen at high concentration (non-rebreather mask). • Start IV lines and give IV fluids. • Refer and transport to definitive care immediately. BVM: One provider BVM: Two providers BVM: Child page 12 AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 157 Chest tube should be placed as soon as possible following needle decompression (even if there was no rush of air) or for any suspected haemothorax. Needle decompression BREATHING SKILL STATION: MANAGEMENT OF OPEN PNEUMOTHORAX (SUCKING CHEST WOUND) An open pneumothorax is an open chest wall wound that sucks air in when the patient breathes in. Normally, when the chest wall is expanded, air is drawn into the lungs through the airway (through a vacuum effect). If there is another hole in the chest wall (due to trauma) air will also be drawn in that hole, but, rather than going into the lungs, it goes into the space between the chest wall and lungs, creating a pneumothorax. A 3-sided dressing is placed to prevent more air from coming in during inhalation, but to allow air from the pneumothorax to escape during exhalation to avoid developing a tension pneumothorax. To manage a sucking chest wound (open pneumothorax): • Give high flow oxygen. • Cover the sucking chest wound with petroleum gauze or other non-adhesive dressing such as the plastic wrapper from gauze packaging. • Tape three sides of the dressing, leaving one side un-taped to act as a flap valve. • These patients need to be transferred as soon as possible to a centre where a chest tube can be placed. (DO NOT place a chest tube through the injury.) Caution! There is a danger of the dressing becoming stuck to the chest wall with clotted blood. When this happens, air cannot escape from the chest cavity and pressure can build up, leading to a tension pneumothorax. Remove the dressing completely if there is worsening respiratory status or evidence of worsening perfusion. If the patient cannot be observed continuously, a three-sided dressing should NOT be placed. Needle decompression page 13 SKILLS 158 BREATHING SKILL STATION: HOW TO MAKE A SPACER FROM A PLASTIC BOTTLE The purpose of a spacer is to hold the medication (salbutamol) released from a metered dose inhaler so the person has time to effectively inhale the medication. (Without experience and proper training, it can be difficult to use a metered dose inhaler effectively and medication is often lost into the mouth or throat). Spacers should be made in advance, however. Do not delay salbutamol delivery to make a spacer. Spacer made from a plastic bottle • Use a clean 300–500ml plastic bottle (wash with detergent and rinse and dry well). • Take the cap off the metered dose inhaler and trace the shape of the opening of the inhaler on the base of the bottle directly opposite the mouth of the bottle. • Cut an opening into the base of the bottle slightly smaller than the traced shape. You can cut this with scissors or a heated paper clip. • Insert the inhaler into the spacer to check the size (the inhaler should fit tightly into the cut opening). • Always remember to prime the spacer with five puffs before use to clear the dead space. Breathing skill station assessments Skills station marking criteria 1st pass 2nd pass 3rd pass Safety: Personal protective equipment used or verbalized use. Skill 1– Assess breathing Assess and count rate of breathing. Look for increased work of breathing (nasal flaring, retractions). Feel for chest rise and chest wall tenderness. Percuss the chest wall. Listen to the chest (auscultate). Comments: Skill 2 – Supplemental oxygen administration State the indication for oxygen (hypoxia, indicated by fast breathing, anxiety, excess sweating, cyanosis (blue tinted skin), or chest pain). Spacer made from a plastic bottle page 14 AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 159 Explain when nasal cannula should be used (mild hypoxia). Demonstrate applying a nasal cannula with a nasal prong in each nostril. Secure the tubing to the cheek or loop over the patient’s ears. (The participant should NOT put the patient’s head through the loop in the tubing.) State that the oxygen flow rate should be no more than 5 l/min. If the patient still has signs of hypoxia, explain which oxygen delivery method should be used next. (Simple facemask) Apply simple facemask – mask over nose bridge and below lower lip. Ensure minimal air leak – adjust elastic to hold in place. Explain that the oxygen flow rate should be between 6–10 L/min. If the patient still has signs of hypoxia, explain which oxygen delivery method should be used next. (Non-rebreather facemask) To prepare the non-rebreather facemask, put one finger over the valve at the top of the reservoir bag inside the mask to inflate the bag. Ensure that the bag is inflated. Apply non-rebreather facemask – mask over nose bridge and below lower lip. Ensure minimal air leak – adjust elastic to hold in place. Turn on oxygen to 10–15 L/min depending on patient’s breathing. Adjust non-rebreather mask, and adjust flow to ensure bag is filled partially. Comments: Skill 3 – Bag-valve-mask ventilation State the indication for bag-valve-mask ventilation. State that if oxygen is available, connect it to the bag – but do not delay BVM to prepare oxygen. Ensure adequate mask-face seal. State correct rate of ventilation. State relevant cautions when ventilating a child. Verbalize that over-aggressive ventilation can damage lungs and cause vomiting. State or demonstrate correct volume of ventilation. Assess chest rise. If no chest rise, reposition airway. Consider OPA or NPA. Comments: SKILLS 160 Skill 4 – Emergency needle decompression State the indication for this procedure. Explain procedure to patient. Expose the chest and clean the skin. Identify landmark: second intercostal space (between the 2nd and 3rd ribs) in the midclavicular line. Insert 14–16G IV cannula into the identified location. Slide cannula over needle, and remove needle. State plan to handover/transfer for chest tube Give oxygen and assess respiratory rate, vital signs and oxygen saturation (if available). Start IV line and give IV fluids. Comments: Skill 5 – Management of open pneumothorax (sucking chest wound) Give high flow oxygen. Cover with petroleum gauze. Tape 3 sides of gauze. State the need for a chest tube to be inserted. Describe the risk of a clotted dressing blocking outflow of air. Comments: Competency demonstrated YES NO Remediation required YES NO Signature of Facilitator: AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 161 3. CIRCULATION SKILL STATIONS CIRCULATION SKILL STATION: CIRCULATION EXAM • Check for anxiety, confusion or altered mental status. • Feel for a pulse, assessing rate and quality (normal range is 60–100 beats per minute in adults. See ABCDE for normal paediatric values). • Assess capillary refill (checked by pushing on the fingernail, palms, or soles and releasing to see how long it takes for the colour to return to the skin). The normal range is less than 3 seconds. • Assess the skin colour and touch the skin to assess the temperature. • Measure other vital signs: respiratory rate and blood pressure (normal adult values: RR 10–20 breaths per minute and systolic BP greater than 90 mmHG. See ABCDE for normal paediatric values). CIRCULATION SKILL STATION EXAM: EXTERNAL BLEEDING CONTROL Direct pressure for external bleeding A wound that is deep and bleeding heavily may not stop bleeding on its own. Applying direct pressure with a clean dressing such as gauze can help to slow or stop the bleeding (see figure). • Put on gloves. • Use gauze or another clean non-adherent dressing. • Do not use bulky dressings as they can make it difficult to put enough pressure in the right place. • Apply firm pressure as directly as possible to the source of bleeding, usually with two or three fingers. • If the wound is on a limb, elevate the limb above the heart. • If the first dressing becomes soaked with blood, do not remove as this will dislodge any clots that have formed. Instead add another pad and apply firm pressure. • When bleeding stops, apply a bandage to keep the gauze/pad in place. • If bleeding does not stop, consider deep wound packing or tourniquet (see next section). Applying direct pressure to a wound Applying direct pressure to a wound page 15 SKILLS 162 Deep wound packing for external bleeding If the wound is deep or gaping and simple pressure does not stop the bleeding, deep wound packing may help. However, deep wound packing is a temporary procedure to stop the bleeding since it can lead to infection if left for more than 24 hours. • Put on gloves. • Always assess pulses, capillary refill and sensation before and after dressing or splinting any wound. • Thoroughly wash out the wound by flushing with at least a litre of clean water (under pressure when possible; see next section). • Use gauze or another clean, compact material to completely fill the space within the wound. • Use additional gauze on top of the wound surface and apply direct pressure with your gloved hand or a bandage wrapped firmly around the wound/limb. • For limb wounds requiring packing, apply a splint to reduce the risk of re-bleeding. • A deep wound pack should not be left in place for more than 24 hours because of the risk of infection. • If bleeding does not stop, consider tourniquet (see next section). Tourniquet technique for uncontrolled external bleeding You will not be expected to perform the tourniquet technique BUT you will be expected to know what life-threatening conditions it can be used for, the special considerations around use of a tourniquet and the ongoing care of the patient. Use this technique ONLY if all other bleeding control measures have failed AND haemorrhage is life-threatening. If you place a tourniquet, there is a possibility that tissues below the tourniquet will be permanently damaged and even require amputation. If you are considering using a tourniquet, CALL FOR HELP IMMEDIATELY and plan for handover/transfer to a unit where surgery is possible. • If available, use a pneumatic tourniquet (like a blood pressure cuff) over padded skin and inflate until bleeding stops. If not, use a thick band or piece of cloth or belt (the wider, the better), over padded skin. • Apply as close to wound as possible, but do not place over a wound or a fracture. • Apply enough pressure to make distal pulses disappear and re-assess bleeding. • If bleeding stops, leave dressing in place if already present or dress the wound and prepare for handover/transfer to a surgical care unit. • If the bleeding does not stop, increase tourniquet pressure until major bleeding ceases. • Record the exact time the tourniquet was applied in the notes AND write it on the patient’s skin or the tourniquet itself. • Consult advanced provider as soon as possible (and never more than 2 hours) after placing a tourniquet. • The tourniquet should be released every 2 hours for at least 10 minutes. Hold direct pressure to the bleeding area during this time. Do not re-apply the tourniquet unless evidence of continued active bleeding. • Location of the tourniquet: tourniquets should only be placed on extremities and should be placed above the level of the bleeding. Because of the relationship between the bones and blood vessels, tourniquets on the upper arm or leg are often more effective than tourniquets placed below the elbow or knee. • Make sure the tourniquet is clearly visible. • Remember tourniquet should be placed as a last resort. If you place a tourniquet, you are cutting off blood supply to the limb, so only do this for life-threatening bleeding. When tourniquet use is absolutely necessary, use a wide, yet constrictive, band. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 163 CIRCULATION SKILL: UTERINE MASSAGE FOR POSTPARTUM HAEMORRHAGE Some bleeding will occur with every delivery. After delivery, the uterus should contract, which compresses vessels and limits bleeding. Failure of the uterus to contract is the top cause of abnormal bleeding after delivery (postpartum haemorrhage). Call for help, arrange for rapid handover/transfer, start uterine massage and give oxytocin immediately. Postpartum Haemorrhage 1. Arrange immediate transfer to qualifi ed obstetric provider! 2. Attempt to control bleeding while arranging and during transfer. 3. Check: 4. Transfer immediately Heavy bleeding after delivery? Has the placenta delivered? Still bleeding? Is there a perineal or lower vaginal tear? Massage uterus until it is hard. Give oxytocin IM. Give IV uids and IV oxytocin. Empty bladder. Continue uterine massage. When uterus is hard, the placenta will likely deliver. Collect placenta and keep with patient. Continue oxytocin. Continue oxytocin for at least 1 hour after bleeding stops. Apply pressure with sterile gauze, put legs together. Continue to massage uterus until hard. Continue oxytocin. Continue IV uids with oxytocin. Insert second IV line. YES YES NO NO YES SKILLS 164 Performing uterine massage for postpartum haemorrhage • Explain to the woman what you will do and why. • The goal is to compress the uterus between your hand and bony structures behind the uterus (e.g. sacrum/lower back). • Place your hand on the woman’s abdomen. Through the abdominal wall, feel for the uterus and cup it with your hand. This will ensure it stays under your hand whilst you are massaging it. Do not simply squeeze the uterus, but ensure that you are applying strong pressure toward the patient’s back while massaging with a circular motion. • Massage the uterus until it is very firm. It should feel like a 10 cm rock in the lower abdomen when contracted. • Do not stop massaging until the uterus is contracted (hard). • Make sure the uterus does not become relaxed (soft) after you stop uterine massage. If it becomes relaxed, resume massage. • Continuously re-assess for vaginal bleeding. • Perform frequent vital signs. Uterine massage for postpartum hemorrhage Uterine massage for postpartum hemorrhage page 17 AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 165 CIRCULATION SKILL: IV CANNULATION Insertion of IV cannula (adult) Inserting an IV cannula is an essential skill required for the treatment of shock. If an adult displays any signs and symptoms of shock, insert two large-bore cannulae (14 or 16 gauge). • Prepare cannula, IV fluid of choice, tourniquet, gloves, dressing to cover the cannula and alcohol swab. • Put on gloves. • Place an elastic band or glove around the arm to function as a temporary tourniquet to help the veins engorge (this “tourniquet” is different from the one above and should not be so tight as to cut off arterial blood flow). Avoid placing an IV in any arm that might have a fistula for treatment of kidney disease. • Look and feel for a vein that is straight. Avoid blood vessels that have a pulse. If a person is in shock, it may be difficult to find a vein. In this case search for a vein in the antecubital fossa (where the elbow bends, see figure). IV in antecubital fossa • Use alcohol or other appropriate skin cleanser to wipe the skin around the vein you plan to use. • DO NOT insert an IV through skin that is broken or appears infected. • Prepare the cannula. Preparation may vary depending on local resources and types of cannula. • Tell the patient what you are doing. • Remove the safety covering over the cannula (the only thing that should be inserted is the needle with overlying plastic cannula). • Insert the needle directly over and in line with the vein as flat and parallel to the skin as possible. Watch for flashback (flash of blood in the cannula) when you enter the vein. – If blood has a regular pumping pattern, you have likely hit an artery and you should remove the needle/catheter and apply firm pressure to the site for at least 5–10 minutes. • After seeing the flash of blood, insert the needle a few millimeters further, then advance the plastic cannula over the needle fully into the patient’s vein. (Do NOT let the needle move forward when you start to move the plastic cannula.) • Hold the cannula in place, applying pressure to the base of the cannula (to occlude it and stop the flow of blood) and withdraw the needle, leaving the cannula positioned in the vein. If needed, withdraw blood to send for laboratory testing. • Remove the IV tourniquet and flush the cannula with normal saline. • Place a cap on the end of the cannula, secure the cannula well and dress the site. Document the date the cannula was inserted in the notes. • Ensure the needle is placed into a sharps container. Check IV site daily for signs of infections such as skin redness, pain and swelling. Ensure the cannula is still in the vein and not sitting in the skin next to the vein allowing fluid to be infused under the skin creating pain and swelling. If any sign of swelling or infection, remove the IV cannula and re-assess. IV in antecubital fossa page 16 SKILLS 166 Insertion of IV cannula (paediatric) Attempt to place the cannula in the hand of the child first. Other sites that can be used to insert a cannula include: • Scalp veins • External jugular veins • Antecubital veins • Femoral veins When preparing for IV cannulation in children ask another assistant or parent to help keep the child’s arm still. Veins in infants • Prepare a 21 or 23 gauge cannula. • When inserting the cannula into the back of the hand, keep the hand bent to obstruct venous return and make the veins visible. Place an “IV tourniquet” (as above) if needed. If you use an IV tourniquet, be sure you don’t forget to remove it. • Insert the cannula using the same technique used in adults. Again, be sure that the blood flows smoothly from the catheter and is not pumping. After insertion, withdraw blood if required for laboratory investigation. Remove the tourniquet and flush the cannula with a small amount of normal saline after insertion. • Secure the cannula well. Children will attempt to remove the cannula and will undo dressings. Avoid placing a single piece of tape (plaster) that goes all the way around an extremity as this may limit blood flow. • If the IV is placed near a joint (hand, antecubital fossa, femoral area) splint the joint to stop it from bending and preventing the IV fluid flowing in, and lightly bandage the IV site with bulky dressings to prevent the child from pulling at the adhesive dressing underneath. Veins in infants Scalp veins External jugular veins Antecubital veins Veins on dorsum of hand Femoral veins Ankle veins page 18 AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 167 Securing an IV in a child page 20 Securing an IV in a child Inserting IV in a small child's hand page 19 Inserting IV in a small child’s hand Check IV site daily for signs of infections such as skin redness, pain and swelling. Ensure the cannula is still in the vein and not sitting in the skin next to the vein allowing fluid to be infused into the skin creating pain, swelling and another source of infection. If any sign of infection, remove the IV cannula and re-assess. CIRCULATION SKILL: IV FLUID – ADJUSTING FLUID VOLUME FOR SPECIAL CONDITIONS Shock should be treated with IV fluids. Fluid volume must be adjusted for patients with three conditions: malnutrition, severe anaemia and fluid overload. When administering IV fluid to any patient, look for signs of new or worsening fluid overload: difficulty in breathing, crackles in the lungs, increasing respiratory rate or increasing heart rate. Stop IV fluids if there are any of these signs and plan for immediate handover to an advanced provider. Recognizing conditions needing IV fluid adjustment in patients with shock – fluid overload, malnutrition, and severe anaemia. 1. Is there fluid overload? In some patients, such as those with heart or kidney failure, there may be extra fluid in the tissues (for example, in the lungs or the soft tissues of the legs). These patients can be fluid “overloaded” even when they have poor perfusion (because the extra fluid is not in the blood vessels). These patients still need IV fluid if they are in shock, but IV fluid must be given more slowly with careful monitoring so that the fluid overload does not get worse. SKILLS 168 CHECK FOR: Signs of fluid overload. • Difficulty in breathing with crackles on chest exam • Lower body swelling (usually in the legs) • Unable to lie flat • Distended neck veins – If signs of fluid overload are present, you must adjust fluids: Small amount of fluids may be given (250–500 ml boluses in adults). Slow the rate of fluid administration. Monitor closely for worsening signs of fluid overload (increasing respiratory rate or heart rate, new or worsening difficulty breathing and increasing crackles in the chest). Stop IV fluids if any of these signs develop. REMEMBER: It is important to go slowly so you can stop for early signs of fluid overload. If you don’t stop IV fluid when these early signs develop, too much IV fluid can cause a patient’s lungs to fill with fluid and create severe difficulty in breathing, or even death. 2. Does the patient have severe anaemia? In patients with severe anaemia, IV fluid can dilute the blood and lower its capacity to carry oxygen to dangerous levels. Additionally, patients with severe anaemia tend to show signs of fluid overload more quickly with IV fluid administration. Remember: you should only give IV fluids to someone with severe anaemia if there are signs of shock (see figure). CHECK FOR: Signs of severe anaemia. • Severe pallor to the palms of the hands (compare to your own palm) or the mucous membranes. • Fast breathing or fast heart rate • Confusion or restlessness • May also have signs of heart failure/fluid overload • If these signs of severe anaemia are present, you must adjust fluids: Slow the rate of fluid administration. Monitor closely and stop IV fluids for worsening. Rapid handover/transfer to a centre capable of blood transfusion. 3. Is the patient severely malnourished? • IV fluid can cause life-threatening swelling and heart failure in malnourished patients and must be adjusted very carefully. Malnourished patients are also at very high risk of hypoglycaemia. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 169 CHECK FOR: Signs of malnourishment. • Visible wasting: a child with severe wasting does not look just thin, but is visibly bony with skin that appears too large for the body. The arms, legs and buttocks may be thin, and the head may appear relatively large because of wasting of the body. • Oedema of both feet: take shoes or socks off and assess both feet for oedema. Press the top of the foot gently with your thumb for a few seconds to see if a dent remains in the tissues. Remember that a severely malnourished child may not appear very thin if there is a lot of oedema. – If these signs of severe malnutrition are present, you must adjust fluids. [See FLUID ADMINISTRATION IN SHOCK (CHILD WITH SEVERE MALNUTRITION) for detailed fluid choice and administration rates] Oral fluid is preferred if the patient can tolerate it. Add dextrose: use dextrose-containing fluids or give a dose of dextrose with IV fluids. Slow the rate of fluid administration. Monitor closely and stop IV fluids for any signs of fluid overload. Switch to oral fluid as soon as possible. Visible severe wasting in a child: Assessing for bilateral oedema in severe malnutrition in children: • Skin looks too large for the body • There is no fat on the child • Outlines of ribs can be seen • Severe muscle wasting of the arms, legs and buttocks • The head may appear relatively large because of wasting of the body (see figure) Visible severe wasting in a child • Use your thumb to press gently for a few seconds on the top of each foot – the child has oedema if there is an impression when you lift your thumb • Repeat on the other foot (see figure) Assessing for pitting edema in children with malnutrition Visible severe asting in a child page 23 Assessing for pitting edema in children with malnutrition page 22 SKILLS 170 CIRCULATION SKILL: IV FLUID – ADMINISTRATION Fluid administration for shock in adults • Attach normal saline or Lactated Ringer’s solution to the cannula. • In adults give 1 litre over less than 30 minutes. • Assess response to fluid immediately after the fluid bolus. Assess perfusion (capillary refill, mental status, urine output), and check for pulse rate and blood pressure. If improving, the pulse rate should lower and the blood pressure should increase. Mental status may also improve. • Assess for fluid overload (see signs above). • If still in shock with no evidence of fluid overload, give another 1 litre bolus. • If still in shock after 2 litres of IV fluid, re-assess for ongoing blood loss (external and internal) or spinal injury, and call for advanced provider. If there is evidence of severe malnutrition, severe anaemia or fluid overload: • Patients with shock still need IV fluids, but it is important to re-assess frequently for signs of worsening overload. – For these adult patients who are at high risk for fluid overload, bolus with 500 ml IV fluid initially, then re-assess. If no signs of fluid overload or fluid in the lungs, give additional 500 ml. Fluid administration for shock in children The appropriate amount of fluid for critically ill children is controversial given recent evidence that bolus fluids can worsen outcomes in some children. In addition, relevant criteria for poor perfusion and shock may vary by context. The 2016 WHO guidelines for the care of critically ill children (see WHO Sources section) use the presence of three clinical features to define shock requiring bolus fluids: cold extremities, capillary refill greater than 3 seconds, and weak and fast pulse. For children with poor perfusion that is due to loss of fluid, such as those with bleeding, burns or severe diarrhoea/vomiting, bolus fluids are also recommended. For other children with evidence of poor perfusion, smaller amounts of fluids given more slowly may be safer. Country teams should consider the clinical presentation of the child, the capacity of providers to detect signs of fluid overload, and the availability of monitoring and support equipment when adapting recommendations to the national context. To give IV fluid resuscitation to a child in shock WITHOUT severe malnutrition, severe anaemia or overload: • Insert IV cannula as described above. • Weigh the child or ask the parents for a recent weight. • Give normal saline or Lactated Ringer’s: 10–20 ml per kilogram of body weight over 30 minutes. Re-assess the child after the first infusion. • If no improvement, repeat 10 ml per kilogram of body weight over 30 minutes. Call for help and plan to handover to an advanced provider and unit with the capacity for blood transfusion. IV fluid resuscitation for a child in shock WITH severe malnutrition Children that are in shock AND have severe malnutrition require specialized fluids (if available) with different rates of infusion. Children with severe malnutrition and shock are at very high risk of hypoglycaemia and will need sugar in addition to fluids. [See MEDICATIONS] If the child can take oral fluids, give oral rehydration with ReSoMal (unless the child is in shock due to cholera, then use ORS). If the child is lethargic, unconscious or not capable of taking oral fluids, then give IV fluids. CAUTION! Intravenous fluid administration can be dangerous in malnourished children. While giving fluid in any way, you must check every 5 minutes for the following danger signs: new or worsening DIB, respiratory rate increase of >5 per minute or heart rate increase of >15 beats per minute. Stop fluids if any danger sign develops. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 171 • Insert IV line as above. • Weigh the child. • Give 10–15 ml per kilogram of IV fluid over 1 hour. If specialized fluids are available, give one of the following according to availability: – Ringer’s Lactate with 5% glucose (dextrose) – Half-strength Darrow’s solution with 5% glucose (dextrose) – 0.45% normal saline with 5% glucose (dextrose). • If you do not have dextrose-containing fluids, then give one of the following: – Ringer’s Lactate AND give a separate oral or IV dose of dextrose [See MEDICATIONS] – Normal saline AND give a separate oral or IV dose of dextrose. [See MEDICATIONS] Re-assess the child after the first 5–10 minutes of the infusion and then every 5 minutes: If the child worsens during rehydration (increased difficulty in breathing, breathing rate increases by 5/min and pulse rate increases by 15/min or lung crackles develop): • Stop the fluids. • Call for help and plan for handover to an advanced provider. If there is no improvement after the first infusion: • Call for help. Plan for handover to an advanced provider at a centre with blood transfusion capabilities. • Give fluid at 4 ml per kilogram over 1 hour while awaiting transfer to the advanced provider. If the child displays signs of improvement (improved capillary refill, lower pulse rate and respiratory rate): • Switch to oral or nasogastric rehydration with ReSoMal (low sodium oral rehydration solution) 10 ml per kilogram per hour for up to 10 hours. • Transfer to a malnutrition unit. SPECIAL CONSIDERATIONS: Children with severe anaemia and poor perfusion need urgent handover to an advanced provider and unit with the capacity for blood transfusion. Children who need IV fluids, but in whom bolus fluids are not indicated should be given maintenance fluids. See the WHO Child Health publications page (www.who.int/maternal_child_adolescent/ documents/child/) for recommended maintenance fluid rates in children. Circulation skill station assessments Skills station marking criteria 1st pass 2nd pass 3rd pass Safety: Personal protective equipment used or states intent to use Skill 1 – Assess circulation Look for anxiety, confusion, AMS Feel for pulse: rate, quality Assess capillary refill: >3 seconds indicates poor perfusion Assess skin colour and temperature Verbalize to measure other vital signs: respiratory rate and blood pressure Comments: SKILLS 172 Skill 2 – Bleeding control: direct pressure Put on gloves Uses gauze or another clean, non-adherent dressing, apply firm pressure to the wound Verbalize to not use bulky dressings Apply firm pressure as directly as possible to the source of bleeding, usually with two or three fingers Demonstrate how to elevate a limb with a wound above the heart Verbalize to not remove the first dressing Apply second dressing with firm pressure when wound continues to bleed Apply bandage when bleeding ceased Verbalize the need to call for help Comments: Skill 3 – Bleeding control: deep wound packing Put on gloves Identify deep or gaping wound as an indication for deep wound packing Assesses pulses, capillary refill and sensation after dressing or splinting any wound Irrigate with 1L clean water before packing. Use gauze or another clean, compact material to pack the space within the wound Put additional gauze on top of the wound surface and apply direct pressure with your gloved hand or a bandage wrapped firmly around the wound/limb If a wound is on a limb and requires packing, consider applying a splint to reduce the risk of re-bleeding Assesses pulses, capillary refill and sensation after dressing or splinting any wound State that a deep wound pack should not be left in place for more than 24 hours because of the risk of infection Comments: Skill 4 – Bleeding control: tourniquet Identify continued bleeding as an indication for a tourniquet States intent to use a blood pressure cuff or thick band or piece of cloth or belt (the wider, the better) after padding skin Identifies appropriate location for tourniquet States to tighten tourniquet until the distal pulses disappear. Then re-assess the bleeding to see if it has stopped AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 173 States to secure tightened tourniquet in place States plan to release for 10 minutes every 2 hours. Only re-apply if bleeding resumes States documentation time of tourniquet placement States will not leave tourniquet on for more than 2 hours without consulting advanced provider Comments: Skill 5 – Uterine massage for postpartum haemorrhage States to call for help and initiate handover/transfer States the indication for performing uterine massage States the need to prepare oxytocin and IV fluid States that the goal is to compress the uterus between the hand and bony structures behind the uterus (e.g. sacrum/lower back) Demonstrates how to cup the uterus through the abdominal wall to ensure that it stays under the hand Demonstrates how to apply strong pressure toward the patient’s back while massaging with a circular motion States that massaging should not stop until the uterus is contracted (feels hard) States that the uterus should not become relaxed (soft) after uterine massage has stopped. If it does, resume uterine massage States to continuously re-asses for vaginal bleeding and perform frequent vital signs Comments: Skill 6 –Inserting an iv cannula Prepare equipment: gloves, IV cannula, administration set , fluids, IV tourniquet, swab Tell the patient what you are about to do Place IV tourniquet on limb Identify a straight vein Clean the skin over the vein Remove the safety covering and insert the cannula, keeping cannula flat and in line with vein When flashback is achieved, advance needle slightly and then slide cannula over needle into the vein Hold this in place and withdraw the needle while putting pressure over base of cannula Remove the IV tourniquet Flush with saline or connect IV line SKILLS 174 Secure with tape or dressing States to check IV site daily to assess for redness or signs of infection Disposes of any sharps appropriately Comments: Skill 7 – Recognizing conditions requiring IV fluid re-adjustment State the special considerations for fluid resuscitation: malnutrition/severe anaemia/fluid overload State how to assess for fluid overload: difficulty in breathing with crackles on chest exam, lower body swelling (usually in the legs), unable to lie flat due to shortness of breath, distended neck veins State ways to adjust fluids in patients in shock with fluid overload: • Small amounts of fluids (250–500 ml boluses in adults) • Slow the rate of fluids • Monitor closely for signs of worsening fluid overload Verbalize how to assess for signs of severe anaemia State ways to adjust fluids in patients with severe anaemia: • Slow the rate of fluids • Monitor closely for signs of fluid overload State need for rapid handover/transfer to a centre capable of blood transfusion Verbalize how to assess muscle wasting in severe malnutrition Demonstrate how to assess for bilateral oedema in the feet State ways to adjust fluids in patients with severe malnutrition: • Give oral fluids if possible • Add dextrose to IV fluids or give dextrose with IV fluids • Slow the rate of fluids • Monitor closely for signs of fluid overload Comments: Skill 8 – IV fluid resuscitation for shock Verbalize caution in administering IV fluid in a malnourished, anaemic or fluid-overloaded patient Insert an IV cannula as described above Attach the IV cannula to the correct fluid for administration Fluid administration for an adult should be normal saline or Ringer’s Lactate States fluid administration for shock in an adult should be 1L given over <30 minutes AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 175 Assess perfusion, if still in shock, give another 1L bolus over <30 minutes State that, if still in shock after 2 L IV fluids, suspect ongoing blood loss and plan for handover to higher-level care Give mechanism for modifying fluid for an adult if severe malnutrition, severe anaemia or fluid overload is present: give fluid in smaller boluses and re-assess frequently for signs of worsening fluid overload Signs of fluid overload are: Fluid in the lungs and difficulty in breathing • Oedema • Patient is unable to lie flat • Distended neck veins For a child in shock (WITHOUT severe malnutrition, anaemia or overload): • Obtain the child’s weight • Give 10–20 ml/kg normal saline or Lactated Ringer’s over 30 minutes • Re-assess after the bolus, if no improvement, repeat bolus • If shock persists, transfer For a child in shock (WITH severe malnutrition, anaemia or overload): • Weigh the child • State that these children need specialized IV fluids – Ringer’s Lactate with 5% glucose – Half-strength Darrow’s solution with 5% glucose – 0.45% (HALF) normal saline with 5% glucose • Give 10–15ml/kg IV fluid over 1 hour • Re-assess the child every 5–10 minutes while receiving fluids • State if no improvement, transfer Verbalize to stop IV fluid in any patient if signs of fluid overload develop Dispose of any sharps appropriately Comments: Competency demonstrated YES NO Remediation required YES NO Signature of Facilitator: SKILLS 176 4. EXTENDED PHYSICAL EXAMINATION SKILL STATIONS EXTENDED PHYSICAL EXAMINATION SKILL STATION: NEUROLOGIC EXAM Glasgow Coma Scale (GCS) The GCS is a 15-point scale for assessing and monitoring people with head injury. The person is assessed for eye opening, verbal and motor response, and given a score for the highest level of function in each area. The totals are combined to determine the overall score. The lower the score, the more severe the head injury may be. Please note that the lowest score a patient can receive is 3. Severe head injury – GCS 8 or less Moderate head injury – GCS 9–12 Mild head injury – GCS 13–15 Calculating The Glasgow Coma Score (GCS) Glasgow Coma Score (GCS) Function Response Score Eyes (4) Open spontaneously 4 Open to command 3 Open to pain 2 None 1 Verbal (5) Normal 5 Confused talk 4 Inappropriate words 3 Inappropriate sounds 2 None 1 Motor (6) Obeys command 6 Localizes pain 5 Flexes limbs normally to pain 4 Flexes limbs abnormally to pain 3 Extends limbs to pain 2 None 1 AVPU Scale The AVPU scale is a simplified assessment that can give you an indication of level of consciousness by assessing response to stimuli. The AVPU scale is particularly useful for children and infants. • A= Alert. People who are fully awake and interactive (even if not fully oriented) are alert. • V= Voice. Those who are not fully alert before stimulus (may have eyes closed or appear sleepy), but do respond to voice without being touched (the response may be words, moaning or movement). • P= Pain. Those who do not respond to voice, but do respond to pain: hard chest (sternal) rub in adults, pinch to the sole of the foot in children, or pinch to bridge of nose in suspected spinal injury. The response may be words, moaning or movement. • U= Unresponsive. Those who do not make any movement or verbal response to painful stimuli are unresponsive. • For any patient who is P or U on the AVPU scale, stop and return to the ABCDE as rapid intervention may be needed to protect the airway. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 177 EXTENDED PHYSICAL EXAM SKILL STATION: SECONDARY SURVEY TRAUMA ASSESSMENT A secondary survey (head-to-toe assessment) of an injured person is conducted ONLY when the ABCDE has been completed and life-threatening complications have been addressed. The purpose of a head-to-toe assessment is to identify all injuries, plan ongoing management and plan the appropriate disposition. If the person deteriorates during the head-to-toe assessment, stop and re-assess the ABCDE immediately. Ensure clothes have been removed but the person is kept warm with gown, sheet or blanket. For this session use the workbook section on secondary survey from the TRAUMA module. Extended physical examination skill station assessment Skills station marking criteria 1st pass 2nd pass 3rd pass Safety: Personal protective equipment used or verbalized use HEAD-TO-TOE TRAUMA ASSESSMENT Skill 1 – HEENT examination Look at scalp, face, eyes, and in mouth, nose, ears Listen for stridor, gurgling or other airway sounds Feel for abnormal facial bone or jaw movement, loose teeth, or crepitus. Comments: Skill 2 – Neck examination Look for neck wounds, trauma, haematoma or distended neck veins Feel for air in tissue or pain/deformity of the cervical spine Check for reduced ability to move neck or pain Comments: Skill 3 – Chest examination Look for bruising, uneven chest movement, burns Listen for breath sounds, muffled heart sounds Feel for crepitus Comments: Skill 4 – Abdominal examination Look for distension, wounds, bruising, burns Feel for rebound tenderness, guarding, location of pain Comments: SKILLS 178 Skill 5 – Pelvis and genitourinary examination Look for bruising, lacerations, blood, priapism, urine colour Feel for pelvis instability or tenderness Comments: Skill 6 – Extremity examination Look for swelling, bruising, deformity or open fractures, wounds, pale extremity Feel for pulses, cold extremity, tenderness, firm/painful muscle compartments Comments: Skill 7 – spine/back examination Log roll patient with assistance Look for bruising or deformity Feel for tenderness, deformity in spine and scapulae Comments: Skill 8 – Skin examination Look for bruising, abrasions, lacerations, burns Comments: Skill 9 – Neurologic examination Check level of consciousness (AVPU or GCS) Check movement and strength in each limb Check for priapism Check sensation on face, chest, limbs Comments: Competency demonstrated YES NO Remediation required YES NO Facilitator’s signature: AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 179 5. IMMOBILIZATION SKILL STATIONS Approach to spinal immobilization There are two types of spinal immobilization: cervical spine and thoracic/lumbar spine. Together, these are called full spine immobilization. Immobilization stabilizes the bones to avoid further injury to the spine. Provide spinal immobilization to any person with a history of polytrauma who is unconscious; or who is conscious and has neck pain, spine tenderness, numbness or weakness. Remember, immobilized patients cannot move normally and are at a higher risk of airway blockage (by secretions or vomit) and pressure sore development. Monitor closely. IMMOBILIZATION SKILL STATION: CERVICAL SPINE IMMOBILIZATION To immobilize the cervical spine: • Keep the patient flat on his or her back and face up on a level surface such as a bed. • Tell the patient what you are doing. • Hold the patient’s head in line with the spine with two hands on either side of the head. • Prevent the patient’s neck from moving with locally available materials (towel rolls, newspaper, sandbags, or bags of IV fluids) or cervical collar if available. These can be secured to the head with tape (plaster) but should never be secured to the bed. (If the patient vomits, you will not be able to turn him or her and if the patient falls, the tape (plaster) could cause a cervical spine injury.) • If the patient vomits, use the log-roll technique (see below) to turn the whole patient onto his or her side, keeping the head in line with the body. • Keep someone with the patient at all times to watch the airway. • Remember, a patient who has severe pain/injury elsewhere may not be able to feel neck pain, even if there is a fracture. A concerning mechanism should raise suspicion. SKILLS 180 IMMOBILIZATION SKILL STATION: LOG ROLL To move any immobilized patient or anyone with a suspected spine injury (e.g. if the patient has to vomit or needs to be transferred), use the log-roll technique (see figure): • Ask for assistance. Ideally, have one person at the head to hold the neck, one or two people to hold the body and one for the legs. • The provider at the head must keep the head, neck and torso aligned with the rest of the spine. The provider should place their forearms tightly alongside the head with hands gripping the shoulders to keep the head and neck in line with the rest of the spine. Keep this alignment when turning the patient. • The person controlling the head and neck leads the team and will say, “1–2-3 roll” to guide timing of the roll for all assistants. • Working together, roll the patient onto his or her side, keeping the spine in line. • During the roll, the person providing head and neck control must ensure the cervical spine remains aligned with the rest of the spine. The people rolling the body should also ensure that the rest of the spine stays in as straight a line as possible. • When the patient is turned onto one side, a provider can examine the back, place or remove a backboard and/or manage back wounds as needed. • To lie the patient flat again, the person controlling the head and neck uses the “1–2–3 roll” command to ensure coordinated movement. • Always remove a backboard as soon as possible using the log-roll technique. Time on a backboard increases the risk of pressure sores. Check pressure areas frequently using the log roll. Preparing for log roll page 24 Preparing for log roll AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 181 IMMOBILIZATION SKILL STATION: FULL SPINAL IMMOBILIZATION To immobilize the thoracic and lumbar spine (see previous section for cervical spine immobilization): • Immobilize the cervical spine as in previous section. • Keep the person on a flat surface with instructions to lie flat and not to move. • For transport, log roll the patient onto a flat surface (such as a backboard) to prevent movement of the spine. Do not attach the backboard to the bed, as you will be unable to log roll (see above) if needed. • Before immobilizing, be sure there is no glass or debris on or under the patient’s back. Use the log roll to check. Immobilized patients must be checked regularly to avoid pressure point wounds. • If the person needs to vomit, use the log-roll technique to roll the person to the side so that no vomit enters the airway. • Spine boards should ONLY be used to move patients. Leaving patients on spine boards for long periods of time can cause pressure sores. Remove patients from boards as soon as they arrive at the facility and can be laid flat. Spinal immobilization for moving a patient page 25 Spinal immobilization for moving a patient IMMOBILIZATION SKILL STATION: POSITIONING OF THE PREGNANT PATIENT • If a patient is over 20 weeks pregnant and needs spinal immobilization, immobilize the spine as above. Then place padding under the side of the board near the back and hips to tilt the patient onto her left side. This helps to prevent compression of the large internal blood vessels by the pregnant uterus which could decrease blood returning to the heart. SKILLS 182 IMMOBILIZATION SKILL STATION: RECOVERY POSITION • If the patient is unconscious or semiconscious and if there is NO TRAUMA, place the patient on his or her left side. Stabilize the patient by bending the top leg forward. The left arm should be straight with the patient’s head resting on the arm to elevate the head and position the mouth downward. This position will allow for vomit and other secretions to drain from the mouth with less risk of airway obstruction. This is called the recovery position (see figure). Recovery position page 26 Recovery position AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 183 IMMOBILIZATION SKILL STATION: FRACTURE IMMOBILIZATION FRACTURE IMMOBILIZATION Splints are used for immobilizing suspected fractured limbs, preventing pain caused by movement of broken bones and minimizing further bleeding and damage. Always assess and record perfusion of the limb beyond the fracture by assessing pulses and capillary refill time. Always assess pulses, capillary refill and sensation before AND after dressing or splinting any wound. • If no perfusion (limb cold, pale, no pulse, slow or no capillary refill), rapid re-alignment (reduction) of the limb is required to restore circulation. • If there is still no perfusion after re-alignment of the limb, splint and plan for rapid handover/ transfer to a specialist unit. • If you cannot re-align the limb, rapidly handover/transfer to an advanced provider. Goal of fracture management: • Restore circulation • Treat and reduce pain • Prevent further injury and bleeding • Re-align bony fragments so that healing and union can take place and normal function is restored Splinting materials include: • Padding to protect the skin and allow swelling • Pre-formed splint for base or modified local resources • Bandages to secure the splint • Adhesive tape (plaster) Before applying a splint, tell the person what you are doing and give pain relief. • Remove clothing to clearly see the injury. • Remove all jewelry. • Check pulses, capillary refill, sensation and movement of the limb. Document this before and after application of the splint. • Size the splint to immobilize the joint above and below the fracture site. • If the limb is visibly deformed and pulses beyond the fracture are weak or absent, first straighten (reduce) the fracture prior to applying the splint. Do not force realignment of a deformed limb if the limb has a good pulse. • Place the joint in the desired position and if the injury involves fingers or toes, pad between toes and fingers. • If stocking gauze is available, place it over the limb without wrinkles to avoid skin damage. • Pad the side of the splint that will be in contact with the skin, and pad the limb, especially bony protrusions (like the elbow). • Wrap the limb and splint with a bandage to hold the splint. Ask the patient how it feels to ensure it is not too tight. The splint should be secure, but remember that the limb will swell, so it is important that the splint and bandaging are not too tight. • Check pulses, sensation and movement of the limb following the application of the splint and every hour afterward. SKILLS 184 FRACTURE IMMOBILIZATION: OPEN Consider an open fracture if there is a wound near a fracture site. Open fracture sites can often be contaminated and will require cleaning and potentially surgical debridement before the fracture can be fixed. If an open fracture is suspected, plan for handover/transfer to a surgical or orthopaedic unit after splinting. • Give pain relief prior to splinting. • Control haemorrhage with direct pressure. In limb amputation, if bleeding is uncontrolled apply tourniquet (see above), commence fluid resuscitation and plan for rapid handover/transfer. • Straighten (reduce) the limb if there are signs of poor perfusion or absent pulses in the limb. • Remove any dirt, grass, obvious glass or other debris from the wound and irrigate the wound with 2 litres of normal saline. • Cover the wound with saline-soaked gauze. • Splint as above, but leave a window so you can continue to monitor the wound. • In amputation, cover wound with sterile, saline-soaked gauze or towel. • Give tetanus vaccination. • Begin IV antibiotics. IMMOBILIZATION SKILL STATION: APPLYING A PELVIC BINDER Pelvic fractures can cause life-threatening haemorrhage by damaging blood vessels adjacent to the fractures. If a person has been injured and has pain in and around the pelvis, apply a binder (see figures). As the pelvis is shaped in a ring, the binder will bring together the displaced bones and help limit internal bleeding. Signs of pelvic fractures include pain or abnormal movement of the pelvis on exam; bruising around the hips, at the top of legs, or to the genitals; and signs and symptoms of shock. • Place bed sheet or similar under the pelvis. If the bed sheet is wide, fold it over so that it spans from the lower back to the end of the buttocks. • You may need to log roll the patient in order to get the binder in position. • The sheet should be centered over the greater trochanters (hip bones, as demonstrated by the instructor) and firmly cross-over at the front. • Pull firmly and tie, but do not cause the person undue pain. It should feel firm but not overly painful. • Document what time the pelvic binder was applied. • Check the binder each hour. Confirm that the binder is still applying pressure around the pelvis. Ensure that that skin is intact where the binder has been applied and around the genitals. Normal pelvis Open pelvic fracture page 27 Normal pelvis Open pelvic fracture AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 185 Pelvic immobilization page 28 Pelvic immobilization Immobilization skill station assessments Skills station marking criteria 1st pass 2nd pass 3rd pass Safety: Personal protective equipment used or verbalized use Skill 1 – Cervical spinal immobilization Keep the patient lying flat. Tell the patient what you are doing. Hold the patient’s head in line with the spine using your two hands on either side of the head. A partner should use rolled sheets, shoes, or IV fluid bags on either side of the head. May be secured with tape (plaster) but do not secure to the bed. State that if the patient vomits, log-roll technique will be used to protect the airway, keeping the head aligned with the rest of the body. Comments: Skill 2 – Log roll State indications for a log roll. Ask for assistance. Place one person at the head to hold the neck, one or two people to hold the body and one for the legs. The person with head control must hold the cervical spine firmly aligned with the rest of the spine before and during the roll. When the provider at the head and neck instructs, roll the patient onto the side. Use “1–2–3 roll” to guide the roll. The person controlling the head and neck uses the “1–2–3 roll” to return the patient to his or her back. SKILLS 186 State that the patient should be removed from the backboard as soon as possible to prevent pressure sores. Comments: Skill 3 – Full spine immobilization State indication for full spine immobilization. Ask for assistance to help with the movement. Perform log roll on to backboard for transfer. Ensure no glass or debris on or under the patient’s back. Secure patient to backboard device for transfer (Do NOT attach backboard or patient to bed). State to log roll if patient needs to vomit. Skill 4 – Positioning of the pregnant patient Verbalize the indications for positioning (greater than 20 weeks pregnant and needs spinal immobilization). Left lateral position with cervical spine immobilization and a pillow or wedge under the backboard or bed. Comments: Skill 5 – Recovery position Verbalize the indications. Controlled manoeuver into left lateral position ensuring open airway. Appropriately position the patient (top leg bent forward, left arm straight with the patient’s head resting on the arm to elevate the head and position the mouth downward). Comments: Skill 6 – Fracture immobilization Remove clothing to clearly see the injury, remove all jewelry. Check pulses, sensation and movement of the limb and document findings. Size the splint against the limb. Immobilize the joint above and below the injury. Identify special considerations: • Straighten the limb if signs of poor perfusion or absent pulses in the limb. • Control haemorrhage as needed. • Remove debris and irrigate an open fracture wound with 2 L of normal saline. • Cover open fractures with sterile saline gauze. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 187 Place the joint in the desired position. Pad in between toes and fingers if injury involves digits. If stockinette is available, place it over the limb without wrinkles or pad the side of the splint that will be in contact with the skin. Pad the patient’s limb, especially bony prominences. Wrap the limb and splint with a bandage to hold the splint. Check pulses, sensation and movement of the limb following the application of the splint. State patients with an open fracture will require tetanus vaccination, if not up to date, and antibiotics. Comments: Skill 7 – Applying a pelvic binder Identify pelvic pain after trauma. Place bed sheet under the pelvis. If bed sheet is wide, fold it over so that it is the size of the pelvis (lower back to end of buttocks). Push the binder under the small of the back and pull it into position or log roll patient onto binder. Centre over the great trochanters (hip bones) and firmly cross over at the front. Pull firmly and tie, but do not cause the person undue pain. It should feel firm but not overly painful. Document the time the pelvic binder was applied. Comments: Competency demonstrated YES NO Remediation required YES NO Signature of facilitator: SKILLS 188 6. WOUND MANAGEMENT SKILL STATIONS WOUND MANAGEMENT: GENERAL WOUND MANAGEMENT • Haemorrhage control: stop bleeding as above. • Prevent infection: – Clean wound of blood clots, dirt, dead or dying tissue, foreign bodies. – Clean skin around the wound thoroughly with soap and water or antiseptic. – Thoroughly wash out wound by flushing with at least 1 litre of clean water. The water should be under pressure to thoroughly clean the wound. To create a high pressure stream, use a syringe (with 14 g needle or IV catheter attached) or poke a small hole in a clean bottle and squeeze the bottle. Be sure to use the entire litre. – If not vaccinated or not up to date, give tetanus vaccination. • Dressing wounds: – Dress wound with sterile gauze if available. – Use a pressure dressing if the wound is still bleeding. – Check perfusion (capillary refill and/or distal pulses) and sensation beyond the wound before AND after dressing wounds. • Pain management: – Give local anaesthetic before cleaning the wound if staff and equipment are available. – Splint large lacerations and fractures. WOUND MANAGEMENT: BURN MANAGEMENT It is important to cover burns early in order to keep the area moist and reduce the risk of infection. Burns can be very painful so ensure you give pain relief. • Use sterile technique and normal saline to clean the burn. • Carefully remove any loose, dead skin and broken, tense or infected blisters. • Apply a non-adherent dressing to the burn to provide a moist healing environment. Clean clear plastic wrap can be used over the burn as an interim measure and if you are transferring the person to a surgical unit shortly. • Ensure the entire burn is covered with the dressing. • If the person has presented with an old burn that is now infected, apply a topical antibiotic (such as bacitracin or silver sulfadiazine). This person may also require IV or intramuscular antibiotics. • If there is delay in handover or transfer, ensure the dressings are changed daily. Always give pain control with dressing changes. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 189 ADULT BURN MANAGEMENT: DETERMINE TOTAL BODY SURFACE AREA (TBSA) This is used to calculate the fluids needed using the Parkland Formula. Use the Rule of Nines body chart for adults and modified chart for children and infants (see figure). The body is divided into portions that each make up 9% of the total body surface. Children have different percentages due to the different body proportions, such as a larger head and smaller limbs (see figures). • Assess the person using the diagram below. • Note the areas of burn and shade them in on the diagram. • Next to where you are shading, write the burn depth (see burn depth estimate below). • Once you have marked the diagram (front and back) with all the burns you have assessed on the person, add the percentages. • This will give you the total burn surface area (TBSA). Burn surface area in adults 4.5%4.5% 18% 18% 9% 9%9% 9% 4.5%4.5% 4.5% 4.5% 1% page 29 Burn rface area in adults SKILLS 190 Burn surface area in children 13% A D C B C B F E F E 2% 2% 2% 2% 13%2% 2% 2% 2% 1% 2% 2% 2% 2% 1% 1% 1% 1% page 30 Area Head (A/D) Thigh (B/E) Leg (C/F) 10% 3% 2% 7% 4% 3% 6% 5% 3% 9% 3% 3% By age in years 0 1 5 10 Burn surface area in children PAEDIATRIC BURN MANAGEMENT: DETERMINE TOTAL BODY SURFACE AREA (TBSA) Area By age in years 0 1 5 10 Head (A or D) 10% 9% 7% 6% Thigh (B or E) 3% 3% 4% 5% Leg (C or F) 2% 3% 3% 3% BURN MANAGEMENT: ESTIMATE DEPTH OF BURN The best way to estimate burn depth is by gently pressing two fingers onto the burn to assess capillary refill. • Put gloves on. • With care, press down on the centre of the burn with two fingertips for 3–4 seconds, and then let go. The faster the capillary refill the more superficial the burn is. • Now assess the outer edge of the burn (burn depth can vary for different areas of the burn). • Use the chart below to guide your assessment findings. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 191 Burn type Skin findings Superficial (formerly first degree) • Red or pink • Painful, skin intact, no blisters • When pressed, skin is pink with quick capillary refill Partial thickness (formerly second degree) • Red or mottled red • Intact or broken blisters, wet • Painful • May temporarily turn white when pressed then red colour returns Full thickness (formerly third degree) • White or black • Leathery and dry • No sensation • When pressed, no change in colour BURN MANAGEMENT: FLUID RESUSCITATION IN BURN INJURY As discussed in the TRAUMA module, an adult or child with a burn injury may require fluid resuscitation. Start fluid resuscitation in the following cases: • Full or partial thickness burns greater than or equal to 15% total burn surface area in adults. • Full or partial thickness burns greater than or equal to 10% total burn surface area in children. BURN MANAGEMENT: PARKLAND FORMULA CALCULATION FOR THE FIRST 24 HOURS 4 ml IV fluid X weight in kilograms X % total burn surface area* *% total burn surface area = % partial thickness burn area + % full thickness burn area (% superficial burn area is NOT used in the calculation) The Parkland Formula is a fluid resuscitation management strategy for the initial 24 hours following a burn. Patients presenting beyond 24 hours after the initial burn will also need fluid resuscitation, but the Parkland Formula is not used beyond 24 hours. • The first half of the fluid should be given within the first 8 hours after the burn (NOT after arrival to care). • The second half is to be given over the subsequent 16 hours. • For adults, give normal saline or Ringer’s Lactate. • For children, use a dextrose-containing fluid (Ringer’s Lactate with 5% dextrose or normal saline with 5% dextrose for initial resuscitation). If no dextrose-containing fluids are available, give an additional dose of dextrose (either IV or orally) with IV fluids (see MEDICATIONS). For ongoing care of children, the Parkland emergency resuscitation fluids calculated above MUST BE ADDED to any required maintenance fluids based on hospital care protocols (see WHO Pocket book of hospital care for children, 2013). Your facilitator will review examples using the Parkland Formula. REMEMBER: Patients with serious burns to >15% of their body, burns involving the hand, face, groin area, joints, or burns that go completely around the body or a body part need to be transferred/ handed over for specialized care. SKILLS 192 WOUND MANAGEMENT: SNAKE BITE BANDAGING AND IMMOBILIZATION Note: When possible, take a picture of the snake and send with the patient. Immobilizing a limb after a snake bite is important to reduce movement and absorption of venom. • Always assess pulses, capillary refill and sensation before and after dressing or splinting any wound. • You may choose to use a broad pressure bandage and wrap upwards from the lower portion of the bite. The bandage should be firm, but should not cut off pulses in the limb. Extend the bandage as high up the limb as possible. – This is recommended if the snakes in your area produce a toxin that damages the nerves, causes paralysis, causes the person to become very ill or if there will be prolonged transport time. – This is NOT recommended if the snakes in your area produce toxins that primarily cause tissue damage near the wound and do not cause body-wide symptoms. • Bind a splint to the limb to immobilize as much of the limb as possible. • Note the time the bandage was placed. • Keep the person still and lying down. • DO NOT put a tourniquet around the snake bite or limb. • DO NOT cut the bite out as this will lead to unnecessary bleeding. • DO NOT suck on the bite to remove the venom. Wound management skill station assessments Skills station marking criteria 1st pass 2nd pass 3rd pass Safety: Personal protective equipment used or verbalized use SKILL 1– General wound management Haemorrhage control: stops bleeding as per earlier taught skill. Preventing infection Cleans wound of blood clots, dirt and foreign bodies. Cleans skin around the wound thoroughly with soap and water or antiseptic. Thoroughly washes out wound by flushing with water (state 1 litre of clean water or more). Gives tetanus vaccination as needed. Dressing wounds Assesses pulses, capillary refill and sensation before dressing or splinting any wound. Dresses wound with sterile gauze if available. Applies pressure dressing if the wound is still bleeding. Checks perfusion beyond the wound (capillary refill and/or distal pulses) before and after dressing wounds. Pain management AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 193 Gives local anaesthetic before cleaning the wound if staff and equipment are available. Splints large lacerations and fractures. Assesses pulses, capillary refill and sensation after dressing or splinting any wound. Comments: BURN MANAGEMENT Skill 2 – Burn wound management Uses a sterile technique and normal saline to clean the burn. Removes any loose, dead skin and broken, tense or infected blisters. Applies a non-adherent dressing to the burn to provide a moist healing environment. Ensures the entire burn is covered with the dressing. Considers antibiotics. States transfer or handover plan. Comments: Skill 3 – Fluid resuscitation in burn injury Correctly states indications: • Partial or full thickness burns greater than or equal to 15% total burn surface area in adult. • Partial or full thickness burns greater than or equal to 10% total burn surface area in children. Estimates depth of burn. Determines total body surface area (TBSA). Calculates Parkland Formula. Explains delivery of fluids. (First half in first 8 hrs; second half in next 16 hrs) Chooses correct fluid for initial bolus. (Children weighing less than 20 kg: Ringer’s Lactate with 5% dextrose, normal saline with 5% dextrose) Comments: Skill 4: Snake bite bandaging and immobilization Uses a broad pressure bandage and wrap upwards from the lower portion of the bite. Extends the bandage as high up the limb as possible. SKILLS 194 Immobilize as much of the limb as possible with a splint. Notes the time the bandage went on. Keeps the person still. States DO NOT put a tourniquet around the snake bite or limb. States DO NOT cut or suck on the bite wound. Comments: Competency demonstrated YES NO Remediation required YES NO Facilitator’s signature: 7. Medication administration skill discussion The table below summarizes the medications discussed in this course, which represent only a very basic set of treatments for emergency conditions. They have been included based on their wide availability, their appropriateness for use by all of the frontline providers targeted by this course, their feasibility of use in pre-hospital or facility settings, and for their potential importance as early treatments for emergency conditions. Be sure to check locally available drug concentrations, as these can vary. The most common concentrations are used in this table for dosing reference. Almost every condition discussed will require additional treatments beyond these, and many important emergency treatments that may be used by advanced providers are not included here. Table: Medications used in the Basic Emergency Care course Drug indication Dosage Adverse effects Adrenaline (Epinephrine) Anaphylaxis/severe allergic reaction and severe wheezing [see ABCDE, DIB] Solution: 1 mg in 1 ml ampoule (1:1000) Note: • The doses below are for intramuscular not IV administration. • The preferred site for injection is the outer mid-thigh. Adults: Intramuscular(IM): 50 kg or above: 0.5 mg IM (0.5 ml of 1:1000) 40 kg: 0.4 mg IM (0.4 ml of 1:1000) 30 kg: 0.3 mg IM (0.3 ml of 1:1000) • May repeat at 5-minute intervals Paediatrics: Anaphylaxis: 0.15 mg IM (0.15 ml of 1:1000), repeat every 5–15 minutes as needed Severe asthma: 0.01 mg/kg IM up to 0.3 mg, repeat every 15 minutes as needed • Anxiety/fear • Palpitations • Tachycardia (elevated heart rate) • Dizziness • Sweating • Nausea • Vomiting • Hyperglycaemia (elevated blood glucose) • Chest pain • High blood pressure • Tissue necrosis at injection site AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 195 Drug indication Dosage Adverse effects Antibiotics Specific drugs in this category will be determined by local treatment protocols and availability. These should include a broad-spectrum regimen for life-threatening infections that can be used empirically (before the infectious source is definitively identified) in very ill patients. • Allergic reactions • Gastrointestinal upset • Other specific effects vary by antibiotic Acetylsalicylic acid (Aspirin) Suspected heart attack Tablet: 100 mg, 300 mg Oral: 300 mg (preferably chewed or dispersed in water) given immediately as a single dose. Do NOT give aspirin until evaluated by an advanced provider if there is: 1. any active bleeding, or 2. chest pain that is sudden, maximum at onset, sharp and tearing, and radiating to the back (can indicate a tear in the aorta). • Gastrointestinal irritation with blood loss • Tinnitus • Anaphylaxis Benzodiazepines – Diazepam Seizures/convulsions [see AMS] Tablet: 2 mg, 5 mg Solution: 5 mg/1 ml ampoule Adults: First dose: 10 mg slow IV push OR 20 mg rectally Second dose after 10 minutes: 5 mg slow IV push or 10 mg rectally Maximum IV dose: 30 mg Children: First dose: 0.2 mg/kg slow IV push or 0.5 mg/kg rectally. Can repeat half of first dose after 10 minutes if seizures/convulsions continue. Maximum IV dose: 20 mg Do not give second dose if respiratory rate is less than 10 breaths per minute. Do not give diazepam intramuscularly (unpredictable absorption). How to give rectal diazepam: • Draw up the dose from an ampoule of diazepam into a small syringe (tuberculin if available). Base the dose on the weight of the child, when possible. • Remove the needle. • Insert the syringe 4–5 cm into the rectum, and inject the diazepam solution. • Hold the buttocks together for a few minutes. • Sedation • Respiratory depression • Low blood pressure • Bradycardia (low heart rate) • Nausea and vomiting • Abdominal cramps SKILLS 196 Drug indication Dosage Adverse effects Glucose (dextrose) Hypoglycaemia (low blood sugar) [see ABCDE, ALTERED MENTAL STATUS] Solution: 50% dextrose (D50), 25% dextrose (D25), 10% dextrose (D10) NOTE: Dextrose should NEVER be given intramuscularly as it may cause serious tissue damage. Adults and children greater than 40 kg: 25–50 ml IV of D50, or 125–250 ml IV of D10 Children up to 40 kg: 5 ml/kg IV 10% dextrose (D10) • Hyperglycaemia (high blood glucose) • Dizziness • Skin necrosis if injected outside the vein D10 is preferred in children under 40 kg. If D10 is not available, you can use the Rule of 50 to remember the equivalent amount of dextrose in another solution. All of the following contain the same amount of dextrose: 5 ml of D10 2 ml of D25 1 ml of D50 If no IV access: Place 2–5 ml of 50% dextrose in buccal space (inside the cheek) OR Give sugar solution (1 level teaspoon of sugar moistened with water every 10–20 minutes) in buccal space AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 197 Drug indication Dosage Adverse effects Magnesium sulphate Eclampsia or pregnant with seizure/convulsion [see ALTERED MENTAL STATUS] Solution forms: 1 g in 2 ml ampoule (50%) 5 g in 10 ml ampoule (50%) To give IV, make a 20% solution: *add 3 ml of sterile saline to the 2 ml ampule OR *add 15 ml of sterile saline to the 10 ml ampoule. Loading dose (IV + IM): * 4 g IV (dilute to a 20% solution and give 20 ml slowly over 20 minutes) AND *10 g IM (intramuscular): 5 g (10 ml of 50% solution) with 1 ml of 2% lidocaine in upper outer quadrant of each buttock. Magnesium can cause low blood pressure; monitor carefully. IF unable to give IV, give 10 g IM injection only (as above, 5 g in each buttock). If seizures/convulsions recur: after 15 minutes give an additional 2 g (10 ml of 20%) IV over 20 minutes. If transport delayed, continue treatment: Give 5 g of 50% solution IM with 1 ml of 2% lidocaine every four hours in alternate buttocks. • Low blood pressure • Respiratory depression • Drowsiness • Confusion • Loss of reflexes • Muscle weakness • Nausea • Vomiting • Flushed skin • Thirst STOP if: • Respiratory depression (respiratory rate <16) develops. Toxicity: • Low blood pressure • Respiratory depression • Loss of knee jerk • Urine output <100 ml/4 hours Naloxone Opioid overdose [see ABCDE, ALTERED MENTAL STATUS, DIFFICULTY IN BREATHING] Solution: 400 mcg/ml (hydrochloride) in 1 ml ampoule IV: 100 mcg single dose OR IM: 400 mcg in single dose May repeat every 5 minutes as needed. May require continuous infusion at 0.4 mg/ hour for several hours for long-acting opioids. • Hypertension (high blood pressure) • Cardiac arrhythmias • Hyperventilation • Difficulty in breathing • Agitation *** Naloxone effects only last 1–3 hours. Many opioid medications are longer- acting and may need more doses of naloxone or a naloxone infusion. Any patient treated with naloxone must be monitored closely*** SKILLS 198 Drug indication Dosage Adverse effects Oxytocin Treatment of postpartum haemorrhage Solution: 10 IU in 1 ml ampule Initial dose: Give 10 IU IM AND start IV fluids with 20 IU/L at 60 drops/minute. Once the placenta is delivered, continue IV fluids with 20 IU/L at 30 drops/minute if still bleeding. If placenta has to be manually removed or uterus does not contract: Repeat 10 IU IM. Continue IV fluids with 20 IU/L at 20 drops/ minute for 1 hour after bleeding stops. Max Dose: 3 L of IV fluids containing oxytocin. • Nausea/vomiting • Headache • Rash • Anaphylaxis • Uterine spasm (at low doses) • Uterine hyperstimulation (at high doses) Paracetamol (acetaminophen) Mild to moderate pain, fever and headache Tablet: 250 mg, 500 mg Rectal suppositories: 250 mg, 500 mg Adults: 500mg – 1 g every 6 hours Max 4 g daily or max 2 g daily if liver impairment, cirrhosis Children: 10–15 mg/kg up to six times a day • Rash • Liver damage following overdoses Salbutamol (albuterol) Severe wheezing [see ABCDE, DIFFICULTY IN BREATHING] Where available, can use nebulizer with appropriate dose. Inhaler: 100 mcg per puff Inhaler with spacer Adult: Prime with five puffs and give two puffs via spacer every two minutes until improved. Child: Prime with five puffs and give two puffs into spacer. Keep spacer in the child’s mouth for three to five breaths. Repeat until six puffs of the drug have been given to a child < 5 years or 12 puffs for > 5 years of age. Repeat regularly until condition improves. In severe cases, 6 or 12 puffs can be given several times in an hour. • Palpitations • Fine tremor • Headache • Tachycardia (high heart rate) Remember: child must be able to seal mouth around spacer opening. Babies will likely require spacer mask or nebulizer. Nebulizer: (ADULT) 5mg in 5 ml sterile saline. (CHILD) 2.5mg in 3 ml sterile saline. For severe wheezing, above doses can be given several times in an hour. Tetanus vaccination Solution: 5 units per 0.5 ml IM 0.5 ml Give to all injured children whose vaccinations are not up to date and in all adults who have not had this vaccination in the past 5 years. If immunization status is unknown, give vaccination. • Pain to injection site • Allergic reaction • Fever • Nausea AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 199 8. Transfer and handover skills discussion This course is intended for providers working in the field, on ambulances and in health-care facilities. Transferring patients from the scene to first facility, or between facilities, require special attention to destination planning, ongoing management and handover. DESTINATION PLANNING Many patients treated on the scene will require transport to a health-care facility for further management. Additionally, patients already at a facility may require transfer to a different facility for more advanced care. For example, a pregnant woman with seizures will need handover for advanced care and emergency delivery; a patient with severe burns will require transfer for advanced airway management and surgical care; a patient in shock from blood loss will require handover to a centre capable of blood transfusion. When planning any transport, make sure that: the level of services at the destination facility matches the needs of the patient (e.g. there is an operating theatre if surgery is needed); that the expected resources are currently available (e.g., the operating theatre is running, and there is blood for transfusion); and that the destination can be reached in the necessary time frame given the patient’s condition. Do not delay transport for tests or interventions that are not critical to patient safety if they can be performed at the receiving facility. Follow local transfer and destination protocols where they exist. Where there are no clear protocols, balance transport times with facility capabilities – the goal is to reach needed care as soon as possible. It is usually better to have a longer initial transport time than to arrange a second transfer because appropriate care was not available at the first destination. Once the appropriate facility has been determined, communication with a provider at the receiving facility is essential (see ‘Handover’ below). This will allow the receiving centre to prepare for the patient’s arrival and arrange resources (e.g. blood, operating theatre preparation). Follow specific local communication protocols where they exist. Wherever possible, formal protocols for both pre-hospital transport and transfer between facilities should be in place. These should include explicit criteria for when a patient should be transferred. TRANSPORT Transfer includes two aspects: transporting the patient and caring for the patient at all times during transport. One person cannot do both jobs. During transport, at least one provider should always be in the same part of the vehicle as the patient to allow for ongoing monitoring, assessment and management. The ABCDE approach should be used to assess and re-assess ALL patients during transportation; vital signs (including AVPU or GCS) should be checked every 15 minutes, and patients should be closely monitored for response to treatments and for signs of worsening. Remember to plan overall transportation time and route, and check road conditions and weather. This is essential in order to anticipate the patient’s needs during transport (e.g. IV fluid and medication needs). Ensure that the patient and family are aware of the transport plan. Allow a family member to accompany children whenever possible. SKILLS 200 HANDOVER Formal handover should be given any time care is transferred to a new provider, including: between providers within a facility, to or from transport providers, or remotely from a sending facility to a receiving facility provider. In addition to a verbal report at the time a patient is handed over to a new provider, written documentation of the clinical condition and treatment should accompany the patient at all times. You will practise handover summaries throughout the course in the case scenarios. The Situation, Background, Assessment, Recommendations (SBAR) format is a structured way of communicating key information and can be used for all of the handovers mentioned above. SBAR components and examples are: SITUATION Basic patient information (e.g. age, sex). Chief complaint (the patient’s initial description of the problem, such as difficulty in breathing for 3 days, or arm pain after a fall, etc.). BACKGROUND The 2–4 most important and relevant aspects of the patient’s case and/or condition (these may be elements of the history, physical exam, or testing results, depending on the case). Include any important ABCDE findings/interventions. ASSESSMENT What you think is wrong with the patient. The reason for the handover/transfer. RECOMMENDATIONS Specific things the new provider should prepare for: – next steps in the treatment plan; – potential worsening of the patient’s condition (e.g. need for close airway observation if inhalation burn is suspected); – cautions regarding prior therapies or interventions (e.g. time of last adrenaline dose to anticipate return symptoms, need to monitor mental status if sedating medications have been given, need to monitor 3-way dressing for clotting, etc.). Examples: Case 1: A 22 year-old man was riding a motorcycle when he crashed into another vehicle at high speed. He was thrown from his motorcycle and was not wearing a helmet. His airway is open; he has normal breath sounds on both sides of his chest; his pulses are strong and around 90 beats per minute; he is only responsive to pain and has a femur fracture with bone visible in an open wound; there are abrasions on his forehead. You have immobilized his spine, started an IV and splinted the fracture. You and your colleague have transported him from the scene of injury and are handing him over to a hospital provider. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 201 Handover summary: This is a 22-year-old man who was in a motorcycle crash, was not wearing a helmet and was thrown from his motorcycle; he is only responsive to pain and has an open femur fracture, but is currently protecting his airway and has no evidence of shock. We are concerned for his altered mental status, and open femur fracture, but are unable to tell if he has a spinal injury. He needs transfer for surgical management and further neurological assessment. Spinal immobilization should be maintained and he should be monitored for worsening bleeding and mental status changes. Case 2: A 14-year-old girl had a seizure/convulsion at school. She was brought to you by her teachers because she did not stop seizing. You administered a benzodiazepine, which caused the seizures to stop. After, you were able to perform the ABCDE survey and then a complete head-to-toe exam. She does not have a fever; she has a normal heart rate, blood pressure, and respiratory rate. She responds to voice. Her tongue is bitten and she urinated on herself; she has no other injuries or rashes. Handover summary: This is a 14-year-old girl who had a prolonged convulsion and was convulsing on arrival; her seizures were stopped with one 10 mg dose of diazepam and now she remains sleepy, has normal vital signs and no fever. She is being transferred for further evaluation of her seizure. Monitor the airway as she has received sedating medications (diazepam). Case 3: A 75-year-old man had chest pain while walking home from the market. He was brought to you by taxi. He says that the chest pain started 30 minutes ago and felt like a lot of pressure in the centre of his chest. He has no allergies. He takes a blood pressure medication, but cannot recall the medication’s name. He had a heart attack 2 years ago that felt very much like the pain he was having today. His last meal was 6 hours ago. The pain started while he was walking home carrying several heavy bags, though he now has no pain. His vital signs, ABCDE survey, and head-to-toe examination are normal. You have given aspirin and started an IV line and will now handover to an inpatient provider. Handover summary: This is a 75-year-old man with a history of a heart attack who has had chest pain similar to his prior heart attack. The pain started while he was walking and lasted for more than 30 minutes, but is now gone. He has received aspirin and has an IV line. I am concerned he might have problems with his heart. He should be monitored for change in ABCDE or return of the chest pain. 202 Notes ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE GLOSSARY REFS & QUICK CARDS 203 PARTICIPANT WORKBOOK GLOSSARY ABCDE The initial steps of any patient assessment, which includes assessing and treating Airway, Breathing, Circulation, Disability and Exposure. Accessory muscle use Use of muscles other than the diaphragm to assist in breathing (commonly the neck, chest wall, and abdominal muscles). May appear as indrawing/retractions between the ribs, or in the neck muscles. Altered mental status (AMS) Term used for a range of presentations from changes in behaviour or memory, to disorientation, confusion and coma. AMS See altered mental status. Anaemia Decreased concentration of red blood cells, leading to a decreased ability to carry oxygen. Anaphylaxis A severe allergic reaction that can cause shock. Asthma A condition causing mucus production and intermittent spasm in the bronchial airways, resulting in narrowing that causes wheezing. AVPU A system to assess level of consciousness: Alert, Verbal, Pain, and Unresponsive. Bag-valve-mask (BVM) device A manual handheld device consisting of an air-filled bag connected to a mask. The bag is compressed by hand to deliver a breath as the mask is held to the patient’s face. Bolus A defined volume of fluid or other substance given rapidly, usually intravenously. Bradycardia Heart rate lower than normal range. BVM See “bag-valve-mask device”. GLOSSARY 204 Capillary refill A marker of perfusion, checked by pushing on the fingernail, palms or soles and releasing to see long it takes for the colour to come back to the skin (blood flow to return). The normal range is less than 3 seconds. Cardiopulmonary resuscitation (CPR) Performing chest compressions and ventilation with the goal of resuscitating a patient with no pulse. Cervical spine (C-spine) The part of the spine in the neck, containing the first seven vertebrae. Circumferential burn Burns that extend around a body part can act like a rigid band and may limit blood supply (to a limb) or breathing (burn around the chest or abdomen). Cholera Bacterial infection causing a profound watery diarrhoea, often described as rice-water stools. Chronic obstructive pulmonary disease (COPD) Term describing breakdown of lung structure (emphysema) and chronic inflammation causing spasm of the lower airways and wheezing. Coma Prolonged state of unconsciousness. Compartment syndrome A condition of increased pressure from swelling in an area of the body that cannot expand, such as compartments in the forearm or lower leg. Compartment syndrome reduces blood flow to the area and may result in severe pain as well as damage to nerves and other tissues. Confusion Problems with clarity, recall and organization of thought. Convulsion See Seizure. CPR See cardiopulmonary resuscitation. Crackles High pitched sound, like crumpling of a paper bag, heard with a stethoscope. Crackles are caused by fluid in the airspaces of the lungs. Also called rales or crepitations (creps). SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 205 Crepitations See “Crackles”. Crepitus Crackling or popping when pressing on the skin or bones. Cyanosis Blue colouring to the skin or lips, resulting from low blood oxygen levels. Decontamination Removing a dangerous substance, such as chemicals, toxins or infectious materials, from a person’s skin or clothes. Depending on the substance, this is done by brushing off the substance or irrigating with water. Deep wound packing Tight packing of a large or gaping wound with clean, compact gauze to ensure that external pressure can effectively compress an area of bleeding that is too large or too deep to compress otherwise. Defibrillator Machine that delivers high-energy electrical current to convert abnormal heart rhythms. Dehydration Decreased fluid in the body. Delirium Rapidly changing state of confusion, characterized by agitation, loss of focus and inability to interact appropriately. Dementia Chronic condition characterized by abnormal mental state, including loss of memory and problems with thinking. There is often no change in ability to focus on the present. Destination planning Planning the choice of destination facility for transport or transfer in order to best match transport time and the level of services available at the receiving facility to the patient’s clinical needs. Diabetic ketoacidosis (DKA) A condition occurring in diabetics in which lack of insulin causes elevated blood sugar, leading to severe dehydration and build-up of acid in the blood. Diaphoresis Sweating. DIB See difficulty in breathing. GLOSSARY 206 DKA See Diabetic Ketoacidosis. Dilation (of blood vessels) The enlargement or stretching of a part of the body (e.g. blood vessels). Difficulty in breathing (DIB) The feeling of difficulty in breathing (sometimes also called shortness of breath, or SOB) can result from many causes, including problems with the lungs, problems with oxygen, airway blockage, fast breathing, weak respiratory muscles. Direct pressure A way to control external bleeding (haemorrhage) from a wound by applying firm pressure with two or three fingers at the site of bleeding. Disposition The next step in care of a patient – this may be handover of care to another provider through admission or transfer, or discharge to home. Drowning Compromise of breathing from water in the lungs, usually resulting from prolonged time under water. Eclampsia A condition when a pregnant or newly delivered woman has seizures, high blood pressure, and protein in the urine. It can progress to coma and is life-threatening. (“Pre-eclampsia” is diagnosed based on specific criteria and identifies a woman at high-risk of progression to eclampsia.) Ectopic pregnancy A pregnancy outside of the uterus, most often in the fallopian tubes. As an ectopic embryo grows, it may damage the surrounding structures, causing sudden severe bleeding. Ruptured ectopic pregnancy is a surgical emergency. Envenomation The process by which venom is injected by the bite (or sting) of a venomous animal. Escharotomy A surgical procedure to cut and release burned tissue that may restrict breathing or blood supply to a limb. Flail chest When multiple rib fractures in more than one place cause a segment of the rib cage to be separated from the rest of the chest wall and prevent normal breathing movement. SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 207 Fluid status The level of fluid in the body. It can be low (dehydration), normal, or high (fluid overload and/ or oedema). Fontanelle A gap (soft spot) between the developing bones of the skull in babies – changes in the volume of fontanelles may reflect fluid status. Fontanelles normally close between 12 and 18 months of age. Foreign body An object from outside the body (e.g. a foreign body in the airway). Fracture A broken or cracked bone. GCS See Glasgow Coma Scale. Gastroenteritis Infection or inflammation of the stomach and intestine that can cause vomiting, diarrhoea and abdominal pain. Glasgow Coma Scale (GCS) A system of assessing the neurologic function of a trauma patient. It is a score ranging from 3 (unresponsive) to 15 (normal) that assesses responsiveness based on eye movement, verbal response and motor response. Guarding Voluntary or involuntary contraction of the abdominal wall muscles when pressing on the abdomen. Handover A brief summary of critical patient information given by the current provider any time a patient is transferred to a new provider. Handover summarizes the clinical presentation, the care the patient has received, and alerts the new provider of any potential complications. Handover should always be given to transport providers, in addition to receiving-facility providers. Handover should also be given even when care is transferred to a new provider within the same facility. Haemorrhage Large volume bleeding. It may occur externally or within the body. Haemorrhagic shock A state of poor perfusion due to substantial blood loss. GLOSSARY 208 Haematoma Bleeding or a collection of blood within the tissues, outside of the vascular space. Also called bruising. Haemothorax Blood in the space between the chest wall and the lungs. Heart attack (Also called myocardial infarction). Death of heart muscle due to a lack of oxygen-rich blood getting to the heart. Heart failure When the heart fails to pump enough blood to perfuse the organs, usually resulting in oedema in the lungs or extremities. Hives Multiple itchy, red and raised areas on the skin suggestive of an allergic reaction. Human Immunodeficiency Virus (HIV) A virus that weakens the immune system and can lead to AIDS, a syndrome of multiple infections. Hyperthermia High body temperature. Hyperventilation Increased (fast) rate of breathing. Hyperresonance Hollow sounds with percussion. Hypoglycaemia Low blood sugar. Hypothermia Low body temperature. Hypotension Blood pressure lower than the normal range. Hypovolaemic shock Poor perfusion due to low blood volume, which may result from decreased fluid intake or severe fluid or blood loss. Hypoxia Low levels of oxygen in the blood. SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 209 Inflammation Redness and swelling that may result from trauma, infection, allergy or other causes. Ingestion Swallowing a substance – generally used for dangerous substances or doses. Inhalation injury Inflammation or oedema of the airways or lungs resulting from breathing hot gases or irritating chemicals (most commonly smoke inhalation in the setting of fire). Intubation Placing a breathing tube through the mouth, down the throat, and through the vocal cords to allow ventilation of the lungs by bag device or ventilator. Ischaemia Inadequate oxygen and blood supply to tissues that can lead to tissue death (myocardial ischaemia, or lack of oxygen to the heart muscle, is an example). IV (abbreviation for intravenous) Often used to refer to an intravenous catheter, or for the intravenous route of administration of a medication or fluid. Kangaroo care Using skin to skin contact between a newborn infant and mother and covering the child’s head and exposed body, to prevent hypothermia and promote bonding. Laceration A cut or slice to the tissues. Large-bore IV A large IV catheter is needed for rapid volume resuscitation. Ideally, these catheters should be placed in larger blood vessels (that tend to be closer to the heart, like the antecubital fossa in the arms or large veins in the neck). In adults, this is usually defined as 14- or 16-gauge, though in some settings, 18 may be the largest available gauge. Level of consciousness Describes the level of responsiveness or alertness to the environment. Lethargy Excessive drowsiness and slowness to respond. Log roll A method of rolling a person to the side while preventing the spine from bending. Usually performed when spinal injury is suspected to prevent additional damage. GLOSSARY 210 Nasal flaring The widening of nostrils during breathing – it results from increased effort, and is a sign of difficulty in breathing. Nasopharyngeal airway (NPA) A rubber tube inserted through the nostril that reaches to the opening of the throat to allow air to pass. Needle decompression Insertion of a needle into the chest wall to relieve the pressure of a tension pneumothorax. Oedema Abnormal swelling or fluid build-up in the body tissues, outside the vascular space. Oral rehydration solution (ORS) A water, glucose, and salt mixture given by mouth or nasogastric tube to dehydrated patients to replace fluid losses. Orientation Describes a person’s relationship to the surrounding world, including the ability to accurately identify one’s own name and location, as well as the current time and date. Oropharyngeal airway (OPA) A plastic device inserted through the mouth that reaches to the opening of the throat to prevent the tongue from blocking the airway and allows air to pass. ORS See “Oral rehydration solution”. Oxygen (O2) saturation Percent of oxygen in the blood. Parkland Formula A formula used to estimate the amount of IV fluid needed for resuscitation of a burn patient over the first 24 hours after the burn. It is: 4 ml fluid X weight in kilograms X total burn surface area. Half should be given over the first 8 hours, and half over the next 16 hours. Percussion Tapping on the chest wall to assess the lungs. The quality of the sound on tapping may indicate fluid or air in the lungs. Perfusion The delivery of blood to body tissues. Pericardial effusion Fluid in the sac around the heart (the pericardium). SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 211 Pericardial tamponade A critical build-up of fluid in the sac around the heart (the pericardium) that compresses the heart and interferes with normal pumping of blood to the body, leading to shock. Personal protective equipment (PPE) Equipment meant to be worn by a person to protect from infection or injury. This can include gloves, goggles, and protective clothing such as aprons or fluid resistant gowns. Pleural effusion Abnormal fluid collection around the lung that can cause difficulty in breathing and even lung collapse. Common causes include tuberculosis and other infections, heart failure and cancer. Pleuritic pain Pain that is worse with breathing, usually caused by inflammation. Pneumonia Infection of the lungs. Pneumothorax Air in the space between the lungs and the chest wall (pleural space) that causes the lung to collapse. Pre-eclampsia See Eclampsia. Priapism Persistent, abnormal erection of the penis. Psychosis Broadly defined as loss of contact with reality. Pulmonary embolism Blood clot travelling to and blocking the vessels of the lungs. The most common source is the legs. Pulse oximeter Device that detects oxygen saturation (the percentage of red blood cells saturated with oxygen). Rabies A virus that is transmitted through animal bites that affects the brain and nerves and can cause altered mental status. Rebound tenderness Pain that occurs when releasing pressure on the abdomen (as opposed to when pressing on the abdomen). GLOSSARY 212 Resuscitation Time-sensitive interventions performed in an attempt to manage life-threatening conditions. Retractions (sometimes also called “in-drawing” or “recessions”) The visible pulling in of tissues between the ribs or around the collarbones with strained inspiration. Retractions are a sign of serious difficulty in breathing. SAMPLE history An approach to asking key history findings for all patients. SAMPLE stands for: S – Signs and Symptoms, A – Allergies, M – Medications, P – Past history, L – Last oral intake, E – Events surrounding the illness or injury. Seizure Also called convulsions or fits. Abnormal electrical activity in the brain, often seen as altered mental status with abnormal repetitive movements. Seizures may be a primary condition or may be caused by infection, injury, toxins or chemical balance problems. Shock A state where organs do not get enough blood and oxygen (poor perfusion), leading to organs not working properly. Skin pinch testing An easy way to check hydration status in children by pinching the skin, usually on the abdomen. Well-hydrated skin should return to normal in less than 2 seconds. Sprain A stretched, pulled, or torn ligament. Stridor A high pitched sound on breathing in that is caused by swelling or a physical obstruction of the upper airway. Stroke Death of brain tissue due to ischaemia from either blood clot or haemorrhage. Sucking chest wound A wound in the chest wall that allows air in and out of the chest cavity, indicating an open pneumothorax. Tachycardia Heart rate faster than normal range. Tachypnoea Rapid breathing. SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 213 Tension pneumothorax Occurs when a pneumothorax causes sufficient pressure inside the chest cavity that blood vessels collapse (reducing the amount of blood that can return to the heart, and the heart cannot fill or pump enough blood to maintain perfusion of the organs). Tracheal shift Describes a change in the position of the trachea to either side of midline, a finding sometimes associated with tension pneumothorax. Trauma primary survey The trauma primary survey is another term for the ABCDE approach in injured patients. It includes initial assessment of an injured person and management of all immediately life- threatening injuries, in order of priority. The primary survey consists of the ABCDE: Airway, Breathing, Circulation, Disability and Exposure. Trauma secondary survey The head-to-toe (front and back) examination of the trauma patient that includes taking a SAMPLE history. The purpose of this survey is to identify and treat all injuries, with priority given to any hidden life-threatening conditions that were missed by the primary survey. Tripod position Sitting upright with neck extended but leaning slightly forward with hands on knees. People with severe difficulty in breathing will often sit in this position. Wheezing A whistling sound made when breathing out due to inflammation in the lungs, suggestive of lower airway swelling. WHO sources 214 WHO sources Emergency Triage Assessment and Treatment (ETAT). Geneva: World Health Organization; 2005. June 2016 update. Integrated Management of Adolescent and Adult Illness (IMAI) District Clinician Manual. Volume 1 and 2. Geneva: World Health Organization; 2011:Chapter 2–4; 6–8. Pocket book for hospital care of children. Second edition. Geneva: World Health Organization; 2013. GLOSSARY SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE REFS & QUICK CARDS PARTICIPANT WORKBOOK 215 Basic Emergency Care Quick Cards
217 ABCDE APPROACH REMEMBER... Always check for signs of trauma [see also TRAUMA card] ASSESSMENT FINDINGS IMMEDIATE MANAGEMENT Airway A Unconscious with limited or no air movement If NO TRAUMA: head-tilt and chin-lift, use OPA or NPA to keep airway open, place in recovery position or position of comfort. If possible TRAUMA: use jaw thrust with c-spine protection and place OPA to keep the airway open (no NPA if facial trauma). Foreign body in airway Remove visible foreign body. Encourage coughing. • If unable to cough: chest/abdominal thrusts/back blows as indicated • If patient becomes unconscious: CPR Gurgling Open airway as above, suction (avoid gagging). Stridor Keep patient calm and allow position of comfort. • For signs of anaphylaxis: give IM adrenaline • For hypoxia: give oxygen Breathing B Signs of abnormal breathing or hypoxia Give oxygen. Assist ventilation with BVM if breathing NOT adequate. Wheeze Give salbutamol. For signs of anaphylaxis: give IM adrenaline. Signs of tension pneumothorax (absent sounds / hyperresonance on one side WITH hypotension, distended neck veins) Perform needle decompression, give oxygen and IV uids. Will need chest tube Signs of opiate overdose (AMS and slow breathing with small pupils) Give naloxone. Circulation C Signs of poor perfusion/shock If no pulse, follow relevant CPR protocols. Give oxygen and IV uids. Signs of internal or external bleeding Control external bleeding. Give IV uids. Signs of pericardial tamponade (poor perfusion with distended neck veins and mu ed heart sounds) Give IV fl uids, oxygen. Will need rapid pericardial drainage Disability D Altered mental status (AMS) If NO TRAUMA, place in recovery position. Seizure Give benzodiazepine. Seizure in pregnancy (or after recent delivery) Give magnesium sulphate. Hypoglycaemia Give glucose if <3.5 mmol/L or unknown. Signs of opiate overdose (AMS with slow breathing with small pupils) Give naloxone. Signs of life-threatening brain mass or bleed (AMS with unequal pupils) Raise head of bed, monitor airway. Will need rapid transfer for neurosurgical services Exposure E Remove wet clothing and dry skin thoroughly. Remove jewelry, watches and constrictive clothing Prevent hypothermia and protect modesty. Snake bite Immobilize extremity. Send picture of snake with patient. Call for anti-venom if relevant. If cause unknown, remember trauma: Examine the entire body and always consider hidden injuries [see also TRAUMA card] REMEMBER: PATIENTS WITH ABNORMAL ABCDE FINDINGS MAY NEED RAPID HANDOVER/TRANSFER. PLAN EARLY. 218 SPECIAL CONSIDERATIONS IN THE ASSESSMENT OF CHILDREN A • Children have bigger heads and tongues, and shorter, softer necks than adults. Position airway as appropriate for age. • Always consider foreign bodies. B • Look for signs of increased work of breathing (e.g. chest indrawing, retractions, nasal aring). • Listen for abnormal breath sounds (e.g. grunting, stridor, or silent chest). AGE RESPIRATORY RATE (breaths per minute) <2 months 40–60 2–12 months 25–50 1–5 years 20–40 C • Signs of poor perfusion in children include: slow capillary re ll, decreased urine output, lethargy, sunken fontanelle, poor skin pinch • Look for signs of anaemia and malnourishment (adjust uids). • Remember that children may not always report trauma and may have serious internal injury with few external signs. AGE (in years) NORMAL HEART RATE (beats per minute) <1 100–160 1–3 90–150 4–5 80–140 D • Always check AVPU • Hypoglycaemia is common in ill children. • Check for tone and response to stimulus. • Look for lethargy or irritability. E INFANTS AND CHILDREN HAVE DIFFICULTY MAINTAINING TEMPERATURE • Remove wet clothing and dry skin thoroughly. Place infants skin-to-skin when possible. • For hypothermia, cover the head (but be sure mouth and nose are clear). • For hyperthermia, unbundle tightly wrapped babies. DANGER SIGNS IN CHILDREN • Signs of airway obstruction (unable to swallow saliva/ drooling or stridor) • Increased breathing e ort (fast breathing, nasal aring , grunting, chest indrawing or retractions) • Cyanosis (blue colour of the skin, especially at the lips and ngertips) • Altered mental status (including lethargy or unusual sleepiness, confusion, disorientation) • Moves only when stimulated or no movement at all (AVPU other than “A”) • Not feeding well, cannot drink or breastfeed or vomiting everything • Seizures/convulsions • Low body temperature (hypothermia) ESTIMATED WEIGHT in KILOGRAMS for CHILDREN 1–10 YEARS OLD: [age in years + 4] x 2 NORMAL ADULT VITAL SIGNS Pulse rate: 60–100 beats per minute Respiratory rate: 10–20 breaths per minute Systolic blood pressure >90 mmHg Oxygen Saturation > 92% Estimating systolic blood pressure (not reliable in children and the elderly): Carotid (neck) pulse SBP ≥ 60 mmHg Femoral (groin) pulse SBP ≥ 70 mmHg Radial (wrist) pulse SBP ≥80 mmHg SAMPLE History Signs & Symptoms Allergies Medications PMH Last oral intake Events APPROACH TO THE PATIENT WITH TRAUMA Key fi ndings from the Trauma Primary Survey [see also ABCDE card] ASSESSMENT FINDINGS IMMEDIATE MANAGEMENT Airway A Not speaking, with limited or no air movement Use jaw thrust with c-spine protection. Suction if needed, remove visible foreign objects. Place OPA to keep the airway open. Signs of possible airway injury (neck haematoma or wound, crepitus, stridor) Give oxygen. Monitor closely-- swelling can rapidly block the airway. Will need advanced airway management Signs of possible airway burns (soot around the mouth or nose, burned facial hair, facial burns) Give oxygen. Monitor closely-- swelling can rapidly close the airway. Will need advanced airway management Breathing B Signs of tension pneumothorax (hypotension with absent breath sounds/hyperresonance on one side, distended neck veins) Perform needle decompression. Give oxygen, IV uids. Will need chest tube Open (sucking) chest wound Give oxygen, place 3-sided dressing, monitor for tension pneumothorax. Will need chest tube Breathing not adequate Give oxygen, assist ventilation with BVM. Large burns of chest or abdomen (or circumferential burn to limb) Give IV uids per burn size, give oxygen, remove constricting clothing/jewelry. May need escharotomy Signs of ail chest (section of chest wall moving in opposite direction with breathing) Give oxygen. May need advanced airway management and assisted ventilation Signs of haemothorax (decreased breath sounds on one side, dull sounds with percussion) Give oxygen, IV uids. Will need chest tube Circulation C Signs of shock (capillary re ll >3 sec, hypotension, tachycardia) Give oxygen, IV uids, control external bleeding, splint femur/pelvis as indicated. Uncontrolled external bleeding Apply pressure, deep wound packing or tourniquet as indicated. Signs of tamponade (poor perfusion, distended neck veins, mu ed heart sounds) Give IV uids, oxygen. Disability D Signs of brain injury (AMS with wound, deformity or bruising of head/face) Immobilize cervical spine, check glucose, give nothing by mouth. Will need neurosurgical care Signs of open skull fracture (as above, with blood or uid from the ears/nose) As above, and give IV antibiotics per local protocol. REMEMBER: INJURED PATIENTS WITH ABNORMAL ABCDE FINDINGS MAY NEED RAPID HANDOVER/TRANSFER TO A SURGICAL SERVICE. PLAN EARLY. 219 APPROACH TO THE PATIENT WITH TRAUMA Key fi ndings from the Trauma Primary Survey [see also ABCDE card] ASSESSMENT FINDINGS IMMEDIATE MANAGEMENT Airway A Not speaking, with limited or no air movement Use jaw thrust with c-spine protection. Suction if needed, remove visible foreign objects. Place OPA to keep the airway open. Signs of possible airway injury (neck haematoma or wound, crepitus, stridor) Give oxygen. Monitor closely-- swelling can rapidly block the airway. Will need advanced airway management Signs of possible airway burns (soot around the mouth or nose, burned facial hair, facial burns) Give oxygen. Monitor closely-- swelling can rapidly close the airway. Will need advanced airway management Breathing B Signs of tension pneumothorax (hypotension with absent breath sounds/hyperresonance on one side, distended neck veins) Perform needle decompression. Give oxygen, IV uids. Will need chest tube Open (sucking) chest wound Give oxygen, place 3-sided dressing, monitor for tension pneumothorax. Will need chest tube Breathing not adequate Give oxygen, assist ventilation with BVM. Large burns of chest or abdomen (or circumferential burn to limb) Give IV uids per burn size, give oxygen, remove constricting clothing/jewelry. May need escharotomy Signs of ail chest (section of chest wall moving in opposite direction with breathing) Give oxygen. May need advanced airway management and assisted ventilation Signs of haemothorax (decreased breath sounds on one side, dull sounds with percussion) Give oxygen, IV uids. Will need chest tube Circulation C Signs of shock (capillary re ll >3 sec, hypotension, tachycardia) Give oxygen, IV uids, control external bleeding, splint femur/pelvis as indicated. Uncontrolled external bleeding Apply pressure, deep wound packing or tourniquet as indicated. Signs of tamponade (poor perfusion, distended neck veins, mu ed heart sounds) Give IV uids, oxygen. Disability D Signs of brain injury (AMS with wound, deformity or bruising of head/face) Immobilize cervical spine, check glucose, give nothing by mouth. Will need neurosurgical care Signs of open skull fracture (as above, with blood or uid from the ears/nose) As above, and give IV antibiotics per local protocol. REMEMBER: INJURED PATIENTS WITH ABNORMAL ABCDE FINDINGS MAY NEED RAPID HANDOVER/TRANSFER TO A SURGICAL SERVICE. PLAN EARLY. 220 MANAGEMENT OF SPECIFIC CONDITIONS Facial fracture Immobilize cervical spine if indicated, give IV antibiotics for open fractures, avoid nasal airway/ nasogastric tubes. Penetrating eye injury Avoid pressure on the eye, stabilize but do not remove foreign objects, give antibiotics and tetanus, elevate head of bed. Open abdominal wound Give IV uids, nothing by mouth. Cover visible bowel with sterile gauze soaked in sterile saline, give antibiotics. Pelvic fracture Give IV uids, stabilize with sheet or pelvic binder. Fracture with poor limb perfusion Reduce fracture, splint. Open fracture Irrigate well, dress wound, splint, give antibiotics, rapid handover for operative management. Penetrating object Leave object in place and stabilize it to prevent further injury. Crush injury Give IV uids, monitor urine output, monitor for compartment syndrome. Burn injury Assess size and calculate uid needs, give IV uids and oxygen, monitor for airway oedema. Blast injury Give oxygen, treat burns as below, give IV uids, monitor closely for delayed e ects of internal injury. REMEMBER: INJURED PATIENTS WITH WOUNDS, INCLUDING BURNS AND OPEN FRACTURES, NEED TETANUS VACCINATION. HIGH-RISK MECHANISMS AND INJURIES High-Risk Mechanisms High-Risk Injuries • Pedestrian or cyclist hit by a vehicle • Motorcycle crash or any vehicle crash with unrestrained occupants • Falls from heights greater than 3 metres (or twice a child’s height) • Gunshot or stabbing • Explosion or re in an enclosed space. • Penetrating injuries to head, neck or torso • Blast or crush injuries • Flail chest • Two or more large bone fractures, or pelvic fracture • Spinal injury • Limb paralysis • Amputation above wrist or ankle SPECIAL CONSIDERATIONS IN CHILDREN • Children can look well but then deteriorate quickly. • Children have more exible bones than adults and can have serious internal injuries with few external signs. • Use caution when calculating uid and medication dosages. Use exact weight whenever possible. • Watch carefully for hypothermia and hypoglycaemia. DISPOSITION Conditions that require handover or transfer to a specialist unit include: • ABCDE nding that has required intervention • Evidence of internal bleeding • Any pneumothorax or sucking chest wound • Shock, even if treated successfully • Altered mental status • Trauma during pregnancy • ABCDE abnormalities or any chest /abdomen injury in a child • Signi cant burn injuries Considerations for transfer: • Any patient who has required oxygen should have oxygen during transport and after handover. • For signs of shock, ensure IV uid started and continued during transfer. • Control any external bleeding and monitor site closely during transport. APPROACH TO THE PATIENT WITH DIFFICULTY IN BREATHING Key ABCDE Findings (Always perform a complete ABCDE approach rst!) IF YOU FIND... REMEMBER... Choking, coughing Foreign body Stridor Partial airway obstruction due to foreign body or in ammation (from infection, chemical exposure or burn) Facial swelling Severe allergic reaction, medication e ect Drooling Indicates a blockage to swallowing Soot around the mouth or nose, burned facial hair, facial burns Smoke inhalation and airway burns – rapid swelling can block the airway Signs of chest wall trauma Rib fracture, ail chest, pneumothorax, contusion, tamponade Decreased breath sounds on one side Pneumothorax (consider tension pneumothorax if with hypotension and hyperresonance to percussion), haemothorax, large pleural e usion/pneumonia Decreased breath sounds and crackles on both sides Pulmonary oedema, heart failure Wheezing Asthma, allergic reaction, COPD Fast or deep breathing DKA Low blood pressure, tachycardia, mu ed heart sounds Pericardial tamponade Altered mental status with small pupils and slow breathing Opioid overdose Key Findings from the SAMPLE History and Secondary Exam IF YOU FIND... REMEMBER... DIB worse with exertion or activity Heart failure, heart attack DIB that began with choking or during eating Foreign body, allergic reaction History of fever, cough Pneumonia, infection Pesticide exposure Poisoning Recent fall or other trauma Rib fracture, ail chest, pneumothorax, contusion, tamponade Known allergies, allergen exposure, bite or sting Allergic reaction Recent medication or dose change Allergic reaction or side e ect History of opioid or sedative drug use Overdose History of wheezing Asthma or COPD History of diabetes DKA History of tuberculosis or malignancy Pericardial tamponade, pleural e usion History of heart failure Pulmonary oedema History of sickle cell disease Acute chest syndrome 221 APPROACH TO THE PATIENT WITH DIFFICULTY IN BREATHING Key ABCDE Findings (Always perform a complete ABCDE approach rst!) IF YOU FIND... REMEMBER... Choking, coughing Foreign body Stridor Partial airway obstruction due to foreign body or in ammation (from infection, chemical exposure or burn) Facial swelling Severe allergic reaction, medication e ect Drooling Indicates a blockage to swallowing Soot around the mouth or nose, burned facial hair, facial burns Smoke inhalation and airway burns – rapid swelling can block the airway Signs of chest wall trauma Rib fracture, ail chest, pneumothorax, contusion, tamponade Decreased breath sounds on one side Pneumothorax (consider tension pneumothorax if with hypotension and hyperresonance to percussion), haemothorax, large pleural e usion/pneumonia Decreased breath sounds and crackles on both sides Pulmonary oedema, heart failure Wheezing Asthma, allergic reaction, COPD Fast or deep breathing DKA Low blood pressure, tachycardia, mu ed heart sounds Pericardial tamponade Altered mental status with small pupils and slow breathing Opioid overdose Key Findings from the SAMPLE History and Secondary Exam IF YOU FIND... REMEMBER... DIB worse with exertion or activity Heart failure, heart attack DIB that began with choking or during eating Foreign body, allergic reaction History of fever, cough Pneumonia, infection Pesticide exposure Poisoning Recent fall or other trauma Rib fracture, ail chest, pneumothorax, contusion, tamponade Known allergies, allergen exposure, bite or sting Allergic reaction Recent medication or dose change Allergic reaction or side e ect History of opioid or sedative drug use Overdose History of wheezing Asthma or COPD History of diabetes DKA History of tuberculosis or malignancy Pericardial tamponade, pleural e usion History of heart failure Pulmonary oedema History of sickle cell disease Acute chest syndrome 222 CRITICAL ACTIONS FOR HIGH-RISK CONDITIONS CHOKING unable to cough, not making sounds STRIDOR high pitched sounds on breathing IN WHEEZING high pitched sounds on breathing OUT SEVERE INFECTION TRAUMA Remove any visible foreign body Perform age- appropriate chest/ abdominal thrusts or back blows CPR if becomes unconscious Keep patient calm and allow position of comfort IM adrenaline for suspected allergic reaction Oxygen if concern for hypoxia Early handover/ transfer for advanced airway management Give salbutamol IM adrenaline for suspected allergic reaction Oxygen if concern for hypoxia Oxygen Antibiotics Oral/IV uids as appropriate Oxygen Needle decompression and IV uids for tension pneumothorax Three-sided dressing for sucking chest wound Rapid transfer to surgical service SPECIAL CONSIDERATIONS IN CHILDREN THE FOLLOWING ARE DANGER SIGNS IN CHILDREN WITH BREATHING COMPLAINTS: • Fast breathing • Increased breathing e ort (chest indrawing/retractions) • Cyanosis • Altered mental status (including lethargy) • Poor feeding or drinking, or vomits everything • Seizures/convulsions, current or recent • Drooling or stridor when calm • Hypothermia Wheezing in children is often caused by an object inhaled into the airway, viral infection or asthma. Stridor in children is often caused by an object stuck in the airway or airway swelling from infection. Fast or deep breathing can indicate diabetic crisis (DKA), which may be the rst sign of diabetes in a child. FAST BREATHING MAY BE THE ONLY SIGN OF A SERIOUS BREATHING PROBLEM IN A CHILD. DISPOSITION Salbutamol and IM adrenaline e ects last for about 3 hours, and life-threatening symptoms may recur. Monitor closely, always have repeat dose available during transport and caution new providers at handover. Naloxone lasts approximately 1 hour, and most opioids last longer. Monitor closely, always have repeat dose available during transport and caution new providers. Following immersion in water (drowning), a person may develop delayed breathing problems after several hours. Monitor closely and caution new providers. Never leave patients with di culty in breathing unmonitored during handover/transfer. Make transfer arrangements as early as possible for any patient who may require intubation or assisted ventilation. 223 CRITICAL ACTIONS FOR HIGH-RISK CONDITIONS CHOKING unable to cough, not making sounds STRIDOR high pitched sounds on breathing IN WHEEZING high pitched sounds on breathing OUT SEVERE INFECTION TRAUMA Remove any visible foreign body Perform age- appropriate chest/ abdominal thrusts or back blows CPR if becomes unconscious Keep patient calm and allow position of comfort IM adrenaline for suspected allergic reaction Oxygen if concern for hypoxia Early handover/ transfer for advanced airway management Give salbutamol IM adrenaline for suspected allergic reaction Oxygen if concern for hypoxia Oxygen Antibiotics Oral/IV uids as appropriate Oxygen Needle decompression and IV uids for tension pneumothorax Three-sided dressing for sucking chest wound Rapid transfer to surgical service SPECIAL CONSIDERATIONS IN CHILDREN THE FOLLOWING ARE DANGER SIGNS IN CHILDREN WITH BREATHING COMPLAINTS: • Fast breathing • Increased breathing e ort (chest indrawing/retractions) • Cyanosis • Altered mental status (including lethargy) • Poor feeding or drinking, or vomits everything • Seizures/convulsions, current or recent • Drooling or stridor when calm • Hypothermia Wheezing in children is often caused by an object inhaled into the airway, viral infection or asthma. Stridor in children is often caused by an object stuck in the airway or airway swelling from infection. Fast or deep breathing can indicate diabetic crisis (DKA), which may be the rst sign of diabetes in a child. FAST BREATHING MAY BE THE ONLY SIGN OF A SERIOUS BREATHING PROBLEM IN A CHILD. DISPOSITION Salbutamol and IM adrenaline e ects last for about 3 hours, and life-threatening symptoms may recur. Monitor closely, always have repeat dose available during transport and caution new providers at handover. Naloxone lasts approximately 1 hour, and most opioids last longer. Monitor closely, always have repeat dose available during transport and caution new providers. Following immersion in water (drowning), a person may develop delayed breathing problems after several hours. Monitor closely and caution new providers. Never leave patients with di culty in breathing unmonitored during handover/transfer. Make transfer arrangements as early as possible for any patient who may require intubation or assisted ventilation. APPROACH TO THE PATIENT WITH SHOCK Key ABCDE Findings (Always perform a complete ABCDE approach fi rst!) IF YOU FIND... REMEMBER... Di culty breathing, stridor/wheezing, skin rash, swelling of mouth Severe allergic reaction Hypotension with absent breath sounds and hyperresonance on one side, distended neck veins Tension pneumothorax Distended neck veins, mu ed heart sounds, tachycardia, hypotension Pericardial tamponade Sweet smelling breath, deep or rapid breathing DKA History of trauma or no known cause Hidden sources of signi cant blood loss (stomach, intestines, intra-abdominal, chest, long-bone trauma) or spinal injury Key Findings from the SAMPLE History and Secondary Exam IF YOU FIND... REMEMBER... Vomiting and diarrhoea Ask about contacts and report cases per protocol. Black or bloody vomit or stool Stomach or intestinal bleeding Rapid or deep breathing, dehydration, high glucose, sweet- smelling breath, history of frequent urination or known diabetes Diabetic ketoacidosis Burns Severe uid loss (calculate uid needs based on burn size) Fever or HIV Infection Recent fall or other trauma Internal AND external bleeding Pale conjunctiva or malnutrition Severe anemia (adjust uids) Chest pain Heart attack (give aspirin if indicated) Vaginal bleeding Pregnancy and non-pregnancy related bleeding Numbness, weakness or shock that does not improve with uids Spinal shock (immobilize spine if indicated) CRITICAL ACTIONS FOR HIGH-RISK CONDITIONS For all shock: • Give oxygen • Give IV uids – ADULTS: 1 liter RL or NS bolus – CHILDREN with NO severe anaemia, NO malnutrition, NO uid overload: 10–20 ml/kg bolus – CHILDREN with malnutrition or severe anaemia: give 10–15 ml/kg dextrose-containing uid over 1 hour and assess for uid overload every 5 minutes. – For suspected heart attack with shock, give smaller boluses, and monitor closely for uid overload. • Monitor vital signs, mental status, breathing and urine output AND for speci c conditions: SEVERE ALLER- GIC REACTION TENSION PNEUMO- THORAX TAMPONADE FEVER WATERY DIARRHOEA POSTPARTUM BLEEDING DKA TRAUMA IM adrenaline Monitor for recurrence, may need repeat doses Rapid needle decompression Transfer for chest tube Rapid transfer to advanced provider for drainage Antibiotics (and anti- malarials if indicated) Assess for source of infection Full contact precautions Monitor output and continue uids Assess for cholera and notify public health authorities Oxytocin and uterine massage Direct pressure for perineal and vaginal tears Rapid transfer to advanced obstetric care Close monitor- ing for uid over- load in children Handover/ transfer for insulin Control external haemorrhage with direct pressure, wound packing, tour- niquet if indicated Calculate uid needs based on burn size Rapid transfer for sur- gery/transfusion as needed 224 SPECIAL CONSIDERATIONS IN CHILDREN IV FLUID IMMEDIATELY AVAILABLE? IV FLUID AVAILABLE NEARBY? START ORS via NG NASOGASTRIC TUBE REASSESS IMMEDIATELY AFTER BOLUS DID PERFUSION IMPROVE? TRANSFER IMMEDIATELY CONTINUE ORS VIA NG YES YES YES YES No No No No DID PERFUSION IMPROVE? IV FLUIDS REASSESS IMMEDIATELY AFTER BOLUS CONTINUE E <30 MINUTES <30 MINUTES START IV FLUIDS RE-BOLUS GIVING FLUID IN SHOCK NO malnutrition, overload or severe anaemia DISPOSITION Patients with shock should be at a unit capable of providing IV uid resuscitation, blood transfusion, and/or surgery, depending on the type of shock. Maintain uids during transport. Repeat ABCDE approach and monitor perfusion and breathing closely at all times. ASSESSING SHOCK IN CHILDREN The 2016 WHO guidelines for the care of critically ill children use the presence of three clinical features to de ne shock: • Cold extremities • Weak and fast pulse • Capillary re ll greater than 3 seconds Additional important considerations include: • Young children may not be able to drink enough uid on their own. • Children have larger surface area to volume ratio and can lose uids more quickly than adults. • For a child in shock WITH severe malnutrition or uid overload, add dextrose and reduce uids to 10–15 ml/kg over 1 hour. Other important signs of poor perfusion include: • Sunken eyes; sunken fontanelles in infants • Abnormal skin pinch test • Pallor (dehydration with anaemia is more di cult to treat) • Decreased and dark urine (number of nappies for infants) • Low blood pressure • Fast breathing • Altered mental status • Very dry mouth and lips • Lethargy (excessive drowsiness, slow to respond, not interactive) In children without severe malnutrition, severe anaemia or uid overload, give uid resuscitation over 30 minutes. WEIGHT (kg) FLUID VOLUME (15ml/kg) 4 60 6 90 10 150 14 210 20 300 30 450 APPROACH TO THE PATIENT WITH ALTERED MENTAL STATUS (AMS) Key ABCDE Findings (Always perform a complete ABCDE approach fi rst!) IF YOU FIND... REMEMBER... Tachypnoea Hypoxia, DKA, toxic ingestion Poor perfusion/shock Infection, internal bleeding Tachycardia with normal perfusion Alcohol withdrawal Coma Hypoxia, high or low blood glucose, DKA and toxic ingestion Hypoglycaemia Infection, medication side e ect (eg, diabetes medications, quinine) Very small pupils with slow breathing Opioid overdose Seizure/convulsion Abnormal glucose, infection, toxic ingestion (eg, TB meds) or withdrawal (eg, alcohol). Consider eclampsia if current pregnancy or recent delivery. Weakness on one side or unequal pupil size Brain mass or bleed Signs of trauma or unknown cause of AMS Consider brain injury (with possible spine injury) Key Findings from SAMPLE History and Secondary Exam IF YOU FIND... REMEMBER... History of wheezing Severe COPD crisis can cause AMS History of diabetes High or low blood sugar, DKA History of epilepsy Post-seizure confusion and sleepiness should improve over minutes to hours. Prolonged AMS or multiple convulsions without waking up in between require further workup. History of agricultural work or known pesticide exposure Organophosphate poisoning History of regular alcohol use Alcohol withdrawal History of substance use or depression Acute intoxication, accidental or intentional overdose History of HIV Infection, medication side e ect Rash on the lower abdomen or legs or bulging fontanelle in infants Brain infection (meningitis) Fever/Hyperthermia Infectious, toxic, and environmental causes 225 APPROACH TO THE PATIENT WITH ALTERED MENTAL STATUS (AMS) Key ABCDE Findings (Always perform a complete ABCDE approach fi rst!) IF YOU FIND... REMEMBER... Tachypnoea Hypoxia, DKA, toxic ingestion Poor perfusion/shock Infection, internal bleeding Tachycardia with normal perfusion Alcohol withdrawal Coma Hypoxia, high or low blood glucose, DKA and toxic ingestion Hypoglycaemia Infection, medication side e ect (eg, diabetes medications, quinine) Very small pupils with slow breathing Opioid overdose Seizure/convulsion Abnormal glucose, infection, toxic ingestion (eg, TB meds) or withdrawal (eg, alcohol). Consider eclampsia if current pregnancy or recent delivery. Weakness on one side or unequal pupil size Brain mass or bleed Signs of trauma or unknown cause of AMS Consider brain injury (with possible spine injury) Key Findings from SAMPLE History and Secondary Exam IF YOU FIND... REMEMBER... History of wheezing Severe COPD crisis can cause AMS History of diabetes High or low blood sugar, DKA History of epilepsy Post-seizure confusion and sleepiness should improve over minutes to hours. Prolonged AMS or multiple convulsions without waking up in between require further workup. History of agricultural work or known pesticide exposure Organophosphate poisoning History of regular alcohol use Alcohol withdrawal History of substance use or depression Acute intoxication, accidental or intentional overdose History of HIV Infection, medication side e ect Rash on the lower abdomen or legs or bulging fontanelle in infants Brain infection (meningitis) Fever/Hyperthermia Infectious, toxic, and environmental causes 226 CRITICAL ACTIONS FOR HIGH-RISK CONDITIONS (Always check blood glucose in AMS, or give glucose if unable to check.) HYPOGLYCAEMIA OPIOID OVERDOSE LIFE-THREATENING INFECTIONS SEVERE DEHYDRATION TOXIC EXPOSURE OR WITHDRAWAL Give glucose Evaluate for infection Monitor for return of hypoglycaemia Naloxone Monitor need for repeat doses (many opioids last longer than naloxone) IV uids Antibiotics For AMS with fever or rash, consider brain infection (meningitis) – isolate patient and wear mask. Cool if indicated for very high fever (avoid shivering). IV uids Assess for infection Consider DKA Gather history and consult advanced provider for locally- appropriate antidotes. Treat alcohol withdrawal with benzodiazepine. Decontaminate for chemical exposures (eg, pesticides). PAEDIATRIC CONSIDERATIONS ALWAYS consider unwitnessed toxic ingestion Ask about any medications in the household, and any chemicals (eg cleaning products, antifreeze) in or near the house. Check and regularly re-check blood glucose Low blood glucose is common in ill young children. High blood glucose can present with AMS and dehydration. AVOID hypothermia Keep skin-to-skin with mother, cover child’s head. Uncover only the parts you need to see, one at a time, during exam. Danger signs with ingestions • Stridor • Oral chemical burns Monitor closely and arrange handover/transfer for advanced airway management. Monitor uid status closely Paediatric patients are more susceptible to both uid losses and uid overload. DISPOSITION CONSIDERATIONS Patients with AMS who may not be able to protect the airway should never be left alone. Monitor closely and give direct handover to new provider. Naloxone lasts approximately 1 hour. Most opioids last longer-- always alert new providers that patients may need repeat doses. Hypoglycaemia often recurs. Alert new providers to monitor blood glucose frequently in any patient who has been treated for hypoglycaemia. 227 MEDICATIONS MEDICATION DOSAGE INDICATION Adrenaline (Epinephrine) Solution: 1mg in 1ml ampoule (1:1000) Adults: 50 kg or above: 0.5 mg IM (0.5 ml of 1:1000) 40 kg: 0.4 mg (0.4 ml IM of 1:1000) 30 kg: 0.3 mg (0.3 ml IM of 1:1000) Repeat every 5 minutes as needed Children: Anaphylaxis: 0.15 mg IM (0.15ml of 1:1000). Repeat every 5–15 minutes as needed Severe Asthma: 0.01 mg/kg IM up to 0.3mg. Repeat every 15 minutes as needed Anaphylaxis/severe allergic reaction and severe wheezing Acetylsalicylic acid (Aspirin) Oral Tablet: 100 mg, 300 mg 300 mg (preferably chewed or in water) immediately as single dose. Suspected heart attack Diazepam Oral Tablet: 2 mg, 5 mg Solution: 5 mg /1 ml ampoule Adults: First dose: 10 mg slow IV push or 20 mg rectally Second dose after 10 minutes: 5 mg slow IV push or 10 mg rectally Maximum IV Dose: 30 mg Children: First dose: 0.2 mg/kg slow IV push or 0.5 mg/kg rectally. Can repeat half of rst dose after 10 minutes if seizures/convulsions continue. Max IV Dose: 20 mg MONITOR BREATHING CLOSELY in all patients given diazepam. Seizures/ convulsions Glucose (Dextrose) Solution: 50% dextrose (D50), 25% dextrose (D25), or 10% Dextrose (D10) Adults and children greater than 40kg: 25–50 ml IV of D50, or 125–250 ml IV of D10 Children up to 40kg: 5 ml/kg IV of D10 (PREFERRED) 2 ml/kg IV of D25 1 ml/kg IV of D50 If no IV access: 2–5 ml of 50% Dextrose OR sugar solution in buccal space Hypoglycaemia (low blood sugar) Magnesium Sulphate Solution: 1 g in 2 ml ampoule (50% or 500 mg/ml), 5 g in 10 ml ampoule (50% or 500 mg/ml) Give 4 g IV (dilute to a 20% solution and give 20ml) slowly over 20 minutes AND give 10 g IM: 5 g (10 ml of 50% solution) with 1 ml of 2% lidocaine in each buttock. If unable to give IV, give 10 g IM injection only (as above, 5 g in each buttock). If seizures/convulsions recur: after 15 minutes give additional 2 g (10 ml of 20%) IV over 20 minutes. If transport delayed continue: Give 5 g of 50% solution IM with 1 ml of 2% lidocaine every 4h in alternate buttocks. Eclampsia or Pregnant with seizure/convulsion Naloxone Solution: 400 mcg/ml (hydrochloride) in 1 ml ampoule IV: 100 mcg single dose OR IM: 400 mcg single dose May repeat every 5 minutes as needed. May require 0.4 mg/hr infusion for several hours for long-acting opioids. Opioid overdose 228 MEDICATION DOSAGE INDICATION Oxytocin Solution: 10 IU in 1ml ampule Initial Dose: Give 10 IU IM AND start IV uids with 20 IU/L at 60 drops/minute. Once placenta is delivered, continue IV uids with 20 IU/L at 30 drops/minute if still bleeding. If placenta has to be manually removed or uterus does not contract: Repeat 10 IU IM. Continue IV uids with 20 IU/L at 20 drops/minute for one hour after bleeding stops. Max Dose: 3 L of IV uids containing oxytocin. Treatment of postpartum haemorrhage Paracetamol (acetaminophen) Oral Tablet: 250 mg, 500 mg. Rectal Suppositories: 250 mg, 500 mg Adults: 500 mg–1 g oral/rectal every 6hrs Max 4 g daily or max 2 g daily if liver impairment, cirrhosis Children: 10–15 mg/kg oral/rectal up to six times per day Mild to moderate pain, fever, headache Salbutamol (Albuterol) Inhaler: 100 mcg per pu • Adult: Prime with 5 pu s and give 2 pu s via spacer every 2 minutes until improved. • Child: Prime with 5 pu s and give 2 pu s into spacer. Keep spacer in mouth for 3–5 breaths. Repeat until 6 pu s given for < 5 years, or 12 pu s for > 5 years. Nebulizer: (ADULT) 5 mg in 5 ml sterile saline. (CHILD) 2.5 mg in 3 ml sterile saline. For severe wheezing, above doses can be given several times in an hour. Severe wheezing Tetanus Vaccine IM Injection: 0.5 ml (Give for children not up to date; adults with none in 5 years; or status unknown) Wounds (including burns and open fractures) 229 MEDICATION DOSAGE INDICATION Oxytocin Solution: 10 IU in 1ml ampule Initial Dose: Give 10 IU IM AND start IV uids with 20 IU/L at 60 drops/minute. Once placenta is delivered, continue IV uids with 20 IU/L at 30 drops/minute if still bleeding. If placenta has to be manually removed or uterus does not contract: Repeat 10 IU IM. Continue IV uids with 20 IU/L at 20 drops/minute for one hour after bleeding stops. Max Dose: 3 L of IV uids containing oxytocin. Treatment of postpartum haemorrhage Paracetamol (acetaminophen) Oral Tablet: 250 mg, 500 mg. Rectal Suppositories: 250 mg, 500 mg Adults: 500 mg–1 g oral/rectal every 6hrs Max 4 g daily or max 2 g daily if liver impairment, cirrhosis Children: 10–15 mg/kg oral/rectal up to six times per day Mild to moderate pain, fever, headache Salbutamol (Albuterol) Inhaler: 100 mcg per pu • Adult: Prime with 5 pu s and give 2 pu s via spacer every 2 minutes until improved. • Child: Prime with 5 pu s and give 2 pu s into spacer. Keep spacer in mouth for 3–5 breaths. Repeat until 6 pu s given for < 5 years, or 12 pu s for > 5 years. Nebulizer: (ADULT) 5 mg in 5 ml sterile saline. (CHILD) 2.5 mg in 3 ml sterile saline. For severe wheezing, above doses can be given several times in an hour. Severe wheezing Tetanus Vaccine IM Injection: 0.5 ml (Give for children not up to date; adults with none in 5 years; or status unknown) Wounds (including burns and open fractures) TRANSFER AND HANDOVER Arrange transfer • Check that patient needs match the available services at the destination facility (eg, operating theatre open, blood available) • Communicate directly with an accepting provider at the receiving facility prior to departure • Ensure that destination facility can be reached in time given patient condition • Ensure that patient and family are aware of reasons, plan, and destination for transport • Record family contact name and number in sending facility chart and in paperwork sent with patient • Secure patient valuables for transport (whenever possible, leave with family) • A brief written record (including name, date of birth, clinical presentation and all interventions) should ALWAYS accompany the patient. Prepare for needs during transport • PPE for sta • Airway equipment and suction (check if working before departure) • Adequate oxygen (with replacement tank if needed) and bag valve mask (BVM) • IV access: Check that IV is secured prior to transport; consider second IV or backup supply • Medications: Bring additional doses of medications and uids, and consider other medications that may be needed • Prepare for new or recurrent symptoms. • Seizure/convulsion patients: place pads/pillows around patient to limit injury from a seizure during transport. • Watch for vomiting and ensure that airway remains clear, particularly for those with cervical spine immobilization. • Check that there is adequate fuel for transport. • Ensure that telephone or radio is present in vehicle and working Patient positioning • Position patient for best airway opening and breathing. • Use recovery position if no trauma. • If >20 weeks pregnant and NO spine injury: Place pillows along the length of her right back to tilt patient onto her left side. This avoids compression of the large blood vessels by the pregnant uterus. • Check that cervical spine has been immobilized if indicated. • Possible spine injury: use backboard and log-roll manoeuvre to move patients. Check for pressure spots every 2 hours; pad areas with soft material as needed. If >20-weeks pregnant: Tip backboard slightly to the left using a wedge or other materials. • Splint or immobilize fractures to protect soft tissues and decrease pain and bleeding. On-going care during transport • Re-assess the ABCDE approach at least every 15 minutes, including repeat vital signs and glucose checks if patient has been hypoglycaemic • Control bleeding prior to transport and monitor site for new bleeding • Perform regular re-assessment of any splinted extremity • Continue necessary treatments (e.g. oxygen, IV uids, oxytocin, glucose) • Keep the patient from getting too hot or too cold during transport. 230 Paediatric Considerations • Prepare appropriate size equipment and weight-adjusted dosages of critical medications. • Bring a family member or friend, and tell the receiving facility who is accompanying the child. • Remember that critically ill or injured children can look well initially and then worsen quickly. Monitor closely. • Hypothermia and hypoglycaemia are common in children. Monitor closely. SBAR handover • Situation: Basic patient information (e.g. age, sex); chief complaint (the patient’s initial description of the problem, such as di culty in breathing for 3 days, or arm pain after a fall) • Background: 2–4 most important and relevant aspects of patient’s case and/or condition; important ABCDE ndings/ interventions. • Assessment: What you think is wrong with the patient; reason for the handover/transfer. • Recommendations: next steps in treatment plan; potential worsening of the patient’s condition (e.g. need for close airway observation if inhalation burn is suspected); cautions regarding prior therapies or interventions (e.g. time of last adrenaline dose to anticipate return symptoms, need to monitor mental status if sedating medications have been given, need to monitor 3-way dressing for clotting, etc.).
ISBN 978-92-4-151308-1 World Health Organization Avenue Appia 20 1211 Geneva 27 Switzerland Email: emergencycare@who.int B A SIC EM ER G EN C Y C A R E: A pproach to the acutely ill and injured
PA R TI C IP A N T W O R K B O O K B A SIC EM ER G EN C Y C A R E: A pproach to the acutely ill and injured APPROACH TO THE ACUTELY ILL AND INJURED BASIC EMERGENCY CARE APPROACH TO THE ACUTELY ILL AND INJURED Basic emergency care: approach to the acutely ill and injured ISBN (WHO) 978–92–4-151308–1 ISBN (ICRC) 978–2-940396–58–0 © World Health Organization (WHO) and the International Committee of the Red Cross (ICRC), 2018. Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. 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The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization, the International Committee of the Red Cross or the International Federation for Emergency Medicine concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization, the International Committee of the Red Cross or the International Federation for Emergency Medicine in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization and the International Committee of the Red Cross and the International Federation for Emergency Medicine to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization or the International Committee of the Red Cross or the International Federation for Emergency Medicine be liable for damages arising from its use. Design by Inís Communication – www.iniscommunication.com BEC | Contributors Editors Teri Reynolds, Nikki Roddie, Andi Tenner, Heike Geduld. Other contributors of written material Kalie Dove-Maguire, Vijay Kannan, Sean Kivlehan, Nelson Olim, Max Ritzenberg, Stas Salerno Amato, Morgan Broccoli, Farrah Kashfipour, Harald Veen, Lee Wallis Peer reviewers Annet Alenyo, John Brown, Emilie Calvello, Brendan Carr, Keegan Checkett, Matthew Cooke, Megan Cox, Anne Creaton, Rochelle Dicker, Shaheem De Vries, Stephen Dunlop, Rajith Ellawala, George Etoundi, Sabariah Faizah, Scott Fruhan, Nicolaus Glomb, Renee Hsia, Christina Huwer, Muhumpu Kafwamfwa, Joseph Kalanzi, Gamal Khalifa, Olive Kobusingye, Clifford Mann, Edgardo Menendez, Juma Mfinanga, Nee-Kofi Mould-Millman, Hani Mowafi, Andrew Muck, Brittany Murray, Marcos Musafir, Theresa Olasveengen, Gerard O’Reilly, Tom Potokar, Junaid Razzak, Anthony Redmond, Andres Rubiano, Kelly Schmiedeknecht, Chris Stein, Janis Tupesis, Vikas Kapil, and Benjamin Wachira. The following members of the International Liaison Committee on Resuscitation (ILCOR) Pediatric Task Force provided essential peer review on relevant sections: Ng Kee Chong, Allan de Caen, Ian Maconochie, and Remigio Véiz. The following members of the International Federation for Emergency Medicine executive committee provided essential peer review: Peter Cameron, James Ducharme, Jim Holliman, Bob Schafermeyer, and Andrew Singer. Focus groups and pilots We thank the nurses and doctors of Muhimbili National Hospital in Dar es Salaam, United Republic of Tanzania, for their invaluable input during early focus groups: Ally M. Akrabi, Prosper J. Bashaka, Avelina N. Ijumba, Jennifer Jamieson, Khadija H. Juma, Bernard Kepha, Said Kilindimo, Josephine Lazaro, Wendy Lukwambe, Peter S. Mabula, Deogratius Mally, Nyakanda Marwa, Juma Mbugi, Felix D. Mlay, Victoria Mlele, Brittany Murray, Kissa Mwampagama, Meera Nariadhara, Catherine R. Shari, Patrick J. Shao, Shahzmah Suleman, Renatus Tarimo, Tito William. We are grateful to the African Federation for Emergency Medicine for overall coordination of pilots conducted in 2015–2017. Uganda course pilots were led by Joseph Kalanzi, and course facilitators included Aliga Cliff Asher, Charmaine Cunningham, Heike Geduld, Nemganga Kizega, Namaganda Lukia, Grace Magambo, Alex Makupe, Juma Mbugi, Josephine Nabulime, Annet Alenyo Ngabirano, Muzaza Nthele. Participants: Halima Adam, Douglas Akibua, Muhwezi Amos, Beatrice Babirye, Andrew Balinda, Evans Bonabana, Kamara Francis, Alele Franco, Muduwa Grace, Jagwe Hakim, Henry Kagaba, Shadia Kaggwa, Andrew Kagwa, Peter Kavuma, Winnie Kibirige, Bazibu Musa Kireka, Brian Kisembo, Nakiyemba Margaret, Edward Mugisha, Linda Nalugya, Gertrude Namidembe, Joanita Namuddu, Denis Onyang, and Emma Tukehayo. United Republic of Tanzania course pilots were led by Hendry Sawe, and course facilitators included Charmaine Cunningham, Jimmy Ernest, Upendo George, Nemganga Kizega, Deogratius Mally, Juma Mbugi, Juma Mfinanga, Felix Mlay, Brittany L Murray, Suzanna Ngalla, and Nikki Roddie. Participants: Ntuli Abraham, Thomas Bwire, Hamza Haji, Agripina Hugho, Stella Ibrahim, Philomena Jumanne, Teonila Kamba, Neema Kayembe, Sikudhani Khamsini, Clemence Luambono, Raymond Makona, Rosemary Marishay, Rashidi Matitu, Vicent Mboya, Erick Mhaiki, Rashid Mhina, Asha Mkwachu, Frank Mlaguzi, Leonidas Mutakosa, Piensia Nanyimbula, Kiohombo Phim, Mary Shauritanga, and Ndamba Sigonda. Zambia course pilots were led by Muhumpu Kafwamfwa, and course facilitators included: Namasiku Chime, Chipoya Chipoya, Ngandu Hassan, Mwandameda Kabuku, Irene Lufunda, Alex Makupe, and Mzaza Nthele. Participants: Gloria Chambeshi, Maureen Chikwa, Azelina Chulu, Mwanza Jackson, Usaliwa Jere, Tina Malunga, Pidini Mary, Mable Nakazwe Mulenga, Joy Judy Mweshi, Chicco Siame, Ivan Sinaulieni, and Franko Zulu. We wish to thank Morgan Broccoli, Simon Charwey, Catherine Haeffele, Farrah Kashfipour for input on visual design and illustration, and Tein Jung for the original illustrations throughout. INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 The ABCDE and SAMPLE history approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Module 1: The ABCDE and SAMPLE history approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Module 2: Approach to trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 Module 3: Approach to difficulty in breathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75 Module 4: Approach to shock. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95 Module 5: Approach to altered mental status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 WHO BASIC EMERGENCY CARE [SKILLS]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 GLOSSARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 WHO sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214 Basic Emergency Care Quick Cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 Contents vi INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 1 INTRODUCTION Overview Health emergencies happen every day, everywhere. They affect adults and children and include injuries and infections, heart attacks and strokes, acute complications of pregnancy and of chronic disease. While specialised care may never be available at all times in all places, a systematic approach to emergency conditions saves lives. The Disease Control Priorities Project estimates that nearly half of deaths and a third of disabilities in low- and middle-income countries result from conditions that could be addressed by emergency care. The World Health Organization (WHO), in collaboration with the International Committee of the Red Cross (ICRC) and the International Federation for Emergency Medicine (IFEM), has developed the Basic Emergency Care (BEC) course for frontline providers who manage acute life-threatening conditions with limited resources. These may include students, nurses, pre- hospital technicians, clinical officers and doctors who are working in field (pre-hospital) or hospital settings. Emergency care providers must respond to ‘undifferentiated’ patients, those with acute symptoms for which the cause may not be known. This course introduces a systematic approach to managing acute, potentially life-threatening conditions even before a diagnosis is known. BEC is based on the clinical recommendations of the WHO IMAI District Clinician Manual, WHO Pocket Book of Hospital Care for Children, WHO Emergency Triage Assessment and Treatment (ETAT) and WHO Integrated Management of Pregnancy and Childbirth. It includes modules on: the ABCDE and SAMPLE history approach, trauma, difficulty in breathing, shock, and altered mental status. The practical skills section covers the essential time-sensitive interventions for these key acute presentations. The WHO BEC package consists of: Participant workbook: the main reference source for participants, this interactive workbook provides all the necessary course content, and includes an in-depth guide to essential skills, a glossary of terms, review questions and case scenarios. Quick cards: these simple reference cards organize key assessment and management points for use in clinical settings beyond the course. These are found at the end of each module and together at the end of the workbook. Facilitator guide: this is an annotated version of the BEC workbook intended for facilitators. Challenging concepts are highlighted, and notes on teaching strategy and lecture preparation provided on each page. This volume also includes a Coordinator section with information on course planning and logistics, and offers guidance for selecting and training facilitators. Presentation slide sets: these cover all course modules and are provided to support course delivery. INTRODUCTION 2 The BEC course may be implemented in many different ways to meet local needs, but a recommended 5-day schedule is described in detail in the Coordinator section of the Facilitator guide. The BEC content might also be spread across a few weeks as a module in undergraduate nursing or medical curricula. The BEC package is designed to support the efforts of governments, educational institutions, professional societies and others to train emergency care providers acting within their designated scope of practice. WHO does not certify or accredit courses, instructors or providers. Scope of the course Key acute presentations These modules teach a practical and systematic approach to four acute and potentially life- threatening presentations: Trauma Difficulty in breathing Shock Altered mental status Most life-threatening conditions, whether the original cause was medical or surgical, infection or injury, will present with one of these. In some cases the diagnosis may be known, while in others, intervention may be required before a diagnosis can be made, perhaps because of limited diagnostic resources, but often because of the acuity of the condition. These modules introduce a systematic approach to assessment and management that can be used whether or not a diagnosis has been made. Frontline health-care providers will face many more presentations than are covered in this course. This material is not meant to cover every acute condition, but to help providers address time-sensitive conditions where early intervention has the potential to save lives. The course is designed to lay a foundation for broader emergency assessment and management. Many participants may already, or will later, be trained to provide care beyond what is described here. Recommendations for handover to an “advanced provider” are meant to signal the need for care beyond the scope of this course. In some cases, participants themselves may already be trained to provide this additional care. Other emergency presentations There are other complaints that may represent a life-threatening condition requiring emergency care even before it progresses to any of the key acute presentations listed above. These include: chest discomfort; poisoning/ingestion/exposure; envenomation (bites/stings); any severe pain from an unclear source; INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 3 contractions, pain or bleeding in late pregnancy. These complaints may represent the early stage of a critical illness requiring rapid intervention even when the person appears relatively well. The complete assessment and management of these conditions is beyond the scope of this course, but they should always trigger transport to, or consultation with, an advanced provider. In addition, there are certain infectious exposures that require time-sensitive prophylaxis (preventive treatment) whose effectiveness may be reduced by delays. These include: needle stick injury in a health care worker; unprotected sexual encounter, including in the context of assault; exposure to the saliva of an animal with suspected rabies. These exposures should be evaluated as soon as possible at a center capable of providing timely prophylaxis. Special considerations for fever Fever is a very common complaint and may be a sign of a life-threatening condition, or simply a sign of a mild condition that will resolve itself. Because fever does not reliably indicate an emergency condition, it is not addressed in a separate module here, but is covered in each of the core modules. When associated with abnormal ABCDE findings (see “Approach to the emergency patient” section), or any of the acute presentations above (trauma, difficulty in breathing, shock, altered mental status), fever can be an important clue to severe illness and should be taken very seriously. There are many more causes of fever than can be covered in this basic course, but most causes of fever requiring emergency treatment are associated with one of the four key acute presentations. There is no single approach to fever that is right for all emergencies, but there are some general principles that can help in the assessment and management of emergency patients. • Always consider infection in a person with fever (e.g. malaria, meningitis, pneumonia). • Never use the absence of fever to rule out infection. People with overwhelming infection or immune system problems may not be able to produce a fever and may have a normal or low body temperature. • Fever with abnormal vital signs and/or any of the four key acute conditions listed above will likely require early antibiotic (and/or anti-malarial) treatment. • Always consider whether local screening protocols for infectious disease outbreaks (e.g. for haemorrhagic fevers) require further action (e.g. special reporting or management) in a person with fever. Obstetric delivery and neonatal resuscitation Management of obstetric delivery and neonatal resuscitation are critical topics covered else- where in existing WHO materials and are not covered in this course. See the WHO Maternal, Newborn, Child and Adolescent Health department website (http://www.who.int/maternal_ child_adolescent/documents/en/) for training materials on these topics. INTRODUCTION 4 Expected participant background knowledge This course assumes a basic knowledge in the following areas: Use of personal protective equipment Basic human anatomy Basic history taking Basic physical examination skills, including taking vital signs, chest auscultation and abdominal assessment Use of a glucometer Set up of an intravenous (IV) infusion Safe intramuscular injection Cardiopulmonary resuscitation (CPR) Cardiopulmonary resuscitation (CPR) The decision about whether or not CPR is appropriate for a specific patient depends on many factors, including understanding of the cause of the condition, knowledge of available resources, and awareness of relevant institutional protocols and practices. There are many situations where it may be appropriate to initiate and then terminate CPR after a certain interval, and others where it may not be appropriate to initiate CPR. While this course addresses several aspects of resuscitation, it does not cover general CPR protocols, as they may vary greatly by setting. Course facilitators should direct participants to the appropriate source for relevant CPR protocols. Medication The medications discussed in this course are widely available and appropriate for use by the frontline providers for whom the course is designed. They can be used in pre-hospital or facility- based settings and are important early treatments for emergency conditions. The included medications provide a foundation for initial emergency care, but almost every condition discussed in this workbook will require treatments beyond those listed. Many important emergency treatments used by advanced providers are not included in this course. Handover/transfer This course is designed to help providers identify and provide initial management for acute, life-threatening conditions. Most acutely ill patients will require care beyond this initial stage. This may be ongoing care delivered by the same provider, but more often will require handover to a more advanced provider or facility. This process of deciding the appropriate disposition – or next step of care – for the acutely ill patient is a vital part of emergency care. Choosing an appropriate disposition involves assessing severity; estimating how rapidly the condition may progress; considering whether transfer for a specific intervention (e.g. surgery, blood transfusion) is needed; and identifying any specific risks based on a suspected or known diagnosis (e.g. risk of recurrent seizure/convulsion, or worsening airway blockage). The special disposition considerations for each key acute presentation and its associated diagnoses are covered in the modules. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 5 Planning for handover/transfer requires communicating essential information with the receiving facility, creating a transport plan, and ensuring availability of the necessary supplies to protect providers and care for patients. These components will be covered in detail in “Transfer and handover” in the Skills section. Triage Triage is the systematic process of classifying patients by acuity to ensure the best match between available resources and user needs. Triage is an essential component of emergency care during routine and surge conditions, and is a higher-level process applied to all patients, allowing assessment of the individual patient in context. As such, it is not addressed in this course, but is often taught at the same time. WHO and ICRC, in collaboration with Médecins Sans Frontières (MSF) and the South African Triage Score (SATS) team, have developed a set of integrated triage tools and an associated open-access training module. Contact emergencycare@who.int to request these materials. Approach to the emergency patient The BEC course is intended for a wide range of frontline providers and offers a basic approach for life-threatening presentations. Emergency conditions often require urgent intervention long before a diagnosis is established, and a presentation-based approach is essential to managing patients effectively. The modules in this course teach the elements of a general approach that can be used for any emergency patient. Aaron The ABCDE approach allows rapid assessment and intervention for life threats using the following categories: A: AIRWAY B: BREATHING C: CIRCULATION D: DISABILITY E: EXPOSURE Essential ABCDE considerations are listed in the modules for each of the four key presentations. The SAMPLE history is a method of rapidly gathering the history critical to the management of the acutely ill patient. The SAMPLE history categories are: S: SIGNS AND SYMPTOMS A: ALLERGIES M: MEDICATIONS P: PAST MEDICAL HISTORY L: LAST ORAL INTAKE E: EVENTS SURROUNDING ILLNESS Essential SAMPLE questions are listed in the modules for each of the four key presentations. INTRODUCTION 6 The secondary survey is a complete physical examination based on the specific condition. The essential relevant components of the secondary survey are listed in the modules for each of the four key presentations. Further details are covered in the Skills section. How to use this Participant Workbook This Participant Workbook is linked with the WHO BEC course presentations and is designed to help participants prepare for each lesson to maximize learning. Each module provides reading material and exercises to complete before the lesson. Participants should not worry if there are elements they do not fully understand while reading alone, as all workbook content will be reviewed during the lessons. Before each lesson, participants should: write out the definitions for the Key terms of the relevant module by copying from the Glossary in the back of the workbook; complete all workbook review questions in the relevant modules. The multiple choice questions and case scenarios at the end of each module will be covered in the small group sessions during the course, but participants should read through them before the session. On completion of the course, participants can use this book for reference. Accompanying the book are reference quick cards. These cards provide a summary of the essential points from the course and are designed to be carried in the clinical setting to guide day-to-day practice. Module format This course includes one module on the general approach to all emergency patients (ABCDE and SAMPLE); one module on the approach to injured patients (trauma); three modules on other specific clinical presentations (difficulty in breathing, shock, and altered mental status); a skills section; and a Glossary. The modules include the following sections: Objectives: A list of things participants should be able to do by the end of the course. Essential skills: A list of skills relevant to the module (and later taught in the Skills section). Key terms: Important words and phrases needed to understand the module. All definitions can be found in the Glossary and should be written in the space provided prior to the lecture. Overview: A brief introduction to the clinical presentation being discussed in the module. Goals of initial assessment: The main purpose of the assessment of the clinical presentation. Goals of acute management: The desired result of the management of the clinical condition. ABCDE key elements: ABCDE findings and interventions related to the specific clinical condition addressed in the module. Key history findings (ASK): Specific SAMPLE history elements related to the clinical presentation that are critical for management. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 7 Secondary survey findings (CHECK, including Look, Listen and Feel): Relevant secondary examination findings to check for in the clinical presentation the module addresses. Possible causes: Specific diseases, injuries, or illnesses that can cause the condition presented in the module (along with their specific signs and symptoms). Management (DO): These sections describe management of specific conditions. Note that the ABCDE and Trauma modules have much longer lists of possible emergency conditions, and the Possible causes and Management sections are presented in tables. The Trauma module has a separate table for Primary Survey conditions. Special considerations in children: Important differences in the signs and symptoms and management needs of children. Disposition considerations: Specific things to consider when transferring or handing over patients. Facilitator-led case scenarios: These scenarios test participants’ ability to use what they have learned to manage a patient. These scenarios will be led by the instructor. Multiple choice questions (MCQ): There are five multiple choice questions to test your knowledge at the end of each module in preparation for the final written exam. Participant requirements Participants should confirm course requirements with their facilitator. When implemented in full, the Basic Emergency Care course requires completion of ALL components listed below. Pre-test. Before receiving the Basic Emergency Care course workbook, participants should have completed this brief confidential test, which helps facilitators understand their current knowledge level. Attendance report. Participants must sign in for both the morning and afternoon sessions each day. Participants must attend all sessions to pass the course. Workbook completion. As described above, participants should complete all key terms and workbook questions in the relevant module prior to each lesson. All key terms must be defined, and all workbook questions answered for the workbook to be considered completed. The workbooks will be reviewed each day by facilitators. Participants must complete the workbook to pass the course. Skill stations. During the skills day, facilitators will demonstrate skills at a practical station. Participants will have an opportunity to practise the skill at each station several times. Participants may practise a skill as many times as needed within the allotted station time. During practice, participants may use the workbook and skill checklist for reference, and may ask questions as needed of facilitators. During assessment, no reference materials will be allowed, so participants should also practise without references, and have another participant observe for any missed steps. Participants will have plenty of time to practise and feel confident with the skills prior to assessment, and when ready, should request that an instructor assess them performing the skill. All steps in the skill checklist must be performed to pass the assessment. Participants must pass the skill station assessments to pass the course. INTRODUCTION 8 Case scenarios. All participants must successfully lead and manage a case scenario to pass the course. These scenarios give participants an opportunity to practise an integrated approach to management in small groups of 3–4 participants. Facilitators will discuss with the group how to approach the case scenarios using the ABCDE approach. In the later modules, each participant will be assessed on the ability to lead and manage a case scenario. Leading a case scenario includes identifying critical aspects of assessment and management, as well as presenting a handover summary (see the Handover section in Skills). Facilitators will complete the checklist below to assess the participant leading the case. Participants who are unsuccessful in identifying and managing the critical conditions in the scenario will be given a second case in the same or a subsequent session. Assessments are based on a standardized guide and reported on the form below. Case scenario assessment Not identified Identified some Identified all Critical airway interventions Critical breathing interventions Critical circulation interventions Critical disability interventions Critical exposure interventions Critical medications (if needed) Gave appropriate brief handover summary Yes No Participant performed all essential components Yes No Comments (including notation of any missed elements): Written final exam To qualify to sit the final examination participants must: complete the pre-test; complete the key terms and workbook questions; attend all course sessions; lead a case scenario; pass all skill stations as examined by an instructor. The final examination will include multiple choice questions. Participants must score at least 75% to pass. Your input will help improve future training courses. Please send any comments, corrections or questions to emergencycare@who.int. We encourage all participants and facilitators to fill out a short pre- and post-course survey at www.who.int/emergencycare. PARTICIPANT WORKBOOK 9 The ABCDE and SAMPLE history approach 10 Notes ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 11 Module 1: The ABCDE and SAMPLE history approach OBJECTIVES On completing this module you should be able to: 1. list the hazards that must be considered when approaching an ill or injured person; 2. list the elements to approaching an ill or injured person safely; 3. list the components of the systematic ABCDE approach to emergency patients; 4. assess an airway; 5. explain when to use airway devices; 6. explain when advanced airway management is needed; 7. assess breathing; 8. explain when to assist breathing; 9. assess fluid status (circulation); 10. provide appropriate fluid resuscitation; 11. describe the critical ABCDE actions; 12. list the elements of a SAMPLE history; 13. perform a relevant SAMPLE history. Essential skills • Assessing ABCDE • Cervical spine immobilization • Full spine immobilization • Head-tilt and chin-lift/jaw thrust • Airway suctioning • Management of choking • Recovery position • Nasopharyngeal and oropharyngeal airway placement • Bag-valve-mask ventilation • Oxygen administration • Skin pinch test • AVPU (alert, voice, pain, unresponsive) assessment • Glucose administration • Needle decompression for tension pneumothorax • Three-sided dressing for chest wound • Intravenous (IV) line placement • IV fluid resuscitation • Direct pressure for haemorrhage control, including deep wound packing • Tourniquet for haemorrhage control • Pelvic binding • Wound management • Fracture immobilization • Snake bite management Module 1: The ABCDE and SAMPLE history approach 12 KEY TERMS Write the definition using the Glossary at the back of the workbook. ABCDE: Accessory muscle use: Altered mental status (AMS): Anaphylaxis: AVPU: Bag-valve-mask (BVM): Capillary refill: Cardiopulmonary resuscitation (CPR): Cervical spine (c-spine): Convulsion: Crackles (crepitations): Crepitus: Deep wound packing: Defibrillator: Diaphoresis: Difficulty in breathing (DIB): Disposition: Foreign body: INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 13 GCS (Glasgow Coma Scale): Hives: Haematoma: Haemorrhage: Haemothorax: Hyperresonance: Hyperthermia: Hypoglycaemia: Hypothermia: Hypotension: Hypoxia: Inhalation injury: Intubation: Large bore IV: Nasal flaring: Nasopharyngeal airway (NPA): Needle decompression: Oedema: Oropharyngeal airway (OPA): Oxygen saturation (O2 sat): Module 1: The ABCDE and SAMPLE history approach 14 Percussion: Perfusion: Pericardial tamponade: Personal protective equipment (PPE): Pleural effusion: Pneumothorax: Pulse oximeter: Retractions: SAMPLE history: Seizure: Shock: Stridor: Sucking chest wound: Tachypnoea: Tension pneumothorax: Wheezing: INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 15 OVERVIEW Approaching every patient in a systematic way ensures that life-threatening conditions are recognized promptly and that the most critical interventions are done first. In a stable patient, the initial ABCDE approach may only take seconds to a few minutes. The ABCDE should be followed by a rapid history using the SAMPLE approach (Signs and Symptoms, Allergies, Medications, Past medical history, Last oral intake and Events). The SAMPLE history categories are described in general below, and essential questions for a specific presentation are listed in the relevant module. Using the standard SAMPLE and ABCDE approach together ensures that different providers can easily communicate about acutely ill patients. The goal of the ABCDE approach is to rapidly identify life-threatening conditions; ensure the airway stays open; and ensure that breathing and circulation are adequate to deliver oxygen to the body. The goal of the SAMPLE approach is to rapidly gather history critical to the management of the acutely ill patient. This module will address: Safety considerations Elements of the ABCDE approach In-depth: acute life-threatening conditions (signs, symptoms and management) Paediatric considerations in the ABCDE approach Elements of the SAMPLE history Disposition considerations SAFETY CONSIDERATIONS A critical part of the approach to any ill or injured patient is keeping providers and others safe. An ill or injured provider will be unable to help anyone, and instead becomes an extra patient for other responders to treat. Safety consideration involves checking for: scene hazards. Is there a fire, electrical wire or chemical spill that could injure providers or bystanders? At a road traffic crash, is the scene closed to oncoming traffic? If a building has collapsed, is it safe to enter? At the scene of an explosion, always consider the possibility of further explosions. Remember that delayed building collapse may follow explosions, fires and earthquakes. violence. Is there a chance that providers may be harmed by the patient or by others? For patients who are aggressive or agitated, request help as needed from security personnel or police before beginning your assessment. infectious disease risk. Is there a possibility for disease exposure (such as flu or haemorrhagic fever)? Module 1: The ABCDE and SAMPLE history approach 16 USE PERSONAL PROTECTIVE EQUIPMENT You may not know the cause of illness or injury when you first approach a patient, and without appropriate personal protective equipment (PPE), may expose yourself to diseases, chemicals or poisons. You must use appropriate PPE every time you approach a patient. Always protect yourself from any exposure to bodily fluids. This will almost always require gloves and eye protection, and may require a gown and mask. Some circumstances, such as suspected or confirmed haemorrhagic fever outbreaks, require specific protective practices. Always be sure that you are up-to-date on current local recommendations. CLEANING AND DECONTAMINATION Infectious disease exposure is a significant risk. Use PPE and wash your hands before and after every patient contact. At the scene, hand washing may not be immediately possible; carry an alcohol gel cleanser if possible. Between patients, clean and disinfect all facility and vehicle surfaces and all reusable equipment. Decontamination may be required after exposure to pesticides or other chemicals (dry or wet) and, depending on the chemical, may include washing or brushing to remove the substance. Not all chemicals can be safely washed away, and some must be removed in specific ways to avoid further injury. You must wear appropriate PPE for this. Refer to local decontamination protocols for people and equipment. ASK FOR MORE HELP IF NEEDED If multiple people are injured or ill, call for help or send someone to call. If advanced care is needed, begin making arrangements as early as possible for consultations or transfers. Know the relevant local agencies to contact for suspected outbreaks or hazardous exposures, such as chemical spills or radiation. There is often support and guidance available for containment and decontamination. Workbook question 1: Safety A person walks into your health post vomiting, bleeding from the mouth, and complaining of abdominal pain. Using the workbook section above, describe what is needed to safely approach this person: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 17 ELEMENTS OF THE ABCDE APPROACH The ABCDE approach The ABCDE approach provides a framework for the systematic and organized evaluation of acutely ill patients in order to rapidly identify and intervene for life-threatening conditions: A – Airway: check for and correct any obstruction to movement of air into the lungs B – Breathing: ensure adequate movement of air into the lungs C – Circulation: evaluate whether there is adequate perfusion to deliver oxygen to the tissues; check for signs of life-threatening bleeding D – Disability: assess and protect brain and spine functions E – Exposure: identify all injuries and any environmental threats and avoid hypothermia This stepwise approach is designed to ensure that life-threatening conditions can be identified and treated early, in order of priority. If a problem is discovered in any of these steps, it must be addressed immediately before moving on to the next step. The ABCDE approach should be performed in the first 5 minutes and repeated whenever a patient’s condition changes or worsens. Module 1: The ABCDE and SAMPLE history approach 18 THE ABCDE ASSESSMENT AND MANAGEMENT REMEMBER... Always check for signs of trauma in each of the ABCDE sections, and reference the trauma module as needed. [see TRAUMA] ASSESSMENT IMMEDIATE MANAGEMENT Airway A Can the patient talk normally? If YES, the airway is open. If the patient cannot talk normally: • look to see if the chest wall is moving and listen to see if there is air movement from the mouth or nose. • listen for abnormal sounds (such as stridor, grunting, or snoring) or a hoarse or raspy voice that indicates a partially obstructed airway. – Stridor plus swelling and/or hives suggest a severe allergic reaction (anaphylaxis). • Look and listen for fluid (such as blood, vomit) in the airway. • Look for foreign body or abnormal swelling around the airway, and altered mental status. • Check if the patient is able to swallow saliva or is drooling. • If the patient is unconscious and not breathing normally and: – NO TRAUMA: open the airway using the head-tilt and chin-lift manoeuvre. [See SKILLS] – CONCERN FOR TRAUMA: maintain cervical spine immobilization and open the airway using the jaw thrust manoeuvre. [See SKILLS] – Place an oropharyngeal or nasopharyngeal airway to maintain the airway. [See SKILLS] • If a foreign body is suspected: – If the object is visible, remove it – be careful not to push the object any deeper. – If the patient is able to cough or make noises, keep the patient calm and encourage coughing. – If the patient is choking (unable to cough, not making sounds) use age-appropriate chest thrusts/ abdominal thrusts/back blows. [See SKILLS] – If the patient becomes unconscious while choking, follow relevant CPR protocols. • If secretions or vomit are present, suction when available, or wipe clean. Consider placing patient in the recovery position if the rest of the ABCDE is normal and no trauma is suspected. [See SKILLS] • If the patient has swelling, hives or stridor, consider severe allergic reaction (anaphylaxis), and give intramuscular adrenaline. [See SKILLS] • Allow the patient to stay in a position of comfort and prepare for rapid handover/transfer to a centre capable of advanced airway management, if needed. If the airway is open, move onto “Breathing”. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 19 ASSESSMENT IMMEDIATE MANAGEMENT Breathing B • Look, listen, and feel to see if the patient is breathing. • Assess if breathing is very fast, very slow, or very shallow. • Look for signs of increased work of breathing (such as accessory muscle use, chest indrawing/ retractions, nasal flaring) or abnormal chest wall movement. • Listen for abnormal breath sounds such as wheezing or crackles. [See DIFFICULTY IN BREATHING] • With severe wheezing, there may be limited/no breath sounds on examination because narrowing of the airways may be so severe that breathing cannot be heard. • Listen to see if breath sounds are equal on both sides. • Check for the absence of breath sounds and dull sounds with percussion on one side (large pleural effusion or haemothorax). [See SKILLS] • If there are no breath sounds on one side, and hypotension, check for distended neck veins or a shifted trachea (tension pneumothorax). • Check oxygen saturation with a pulse oximeter when available. • If unconscious with abnormal breathing, start bag-valve-mask ventilation and follow relevant CPR protocols. • If not breathing adequately (too slow for age or too shallow), begin bag-valve-mask ventilation with oxygen [See SKILLS]. If oxygen not immediately available, DO NOT DELAY ventilation. Start ventilation while oxygen is being prepared. Plan for rapid handover/transfer. • If breathing fast or hypoxic, give oxygen [See SKILLS] • If wheezing, give salbutamol. [See SKILLS] Repeat salbutamol as needed. • If concern for severe allergic reaction (anaphylaxis), give intramuscular adrenaline. [See SKILLS] • If concern for tension pneumothorax, perform needle decompression immediately and give IV fluids and oxygen. [See SKILLS] Plan for rapid handover/ transfer. • If concern for large pleural effusion or haemothorax, give oxygen and plan for rapid handover/transfer. • If cause unknown, remember the possibility of trauma [See TRAUMA] If breathing is adequate, move onto “Circulation”. Circulation C • Look and feel for signs of poor perfusion (cool, moist extremities, delayed capillary refill greater than 3 seconds, low blood pressure, tachypnoea, tachycardia, absent pulses). • Look for both external AND internal bleeding, including bleeding: – into chest; – into abdomen; – from stomach or intestine; – from pelvic or femur fracture; – from wounds. • Look for hypotension, distended neck veins and muffled heart sounds that might indicate pericardial tamponade. • For cardiopulmonary arrest, follow relevant CPR protocols. • If signs of poor perfusion, give IV fluids and oxygen [See SKILLS] and: – For external bleeding, apply direct pressure or use other technique to control. [See SKILLS] – If internal bleeding or pericardial tamponade are suspected, refer rapidly to a centre with surgical capabilities. If cause unknown, remember the possibility of trauma: Bind pelvic fractures and splint femur fractures, or any fracture with compromised blood flow. [See TRAUMA and SKILLS] If circulation is adequate, move onto “Disability”. Module 1: The ABCDE and SAMPLE history approach 20 ASSESSMENT IMMEDIATE MANAGEMENT Disability D • Assess level of consciousness with the AVPU scale (Alert, Voice, Pain, Unresponsive) or in trauma cases, the Glasgow Coma Scale (GCS). [See SKILLS] • Always check glucose level in the confused or unconscious patient. • Check for pupil size, whether the pupils are equal, and if pupils are reactive to light. • Check movement and sensation in all four limbs. • Look for abnormal repetitive movements or shaking on one or both sides of the body (seizure/convulsion). • If altered mental status and no evidence of trauma, place in recovery position. [See SKILLS] • If glucose low (<3.5 mmol/L) or glucose test not available and patient has altered mental status, give glucose. [See SKILLS] • For active seizures, give a benzodiazepine. [See SKILLS] • If pregnant and having seizures, give magnesium sulphate. [See SKILLS] • If pupils are small and breathing slow, consider opioid overdose and give naloxone. [See SKILLS] • If pupils are not equal, consider increased pressure on the brain and raise head of bed 30 degrees if no concern for spinal injury. Plan for rapid transfer to an advanced provider or facility with neurosurgical care. If cause unknown, remember possibility of trauma: Immobilize the cervical spine if concern for trauma. [See TRAUMA and SKILLS] Exposure E • Examine the entire body for hidden injuries, rashes, bites or other lesions. • Rashes, such as hives, can indicate allergic reaction, and other rashes can indicate serious infection. • If snake bite is suspected, immobilize the limb. [See SKILLS] Take a picture of the snake if possible from a distance and send with patient. Do not risk additional bites to catch/kill snake. • Remove constricting clothing and all jewelry. • Cover the patient as soon as possible to prevent hypothermia. Acutely ill patients have difficulty regulating body temperature. • Remove any wet clothes and dry patient thoroughly. • Respect the patient and protect modesty during exposure. If cause unknown, remember the possibility of trauma: Log roll if suspected spinal injury [See TRAUMA and SKILLS] INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 21 ABCDE IN DEPTH: ACUTE, LIFE-THREATENING CONDITIONS This section takes a deeper look at conditions that must be managed during the ABCDE approach. AIRWAY conditions A CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT Obstruction due to foreign body • Visible secretions, vomit or foreign bodies in the airway • Abnormal sounds from the airway (such as stridor, snoring, gurgling) • Mental status changes leading to airway obstruction from the tongue • Poor chest rise The airway can become obstructed by secretions, vomit or foreign bodies. • Remove the foreign body if possible and suction fluid. Be careful not to push a foreign body further into the airway. Do not try to remove a foreign body unless clearly visible. • Use age-appropriate chest thrusts/abdominal thrusts/back blows if the airway is completely obstructed. [See SKILLS] • The tongue may obstruct the airway in patients with a decreased level of consciousness. – Open the airway using a head-tilt and chin- lift manoeuvre, or use jaw thrust (if there is concern for trauma); and place an oral or nasopharyngeal airway as needed. [See SKILLS] – These patients may also not be able to protect their airway and need to be watched for vomiting and aspiration. • Plan for rapid handover/transfer to advanced provider capable of advanced airway management if the obstruction cannot be removed. Obstruction due to burns • Burns to head and neck • Burned nasal hairs or soot around the nose or mouth • Abnormal sounds from the airway (such as stridor) • Change in voice • Poor chest rise Burns can cause airway swelling due to inhalational injuries. • Give oxygen to ALL patients with suspected airway burn even if they do not show signs of hypoxia. [See SKILLS] • Open the airway using appropriate manoeuvre and place an oral or nasopharyngeal airway as needed. [See SKILLS] • Maintain cervical spine immobilization if there is evidence of trauma. [See SKILLS] • The airway can swell and close off very quickly in burn patients. Plan for rapid handover/transfer to a provider capable of advanced airway management. Module 1: The ABCDE and SAMPLE history approach 22 CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT Obstruction due to severe allergic reaction (anaphylaxis) • Mouth, lip, and tongue swelling • Difficulty breathing with stridor and/or wheezing • Rash or hives (patches of pale or red, itchy, warm, swollen skin) • Tachycardia and hypotension • Abnormal sounds from the airway (such as stridor, snoring, gurgling) • Poor chest rise Severe allergic reactions can cause swelling of the airway that can lead to obstruction. • Give intramuscular adrenaline for airway obstruction, severe wheezing or shock. [See SKILLS] – Adrenaline can wear off in minutes so be prepared to give additional doses. • Place an IV and give IV fluids. [See SKILLS] • Reposition airway as needed (sit patient upright if no trauma) and give oxygen. [See SKILLS] • If severe or not improving, prepare for rapid handover/transfer for advanced airway management. Obstruction due to trauma • Neck haematoma or injuries to head and neck • Abnormal sounds from the airway (such as stridor, snoring, gurgling) • Change in voice • Poor chest rise Airway obstruction may result from injuries to the head or neck. Blood, bone or damaged tissue may block the airway. Penetrating wounds to the neck may also cause obstruction due to swelling or expanding haematoma. • Suction to remove any blood that might block the airway. • Open the airway using jaw thrust only (do not use head-tilt/chin-lift); and place an oral airway as needed (do not use nasopharyngeal airways if there is facial trauma). [See SKILLS} • Maintain cervical spine immobilization if there is evidence of trauma. [See SKILLS] • Plan for rapid handover/transfer to advanced provider capable of advanced airway management or surgical intervention. For any abnormal airway sounds, re-assess airway frequently as partial obstruction may worsen rapidly and block airway. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 23 BREATHING conditions B CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT Tension pneumothorax Hypotension WITH difficulty in breathing AND any of the following: • distended neck veins • absent breath sounds on affected side • hyperresonance with percussion on affected side [See SKILLS] • tracheal shift away from affected side Any pneumothorax can become a tension pneumothorax. Air in the cavity between the lungs and the chest wall can collapse the lung (simple pneumothorax). Building pressure (tension) from a large pneumothorax can displace and block flow from the main vessels back to the heart, causing shock (tension pneumothorax). • If tension pneumothorax is suspected, perform emergency needle decompression. [See SKILLS] • Give oxygen. [See SKILLS] • Give IV fluids. [See SKILLS] • Arrange for rapid handover/transfer to an advanced provider capable of placing a chest tube. Suspected opioid overdose • Slow respiratory rate • Hypoxia • Very small pupils Opioid medications (such as morphine, pethidine, and heroin) can decrease the body’s drive to breathe. • Give naloxone to reverse the effects of opioids. [See SKILLS] – Monitor closely as naloxone will wear off and additional doses may be needed. • Give oxygen. [See SKILLS] Asthma/ COPD (chronic obstructive pulmonary disease) • Wheezing • Cough • Accessory muscle use • May have history of asthma/COPD diagnosis, allergies or smoking Asthma and COPD are conditions causing spasm in the lower airways, resulting in narrowing that causes difficulty in breathing and wheezing. • Administer salbutamol as soon as possible. (Salbutamol helps to relieve the spasm in the air passages) [See SKILLS] • Give oxygen if indicated. [See SKILLS] Large pleural effusion/ haemothorax • Decreased breath sounds on affected side • Dull sounds with percussion on affected side [See SKILLS] • If there is a large amount of fluid, may have shock Pleural effusion occurs when fluid builds up in the space between the lung and the chest wall or diaphragm. As the fluid builds up, it limits expansion of the lungs. • Give oxygen. [See SKILLS] • Arrange for handover/transfer immediately (many of these patients will need a procedure to drain fluid). If cause unknown, remember the possibility of trauma [See TRAUMA] Module 1: The ABCDE and SAMPLE history approach 24 CIRCULATION conditions C CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT Pulselessness • No pulse • Unconscious • Not breathing Follow relevant cardiopulmonary resuscitation (CPR) protocols. Shock • Rapid heart rate (tachycardia) • Rapid breathing (tachypnoea) • Pale and cool skin • Capillary refill>3 seconds • Sweating (diaphoresis) • May have dizziness, confusion, altered mental status • May have hypotension Poor perfusion is the failure to deliver enough oxygen-carrying blood to the vital organs. When poor perfusion continues until organ function is affected, this is called shock and can lead rapidly to death. • Initial treatment for shock includes laying the patient flat (if tolerated). • Give oxygen. [See SKILLS] • Control bleeding. [See SKILLS] • Start an IV and give IV fluids. [See SKILLS] • If there are signs of infection, give antibiotics if available. • Prepare for rapid handover/transfer. Severe bleeding (haemorrhage) • Bleeding wounds • Bruising around the umbilicus (belly button) or over the flanks can be a sign of internal bleeding • Bleeding from the rectum or vagina or in vomit • Pelvic fracture • Femur fracture • Decreased breath sounds on one side of the chest (haemothorax) • Signs of poor perfusion (such as hypotension, tachycardia, pale skin, diaphoresis) External bleeding that is not controlled can lead quickly to shock. A large quantity of blood can also be lost into the chest, pelvis, thigh and abdomen before the bleeding is recognized. • Stop the bleeding. Depending on the source, use: – direct pressure [See SKILLS] – deep wound packing [See SKILLS] – a tourniquet [See SKILLS] – pelvic binder or femur splint. [See SKILLS] • Give IV fluids. [See SKILLS] • Refer for blood transfusion and ongoing surgical management if needed. A tourniquet should be used only for life- threatening bleeding. Pericardial tamponade • Signs of poor perfusion (tachycardia, tachypnoea, hypotension, pale and cool skin, cold extremities, capillary refill >3 seconds) • Distended neck veins • Muffled heart sounds • May have dizziness, confusion, altered mental status Pericardial tamponade occurs when fluid builds up in the sac around the heart. The pressure from this fluid can collapse the chambers of the heart and keep them from filling properly, limiting blood flow to the tissues and causing shock. Treatment is drainage by pericardiocentesis. • In order to keep the patient alive until the fluid around the heart can be drained, give IV fluids to ensure that as much volume as possible enters the heart. [See SKILLS] • Refer rapidly for surgical management. If cause unknown, remember the possibility of trauma [See TRAUMA] INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 25 DISABILITY conditions D CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT Hypoglycaemia • Sweating (diaphoresis) • Altered mental status (ranging from confusion to unconsciousness) • Seizures/convulsions • Blood glucose <3.5 mmol/L • History of diabetes, malaria or severe infection • Responds quickly to glucose Patients with hypoglycaemia (low blood sugar) need glucose immediately. [See SKILLS] • If the person can speak and swallow, give oral glucose. • If the person cannot speak or is unconscious, give IV glucose if possible. • If IV glucose is not possible or available, give buccal (inside of the cheek) glucose. [See SKILLS] Increased pressure on the brain • Headache • Seizures/convulsions • Nausea, vomiting • Altered mental status • Unequal pupils • Weakness on one side of the body Increased pressure on the brain can occur from trauma, tumours, increased fluid, bleeding or infections. Because the skull is rigid, any swelling, fluid, or mass increases the pressure around the brain, limiting blood flow and possibly displacing brain tissue, causing death. • Raise the head of the bed to 30 degrees if there is no concern for trauma and there is no hypotension. • Check glucose. [See SKILLS] • If there are seizures/convulsions, give a benzodiazepine. [See SKILLS] • The pressure must be reduced as quickly as possible. Arrange for rapid handover/transfer to a surgical centre. Seizure/ convulsion Signs and symptoms of active seizure: • Repetitive movements, gaze fixed to one side or alternating rhythmically and not responsive. Sign and symptoms of recent seizure: • Bitten tongue • Urinated on self • Known history of seizures/convulsions • Confusion that gradually improves over minutes to hours The goal in managing seizures/convulsions is to prevent hypoxia and injury. • Protect the seizing person from falls and from any hard or sharp objects nearby. • Do not place anything in the mouth of a person with active seizure except to suction airway. [See SKILLS] • Give oxygen. [See SKILLS] • Check blood glucose. Give glucose if <3.5 mmol/L. [See SKILLS] • Treat with a benzodiazepine [See SKILLS] and monitor closely for slowing or difficult breathing. • Place patient in recovery position if there is no trauma suspected. [See SKILLS] • If the patient is pregnant, or recently gave birth, give magnesium sulphate. [See SKILLS] If cause unknown, remember the possibility of trauma [See TRAUMA] Module 1: The ABCDE and SAMPLE history approach 26 EXPOSURE conditions E CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT Snake bite • History of snake bite • Bite marks may be seen • Oedema • Blistering of the skin • Bruising • Hypotension • Paralysis • Seizures • Bleeding from wounds The goal of managing snake bites is to limit the spread of the venom and the effects of venom on the body. • Immobilize the extremity. [See SKILLS] • Take a picture of the snake when possible and send with the patient (for example, with the patient’s mobile phone). • Give IV fluids if evidence of shock. [See SKILLS] • These patients may have delayed shock or airway problems. Monitor closely and plan early for rapid handover/transfer. Vital signs should be checked at the end of the ABCDE A full set of vital signs (blood pressure, heart rate, respiratory rate, and oxygen saturation if available) should be performed after the ABCDE approach. Do not delay ABCDE interventions for vital signs. ABCDE SHOULD BE REPEATED FREQUENTLY The ABCDE approach is designed to quickly identify reversible life-threatening conditions. Ideally, the ABCDE approach should be repeated at least every 15 minutes or with any change in condition. Workbook question 2: ABCDE approach Using the workbook section above, list the management for airway blocked by a foreign body. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 27 PAEDIATRIC ABCDE CONSIDERATIONS While the ABCDE approach is used in both adults and children, there are some aspects of assessing and managing children that are different from adults. The “Paediatric considerations” sections throughout the workbook highlight these differences. Paediatric considerations Pediatric airway conditions A Excessive drooling, stridor, airway swelling and unwillingness to move the neck are all high-risk signs in children. Look carefully in the airway for foreign bodies, burns or obstruction. Allow the child to remain in a position of comfort. Position airway as needed below. Compared to adults, children have: So you must do this: Bigger tongues. • Place the child in the “sniffing” position (modified head-tilt, chin-lift – like the slight upward and forward tilt of the head when sniffing a flower). Shorter necks with airways that are softer and more easily blocked. • Avoid over-extending or flexing the neck. A larger head compared to the rest of the body. • Watch closely for airway obstruction. • Use the jaw thrust if airway is not open. [See SKILLS] • Position head (using padding under shoulders for very small children) to open airway if no trauma. [See SKILLS] Neutral position in infants page 2 For choking, use age-appropriate chest thrusts/abdominal thrusts/back blows. [See SKILLS] Module 1: The ABCDE and SAMPLE history approach 28 Pediatric breathing conditions B • Nasal flaring, head bobbing, grunting and chest indrawing OR retractions, are signs of respiratory distress in children. • CYANOSIS – a blue/grey discoloration around the lips, mouth or fingertips – is the result of a lack of oxygen and is a danger sign. • CHEST INDRAWING is a common presentation of paediatric accessory muscle use. – Look at the lower chest wall (lower ribs). The child has chest indrawing if the lower chest wall goes IN when the child breathes IN. – In normal breathing, the whole chest wall (upper and lower) and the abdomen move OUT when the child breathes IN. • A SILENT CHEST (no breath sounds when you listen to the chest) is a sign of severe respiratory distress in a child. With severe spasm and narrowing of the airways, there may be limited air movement and few breath sounds on exam. Give salbutamol and oxygen and re-assess frequently. [See SKILLS] • STRIDOR signals severe airway compromise, and there are many possible causes. Children with stridor should be allowed to stay in a position of comfort and transferred immediately to an advanced provider. Further treatment will often include nebulized adrenaline. If immediate transfer is not possible, consider intramuscular adrenaline as per severe allergic reaction treatment. [See SKILLS] Pediatric circulation conditions C • MANAGEMENT OF POOR PERFUSION IN CHILDREN MAY CHANGE based on the cause and on the condition of the child. [See SHOCK and SKILLS modules] • LOW BLOOD PRESSURE IN A CHILD IS A SIGN OF SEVERE SHOCK. Children are able to maintain normal blood pressure for longer than adults when in shock. Closely monitor other signs of poor perfusion, such as decreased urine output and altered mental status. • THE AMOUNT OF INTRAVENOUS FLUID GIVEN TO CHILDREN IS DIFFERENT FROM ADULTS. [See SKILLS] • IN MALNOURISHED CHILDREN, both the rate of fluid administration and the type of fluid are different. [See SKILLS] • SEVERE SIGNS: Sunken fontanelle, poor skin pinch [See SKILLS], lethargy, altered mental status. Chest indrawing page 33 Chest indrawing INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 29 Pediatric disability conditions D • LOW BLOOD GLUCOSE is a very common cause of altered mental status in sick children. – If possible, check blood glucose in children with altered mental status. – When it is not possible to check the blood glucose level, administer glucose. • Always check for seizure/convulsions. • It is sometimes difficult to determine if infants are acting normally. Always ask the person caring for the child. Pediatric exposure conditions E • INFANTS AND CHILDREN HAVE DIFFICULTY MAINTAINING TEMPERATURE and can very quickly become hypothermic (low body temperature) or hyperthermic (high body temperature). – Remove wet clothing and dry skin thoroughly. Place infants skin-to-skin when possible. – For hypothermia, be sure to cover infants’ heads (but do not obstruct face). – For hyperthermia, unbundle tightly wrapped infants. PAEDIATRIC DANGER SIGNS IN ABCDE In addition to performing a thorough ABCDE approach, all paediatric patients should be evaluated for the presence of danger signs. Children with danger signs need URGENT attention and referral/ handover to a provider able to provide advanced paediatric care. Paediatric danger signs include: • Signs of airway obstruction (stridor or drooling/unable to swallow saliva) • Increased breathing effort (fast breathing, nasal flaring, grunting, chest indrawing or retractions) • Cyanosis (blue colour of the skin, especially at the lips and fingertips) • Altered mental status (including lethargy or unusual sleepiness, confusion, disorientation) • Moves only when stimulated or no movement at all (AVPU other than “A”) • Not feeding well or cannot drink or breastfeed • Vomiting everything • Seizures/convulsions • Low body temperature (hypothermia) Module 1: The ABCDE and SAMPLE history approach 30 Workbook question 3: ABCDE approach Using the workbook section above, list one of each of the following: a paediatric airway consideration ______________________________________________________________________ a paediatric breathing consideration ______________________________________________________________________ a paediatric circulation consideration ______________________________________________________________________ a paediatric disability consideration ______________________________________________________________________ a paediatric exposure consideration ______________________________________________________________________ Elements of the SAMPLE history The SAMPLE approach is a standard way of gathering the key history related to an illness or injury. Sources of information include: the ill/injured person, family members, friends, bystanders, or prior providers. SAMPLE stands for: S: Signs and symptoms The patient/family’s report of signs and symptoms is essential to assessment and management. A: Allergies It is important to be aware of medication allergies so that treatments do not cause harm. Allergies may also suggest anaphylaxis as the cause of acute symptoms. M: Medications Obtain a full list of medications that the person currently takes and ask about recent medication or dose changes. These may affect treatment decisions and are important to understanding the person’s chronic conditions. P: Past medical history Knowing prior medical conditions may help in understanding the current illness and may change management choices. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 31 L: Last oral intake Record the time of last oral intake and whether solid or liquid. A full stomach increases the risk of vomiting and subsequent choking, especially with sedation or intubation that might be required for surgical procedures. E: Events surrounding the injury or illness Knowing the circumstances around the injury or illness may be helpful in understanding the cause, progression and severity. Workbook question 4: SAMPLE history Using the workbook section above, list what the letters in SAMPLE stand for: S: ______________________________________________________________________ A: _____________________________________________________________________ M: _____________________________________________________________________ P: ______________________________________________________________________ L: ______________________________________________________________________ E: ______________________________________________________________________ DISPOSITION CONSIDERATIONS If you have to intervene in any of the ABCDE categories, immediately plan for handover/ transfer to a higher level of care. Once you have completed the ABCDE approach, take a SAMPLE history and complete a physical examination based on the specific condition (secondary examination). A good handover summary [See SKILLS] to the next provider requires: – brief identification of the patient; – relevant elements of the SAMPLE history; – physical examination findings; – record of interventions given; – plans for care needed next and other concerns you may have. Module 1: The ABCDE and SAMPLE history approach 32 FOR REFERENCE: NORMAL VITAL SIGNS NORMAL ADULT VITAL SIGNS Pulse rate: 60–100 beats per minute Respiratory rate: 10–20 breaths per minute – A respiratory rate of less than eight breaths per minute is a danger sign and may require intervention. Systolic blood pressure >90 mmHg If you cannot take a blood pressure reading, you can use the pulse to estimate systolic blood pressure. Feeling for a pulse at the locations below can provide an estimate of systolic blood pressure in an adult (although this method may not work well in the elderly): • Carotid (neck) pulse ≥ 60 mmHg • Femoral (groin) pulse ≥ 70 mmHg • Radial (wrist) pulse ≥ 80 mmHg NORMAL PAEDIATRIC VITAL SIGNS Vital signs are age-dependent in children. Normal heart rate and respiratory rate are higher in younger children, and normal blood pressures are lower. The brachial (middle of the upper arm) artery should be used to check the pulse in infants and small children. Normal paediatric vital signs AGE (in years) NORMAL HEART RATE (beats per minute) ≤1 100–160 1–3 90–150 4–5 80–140 AGE RESPIRATORY RATE (breaths per minute) ≤2 months 40–60 2–12 months 25–50 1–5 years 20–40 * To estimate a child’s (1–10 years old) weight in kilograms use the formula: [age in years + 4] x 2 or use weight-estimation tools such as PAWPER, Mercy TAPE, or Broselow tape. Children are able to maintain normal blood pressure for longer than adults when they are in shock. You must check closely for signs of poor perfusion. The amount of IV fluid appropriate for children is different from that for adults. [See SKILLS] Location of brachial pulse in a child page 35 Location of brachial pulse in a child INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 33 FACILITATOR-LED CASE SCENARIOS These case scenarios will be discussed in small groups. These cases in this module will NOT be assessed and are for practice only. It is important that you practise with these scenarios since you will be assessed on how you lead a case in later modules. To complete a case scenario, the group must identify the critical findings and management needed and formulate a 1–2 line handover summary that includes assessment findings and interventions. You should use the Quick Cards to manage these scenarios. CASE #1: ADULT ABCDE A 70-year-old man is brought in by taxi. The driver states the patient lost consciousness while talking with his daughter. There was no trauma, but the daughter poured water on him to try to wake him up. Initially he was confused and vomiting. Now he is unconscious with a respiratory rate of 3 breaths per minute. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate 1–2 sentences to summarize this patient for handover. Module 1: The ABCDE and SAMPLE history approach 34 CASE #2: PAEDIATRIC ABCDE A mother brings in her 2-year-old son for difficulty in breathing. She reports that he has had a fever for 3 days and has had worsening difficulty in breathing. He has been coughing a lot and today will not eat or drink. 1. What is your initial approach to this patient? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator for specific findings when you look, listen and feel; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate a 1–2 sentence summary of this patient for handover. MULTIPLE CHOICE QUESTIONS Answer the questions below. Questions and answers will be discussed within the session. 1. A mother brings in her 3-year-old child because of difficulty in breathing. On assessment, you hear loud, high-pitched sounds when the child breathes in. What is the most immediate concern? A. Severe infection B. Shock C. Asthma attack D. Upper airway obstruction 2. An elderly woman fell at home. She had normal vital signs, but complained of neck and knee pain prior to transport. During transport, she starts snoring and gurgling when taking a breath. What is the most appropriate method to immediately manage this problem? A. Placing her in the recovery position B. Administering salbutamol C. Jaw thrust D. Head-tilt/chin-lift INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 35 3. A 50-year-old man has collapsed in a store and you are called to assist him. He is unconscious, has a respiratory rate of four breaths per minute and a pulse of 100 beats per minute. The collapse was witnessed and there is no trauma. What is the best next step? A. Begin chest compressions B. Open the airway C. Begin bag-valve-mask ventilations D. Check pupils 4. A 2-year-old boy is brought to you for being more sleepy than normal. He is unconscious. You open his airway, and insert an oropharyngeal airway. What is your next step? A. Check blood pressure B. Check AVPU scale C. Check glucose D. Check breathing 5. You are listening to the lungs of a 26-year-old man who has sudden onset chest pain and he is taking 30 breaths a minute. Which lung-sound finding is most suggestive of pneumothorax? A. Crackles on both sides B. Absent lung sounds on one side C. Stridor D. 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INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS 37 PARTICIPANT WORKBOOK Module 2: Approach to trauma Objectives On completing this module you should be able to: 1. recognize key history findings suggestive of high-risk injuries; 2. recognize physical examination findings suggestive of high-risk injuries; 3. perform Trauma Primary Survey (the ABCDE approach to trauma patients); 4. perform Trauma Secondary Survey (the head-to-toe trauma exam); 5. recognize life-threatening injuries; 6. perform critical interventions for high-risk conditions. Essential skills • Cervical spine immobilization • Spine immobilization and log-roll manoeuvre • Jaw-thrust manoeuvre • Airway suctioning • Insertion of oropharyngeal and nasopharyngeal airway • Recovery Position • Oxygen delivery • Bag-valve-mask ventilation • Needle decompression for tension pneumothorax • Three-sided dressing for a sucking chest wound • Direct pressure for haemorrhage control, including deep wound packing • Tourniquet for haemorrhage control • IV line insertion • IV flluid resuscitation • AVPU and GCS assessment • Pelvic binding • Basic fracture immobilization • Trauma secondary survey • Basic wound management, including irrigation (washing) • Burn management KEY TERMS Write the definition using the Glossary at the back of the workbook. AVPU: Bradycardia: Circumferential burn: Crepitus: Compartment syndrome: Module 2: Approach to trauma 38 Cyanosis: Decontamination: Deep wound packing: Diaphoresis: Direct pressure: Disposition: Escharotomy: Flail chest: Fracture: Glasgow Coma Scale: Guarding: Haemorrhage: Haemorrhagic shock: Haematoma: Haemothorax: Hyperresonance: Hypothermia: Hypovolaemic shock: Hypoxia: Laceration: Large bore IV: INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 39 Log-roll manoeuvre: Needle decompression: Parkland Formula: Percussion: Pericardial tamponade: Pneumothorax: Priapism: Rebound tenderness: SAMPLE history: Shock: Sprain: Sucking chest wound: Tension pneumothorax: Trauma primary survey: Trauma secondary survey: Module 2: Approach to trauma 40 Overview GENERAL PRINCIPLES OF TRAUMA CARE Early priorities for an injured person include managing airway and breathing emergencies, controlling bleeding, treating shock and immobilizing the spine if needed. The goal of INITIAL ASSESSMENT is to identify life-threatening injuries. The goal of ACUTE MANAGEMENT is to ensure oxygenation and perfusion, to control pain and to plan ongoing care. This module will guide you through the: Approach to trauma ABCDE: Trauma primary survey DO: Important conditions to recognize and manage in the primary survey (signs, symptoms and management) ASK: Key history findings (SAMPLE history) CHECK: Trauma secondary survey DO: Important conditions to recognize and manage based on the history and secondary survey (Signs, symptoms and management) Special populations – Trauma in pregnancy – Special considerations in children Disposition considerations APPROACH TO TRAUMA Approach to the trauma patient consists of three phases: Trauma primary survey: The ABCDE approach for injured patients SAMPLE history: Signs and Symptoms, Allergies, Medications, Past medical history, Last oral intake, and Events surrounding the injury Trauma secondary survey: A complete head-to-toe examination to look for injuries not identified by the primary survey During primary and secondary surveys, if life-threatening problems are identified, STOP AND MANAGE them. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 41 ABCDE: TRAUMA PRIMARY SURVEY The ABCDE approach in injured patients is often also called the trauma primary survey. As for all patients this should be conducted within the first 5 minutes and repeated whenever the patient’s condition worsens. This trauma-specific ABCDE approach includes the initial assessment and management for all immediately life-threatening injuries. Always suspect head and spine injury in a trauma patient with altered mental status. ASSESSMENT IMMEDIATE MANAGEMENT Airway with cervical spine immobilization A Look for: • blood, vomit, tongue or objects obstructing the airway • burned nasal hairs or soot around the nose or mouth • head or neck trauma • neck haematoma (bleeding under the skin) • altered mental status, as this can affect the ability to protect the airway Listen for abnormal airway sounds (such as gurgling, snoring, stridor, noisy breathing). • Stabilize the cervical spine. [See SKILLS] • Open airway using jaw thrust, NOT head-tilt chin-lift if suspected spine injury. [See SKILLS] • Suction airway secretions, blood and/ or vomit. Remove any visible foreign objects from the airway. [See SKILLS] • Place oral airway (avoid nasal airway if facial trauma). [See SKILLS] • If the patient has an expanding neck haematoma or evidence of airway burns or trauma, plan for rapid handover/transfer to a provider capable of advanced airway management. If the airway is open, move onto “Breathing”. Breathing B Look for: • increased work of breathing • abnormal chest wall movement which may indicate flail chest • tracheal shift • sucking chest wound • cyanosis (blue-grey color of the skin) around the lips and fingertips • abrasion, bruising or other signs of injury to chest • circumferential burns (burns that go all the way around a body part) to chest or abdomen • absent or decreased breath sounds Listen for dull sounds or hyperresonance with percussion. Feel for crepitus (cracking and popping when pressing on the skin). • Give oxygen. [See SKILLS] • Perform needle decompression immediately and give oxygen and IV fluids for tension pneumothorax. [See SKILLS] • Place three-sided dressing for sucking chest wound. [See SKILLS] • If breathing not adequate or patient remains hypoxic on oxygen, assist breathing with bag-valve-mask ventilation. [See SKILLS] • For chest or abdominal burns that restrict breathing, handover for escharotomy (a surgical procedure to cut and release burned tissue that may restrict breathing or blood supply to a limb). If breathing is adequate, move onto “Circulation”. Module 2: Approach to trauma 42 ASSESSMENT IMMEDIATE MANAGEMENT Circulation C Look for: • capillary refill longer than 3 seconds • pale extremities • distended neck veins • external AND internal bleeding Common sources of serious bleeding are: • chest injuries • abdominal injuries • pelvic fractures • femur fractures • amputations or large external wounds • burns, noting size and depth Feel for: • cold extremities • weak pulse or tachycardia • Apply direct pressure to control active bleeding, or deep wound packing if large or gaping. [See SKILLS] • If amputated limbs or any other source of uncontrolled bleeding are present, apply tourniquet (document time of application), start IV fluids and plan for urgent transfer to a surgical unit. [See SKILLS] • If ongoing blood loss or evidence of poor perfusion, place two large bore IVs, give IV fluids and re-assess. [See SKILLS] • If burn injury, start IV fluids according to burn size. • Splint suspected femur fracture. [See SKILLS] • Bind pelvic fracture. [See SKILLS] • Leave any penetrating objects in place and stabilize object for transfer to a surgical team. • Position pregnant patients on their left side while maintaining spinal immobilization. If circulation is adequate, move onto “Disability”. Disability D Look for: • confusion, lethargy or agitation • seizures/convulsions • unequal or poorly reactive pupils • deformities of skull • blood or fluid from ear or nose Check: • AVPU or GCS • movement and sensation in all extremities • blood glucose level if confused or unconscious • If GCS <9 (or for children, AVPU score of P or U), plan for rapid handover/ transfer to a provider capable of advanced airway management. • If patient is lethargic or unconscious, re-assess the airway frequently as above. • Suspect spine injury or closed head injury with any trauma and altered mental status. • Give oxygen if concern for hypoxia as a cause of altered mental status. [See SKILLS] • Give glucose if altered mental status and: measured low blood glucose, unable to check blood glucose, or history of diabetes. [See SKILLS] • If seizing, give a benzodiazepine. [See SKILLS] INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 43 ASSESSMENT IMMEDIATE MANAGEMENT Exposure E Remove all clothing. Examine entire body for evidence of injury (including the back, spine, groin and underarms) using the log-roll manoeuvre. • If spinal injury is suspected, perform log-roll manoeuvre to examine the back. [See SKILLS] • Remove restrictive clothing and all jewellery. • Remove any wet clothes and dry patient thoroughly. • Cover the patient as soon as possible to prevent hypothermia. Acutely injured patients have difficulty regulating body temperature. • Respect the patient and protect modesty during exposure. Workbook question 1: Approach to trauma A middle-aged man is brought in after being hit by a car. Using the workbook section above, list the immediate management for the assessment findings below. PRIMARY SURVEY FINDINGS IMMEDIATE MANAGEMENT On airway assessment: • Gurgling airway sounds • Obvious head trauma 1. ������������������������������������������������ 2. ������������������������������������������������ 3. ������������������������������������������������ 4. ������������������������������������������������ On circulation assessment: • Weak pulses • Capillary refill of <3 seconds • Unstable pelvis on exam 1. ������������������������������������������������ 2. ������������������������������������������������ 3. ������������������������������������������������ Module 2: Approach to trauma 44 DO: IMPORTANT CONDITIONS TO RECOGNIZE AND MANAGE IN THE PRIMARY SURVEY A Airway conditions CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Airway obstruction • Visible blood, secretions, vomit, tongue or foreign bodies in the airway • Changes in voice • Abnormal sounds from the airway (such as stridor, snoring, gurgling) • Neck haematoma or burns to head and neck • Mental status changes leading to airway obstruction • Poor chest rise • Injury causing swelling of the airway (such as anaphylaxis or airway burn) Head and neck injuries may result in obstruction of the airway by blood, secretions, vomit, foreign bodies, or swelling. Penetrating wounds to the neck can cause expanding haematomas. Inhalational injuries due to burns can cause swelling. • Patients with a decreased level of consciousness may not be able to protect their airways and need to be watched for vomiting and aspiration. – Suction the airway and remove foreign bodies. – Open the airway using a jaw thrust manoeuvre (NOT head-tilt/chin-lift) and place an oral airway as needed. [See: SKILLS] • Maintain cervical spine immobilization throughout, if needed. • Plan for rapid handover/transfer to a provider capable of advanced airway management. B Breathing conditions CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Tension pneumothorax • Hypotension WITH: – difficulty breathing – distended neck veins – absent breath sounds on affected side – hyperresonance with percussion on affected side – may have tracheal shift away from affected side Any pneumothorax can become a tension pneumothorax. Air in the cavity between the lungs and the chest wall can collapse the lung (simple pneumothorax). Building pressure (tension) from a large pneumothorax can displace and block flow from the great vessels to the heart, causing shock as the heart cannot receive and pump enough blood to the rest of the body (tension pneumothorax). In tension pneumothorax, perfusion is compromised. • Treat tension pneumothorax immediately with needle depression. [See: SKILLS] • Give oxygen and IV fluids. [See: SKILLS] • Plan for rapid handover/transfer to an advanced provider capable of placing a chest tube. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 45 CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Sucking chest wound (open pneumothorax) • Open wound in the chest wall with air passing through causing bubbling or “sucking” noises • Difficulty in breathing • Chest pain Sucking chest wounds are important to recognize because they can rapidly cause a tension pneumothorax. Air enters the chest cavity (into the space between the chest wall and the lungs) through the wound in the chest wall when the patient takes a breath. Pressure on the lung builds if the air cannot escape. • Give oxygen. [See SKILLS] • Place a three-sided dressing that allows air to leave with exhalation but prevents air from entering when the person inhales. [See SKILLS] – There is a danger of the dressing becoming stuck to the chest wall with clotted blood and causing a tension pneumothorax. – After applying a three-sided dressing the patient should be observed continuously. – Remove the dressing if worsening respiratory status or evidence of worsening perfusion. Plan for rapid handover/transfer to an advanced provider capable of placing a chest tube. Flail chest • Difficulty in breathing • Chest pain • Part of chest wall moving in the opposite direction of the rest of the chest when breathing Flail chest segments occur when ribs are broken in multiple places, freeing an entire section of ribs from the chest wall. Without the connection to the chest wall, this section will move abnormally with breathing and prevent part of the lung from expanding. Flail chest is also usually associated with damage to underlying lung tissue. • Give oxygen and pain control. [See SKILLS] • There is a very high risk of developing difficulty in breathing and hypoxia. • Plan for rapid handover/transfer to a provider capable of chest tube placement, advanced airway placement and ventilation. Haemothorax • Difficulty in breathing • Decreased breath sounds on affected side • Dull sounds with percussion on affected side • Large haemothorax may cause shock Haemothorax (blood in the space between the lungs and the chest wall) can present with decreased or absent breath sounds and dull sounds with percussion on the affected side. • Give oxygen and IV fluids. • Plan for rapid handover/transfer to a centre with surgical capacity. Module 2: Approach to trauma 46 C Circulation conditions CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Hypovolaemic shock • Tachycardia, tachypnoea, pale skin, cold extremities, slow capillary refill • May have dizziness, confusion or altered mental status • May have hypotension • External bleeding or internal bleeding (chest, abdomen, pelvis, femur, blood vessels) Hypovolaemic shock can result from rapid loss of blood (haemorrhagic shock) or from the fluid loss associated with burns. An adult patient in shock may have only tachycardia (elevated heart rate) and/or tachypnoea (high respiratory rate) and may not have low blood pressure until the condition is immediately life-threatening. Even with a systolic blood pressure greater than 90 mmHg, suspect hypovolaemic shock if there is severe bleeding or any sign of poor perfusion (such as cool, moist, or pale skin, slow capillary refill, fast breathing, confusion, restlessness, anxiety). • Stop bleeding with direct pressure, deep wound packing if wound is gaping, a tourniquet, splinting of fractures and binding the pelvis as needed. [See SKILLS] • Start two large-bore IV lines and give IV fluids. [See SKILLS] • Patients with suspected large haemothorax or other internal haemorrhage will need rapid handover/transfer to a unit with surgical care and blood transfusion capabilities. REMEMBER... Children and young people are able to maintain a normal blood pressure until they have lost up to a quarter of their blood. Always check for other signs of shock. [See “Special considerations in children” section] Pericardial tamponade • Signs of poor perfusion (such as tachycardia, tachypnoea, hypotension, pale skin, cold extremities, capillary refill greater than 3 seconds) • Distended neck veins • Muffled heart sounds • May have dizziness, confusion, altered mental status Pericardial tamponade occurs when fluid builds up in the sac around the heart. The pressure from this fluid can collapse the chambers of the heart and prevent them from filling, limiting the amount of blood the heart can pump. • Give IV fluid to improve heart filling. [See SKILLS] • Patients need immediate handover/transfer to an advanced provider for drainage of the fluid. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 47 D Disability conditions CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Severe head injury • Visual changes, loss of memory, seizures/ convulsions, vomiting, headache • Altered mental status or other neurologic deficit • Scalp wound and/or skull deformity • Bruising to head (particularly around eyes or behind ears) • Blood or fluid from the ears or nose • Unequal pupils • Weakness on one side of the body Brain injuries can range from mild bruising to severe bleeding in or around the brain. Because the skull is rigid, the bleeding cannot expand and causes increased pressure on the brain. If the pressure becomes too high, it will prevent blood from entering into the skull and perfusing the brain, and can squeeze part of the brain through the base of the skull, causing death. Any trauma to the brain can cause significant impact on function. • Always remember that head injuries can be associated with spinal injuries. Immobilize the spine and use the log-roll technique to examine the back of the body. • Use the Glasgow Coma Scale (or AVPU in children) to assess and monitor patients with head injury. • Be sure to frequently re-assess ABCDE. • If concern for open skull fracture, give IV antibiotics as per local protocol. • Always check glucose and administer as needed. • Do not give food or drink by mouth. • Plan for early handover/transfer to a facility with specialist care. REMEMBER… People who initially appear well may have hidden life-threatening injuries, such as internal bleeding. It is very important to re-assess trauma patients frequently using the primary survey. Once you find a primary survey problem and manage it, go back and repeat the primary survey to identify any new problems and make sure that the management worked. Ideally, the ABCDE approach should be rechecked every 15 minutes and with any change in condition. Vital signs should be checked at the end of the primary survey A full set of vital signs (blood pressure, heart rate, respiratory rate and oxygen saturation if available) should be performed after the primary survey. Do not delay primary survey interventions for vital signs. Module 2: Approach to trauma 48 Workbook question 2: Approach to trauma Using the workbook section above, list five important conditions to recognize in the primary survey 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ ASK: KEY HISTORY FINDINGS FOR TRAUMA PATIENTS Information about an injured person and the injury event can be critical to planning management. Children, older adults and people with chronic disease have an increased risk of complications from trauma. They may need to be watched for several hours even when they appear well. Certain mechanisms are often associated with multiple injuries, some of which may not be obvious right away. High-risk mechanisms include: pedestrian being hit by a vehicle; motorcycle crashes or any vehicle crash with unrestrained occupants; falls from heights greater than 3 metres (or in children, twice the child’s height); gunshot or stab wounds; and explosion or fire in an enclosed space. Use the SAMPLE approach to obtain a history. Remember that you may be able to obtain information from bystanders, family, police, fire service or other health-care workers. If the history identifies a primary survey condition, STOP AND RETURN IMMEDIATELY TO PRIMARY SURVEY to manage it. S: SIGNS AND SYMPTOMS Is there a history of hoarse or raspy voice, or other voice changes? Changes in voice in the setting of injury to the head, neck or with burns may suggest that the airway is swelling and that it may obstruct. Is there any difficulty in breathing? Problems with breathing may develop over time and might not be present in the initial primary survey. Difficulty in breathing may suggest that the person has an injury to the lungs, ribs, muscles, chest wall or spine. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 49 Is there reported bleeding? It is usually quite difficult for patients to estimate the volume of blood loss, but it may be helpful to know how long there has been bleeding, how many bandages have been soaked and if the bleeding is getting lighter or heavier. Is there confusion or unusual sleepiness? Confusion after injury may be a sign of head injury, lack of oxygen or shock (with decreased blood flow to the brain). A head injury can cause bleeding or increased pressure on the brain leading to confusion, lethargy (increased sleepiness) and coma. Is there pain? Where is the pain, what does it feel like and how severe is it? Pain is a sign of underlying injury. Headache may suggest that the person has an injury to the skull or the brain. Pain along the spine can suggest an injury that may progress to cause damage to the spinal cord. Pain in the chest or abdomen may suggest damage to the heart, lungs or other organs. Pain in the pelvis or hips may suggest a fracture in the pelvis which can cause serious bleeding and shock. Pain may be the first sign of an internal injury in the chest, abdomen or pelvis. Is there nausea or vomiting? This may indicate an abdominal or head injury. Is there reported numbness or weakness? This may indicate a spinal injury. Are there reported vision changes? Direct trauma to the eye, fractures of bones around the eye, and head injuries can all cause vision changes. A: ALLERGIES Any allergies to medications? M: MEDICATIONS Currently taking any medications? Medications that affect blood clotting (e.g. aspirin, warfarin, clopidogrel) can make bleeding more difficult to control and increase the risk of delayed bleeding. Blood pressure medications can make it hard to manage shock. Obtain a full list of medications if possible or ask family members to bring in medications. Module 2: Approach to trauma 50 P: PAST MEDICAL HISTORY Is the person pregnant? Pregnancy causes some of the organs to be moved out of their usual position and causes changes in the body that need to be considered when managing trauma. Always ask women of childbearing age about the date of last menstrual period. Tetanus status? A person who has not had a tetanus vaccination within the past 5 years and who has an injury that damages the skin needs a tetanus vaccination. Are other conditions present that put the person at higher risk for serious injury? RISK FACTORS FOR POOR OUTCOMES FROM INJURY: – Age less than 5 years or greater than 55 years – Heart or lung disease – Diabetes – Liver failure (cirrhosis) – Severely overweight – Pregnancy – Immunosuppression (including HIV) – Bleeding disorder or taking blood-thinning medications (medications that prevent clotting) L: LAST ORAL INTAKE When did the person last eat or drink? E: EVENTS SURROUNDING INJURY Certain mechanisms of injury are so high risk that patients should be observed closely, even if they do not appear to be significantly injured. Was there a fall from 3 metres or more (or twice the height in children)? Falls are a common cause of injury for both adults and children. A greater distance fallen increases the chance of serious injury. Falls in adults are often associated with older age, alcohol intoxication, or the failure of workplace equipment, including scaffolding and ladders. Children often fall from trees, windows or balconies. Was a pedestrian or a cyclist hit by a vehicle? Adults and children who are hit by a vehicle while walking or using non-motorized forms of transport (such as bicycles) are always at high risk of serious injury. Young children may be less able than adults to report events, even major events like being hit by a vehicle. Always consider the possibility of unwitnessed trauma in young children. Children and adults can sustain multiple injuries when hit by a vehicle – both from direct impact to the body, especially the lower extremities, and from secondary impact if they are thrown against the windscreen or road, which may cause injuries anywhere in the body, including to head, neck, chest or limbs. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 51 In a motorcycle (or powered 3-wheeler) crash, was the rider thrown? Motorcycles collisions often result in a rider being thrown. Ask if the motorcyclist was wearing a helmet and how far away from the vehicle the rider was found. Common injury sites include head (especially when no helmet was worn), spine, chest, abdomen and pelvis (as the rider hits the handlebars), as well as limbs and skin (as the rider hits the road). Was there a road traffic crash at high speed? Was the person thrown from or trapped inside a vehicle? Did any vehicle occupants die in this crash? With higher-speed crashes, greater force is transmitted to vehicle occupants increasing the risk of serious injury. Vehicle occupants may be injured by impact with the windscreen or steering wheel, or by the forces that result from the sudden stopping of the vehicle. A person thrown from a vehicle is at very high risk of serious injury. If a person was trapped within a vehicle it is important to find out what part of the body was trapped (arm/leg, etc.) and for how long. Consider crush injury in a person who has been trapped. A death at the scene of a road traffic crash suggests that there was significant force exerted on the vehicle and its passengers. All passengers involved in the crash, even if they appear unhurt, are at high risk for serious injury. In a motor vehicle crash, was the patient wearing a seatbelt? Some types of injuries are more common in patients who were not wearing a seat-belt (being thrown from the vehicle, head strike on the windscreen, chest strike on the steering column). However, in very high-speed crashes, seat belts can also cause certain types of injuries (cervical spine injury, abdominal injury). Was a weapon used? Any time there is a history of a stab or gunshot wound, there may be multiple wounds. Always check the full body for wounds. After a bullet enters the body it may not follow a direct path and can twist throughout the body. Many internal organs can be injured by a single bullet. A stab wound creates a direct path (it is important to know the length of the blade that was used). Remember that blunt injuries from objects such as sticks and bats can cause damage to internal organs in addition to obvious injuries such as fractures, bruises and lacerations. Was there a burn? If so, what type of burn was it? Burns from fires (flame burns) are the most common. A history of flame burn in an enclosed space can also suggest an inhalation or airway injury. Scald burns (due to hot liquids) are common in children. Electrical injuries often come from high-voltage sources such as overhead electrical wires coming in contact with the body. On the surface, these electrical injuries may look small but they can cause extensive tissue and muscle damage. The electrical current often crosses the body, taking the shortest path from the point of contact with the skin to the ground, often leaving entry and exit burn marks. In the case of chemical burns, information about the specific chemical may be needed to remove it properly. For burns, was first aid provided at the scene? It is important to know if the burning process was stopped, and in the event of a chemical exposure, if decontamination was performed. If the burn is less than 3 hours old and no first aid was provided, the wound will need to be washed with clean water to stop the burning process. If there is a history of chemical exposure, protect yourself from the chemical and ensure that it is properly removed from the skin. Module 2: Approach to trauma 52 Did the person sustain a crush injury? Is there severe pain or numbness? Is there dark urine? Crush injuries may damage skin, muscle, blood vessels and bone. Damaged muscle can release a muscle by-product (called myoglobin) that can build up and damage the kidneys. It is important to know how long a body part was crushed. Even a small crushed area can cause the release of a dangerous amount of myoglobin (for example when a limb is caught under falling debris for an extended time). If a person with a crush injury has dark urine, this may be a sign of build-up of myoglobin in the kidneys. Tissue damage and swelling from crush injury can also cause a build-up of pressure (particularly in limb-crush injuries) that can limit blood flow to the muscles and nerves (compartment syndrome). Did the person sustain a blast injury? Blast injuries (from explosions) can involve all systems of the body, especially the hollow organs. Common blast injuries include damage to the lungs, intestines and ears. Patients involved in explosions need to be checked carefully and repeatedly because these injuries are easily missed. Blasts may also be associated with foreign bodies in the skin and eyes, burns or chemical injury, and toxin or radiation exposure. Workbook question 3: Approach to trauma Using the workbook section above, list five questions you would ask when taking a SAMPLE history from a person injured in a road traffic crash: 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ CHECK: TRAUMA SECONDARY SURVEY Following the primary survey and SAMPLE history, the secondary survey is a detailed head-to- toe examination designed to identify any additional injuries or issues requiring intervention. The secondary survey gives the provider an organized way to assess the entire body for signs of trauma that may not have been obvious on the primary survey. Remember that very painful or frightening injuries may distract both patients and providers from recognising other injuries. Always examine the entire body. If the secondary survey identifies a primary survey condition, STOP AND RETURN IMMEDIATELY TO THE PRIMARY SURVEY to manage it. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 53 Head, ears, eyes, nose, and throat (HEENT) Look for: • Scalp wounds or bruising • Skull deformities • Blood in mouth or throat • Unequal or unresponsive pupils indicating head injury • Vision loss or changes and eye injuries • Any problems with eye movements • Blood or fluid from ear or nose, which can indicate tissue injury or skull fracture • Tooth injury or poor alignment of teeth • Signs of airway burns: ash, singed nasal hairs, new or worsening lip/ mouth swelling Listen for: • Stridor which could indicate that the airway will obstruct soon • Gurgling indicating fluid in the airway • Changes in voice, which can indicate airway or vocal cord injury Feel for: • Tenderness or abnormal movement of facial bones, suggesting fracture • Loose teeth that may accidentally be inhaled • Defects or crepitus in the skull or facial bones concerning for fracture Neck Look for: • Reduced ability to move neck or pain on movement • Bruising, bleeding or swelling • Haematoma (bruising/bleeding under the skin) – this may eventually cause airway obstruction • Penetrating neck wounds • Distended neck veins (which may indicate tension pneumothorax or tamponade) Feel for: • Air in the skin or soft tissue – concerning for airway injury or pneumothorax • Tenderness or deformity along the spine – concerning for fracture Chest Look for: • Bruising, deformity, wounds • Uneven chest wall movement–concerning for pneumothorax or flail chest • Burns around the entire chest (circumferential) which can cause difficulty in breathing Listen for: • Breath sounds (decreased, unequal or absent, wheeze, crepitations) • Muffled heart sounds – concerning for pericardial tamponade Feel for: • Tenderness • Crepitus – concerning for fracture or pneumothorax Module 2: Approach to trauma 54 Abdomen Look for: • Abdominal distension • Visible abdominal wounds, bruising or abrasions • Bruising on back or abdomen, which may indicate internal bleeding • Circumferential burns to the abdomen (may cause severe problems with breathing) Feel for: • Abdominal rebound tenderness (pain when releasing pressure on the abdomen) or guarding (sudden contraction of the abdominal wall muscles when the abdomen is pressed), suggesting serious injury • Abdominal tenderness, which can indicate organ or blood vessel injury Pelvis and genitals (always protect patient privacy during exam) Look for: • Bruising/lacerations to pelvis • Blood at the opening of the penis or rectum. May be a sign of sexual assault. • Vaginal lacerations or bleeding – these could indicate open pelvic fracture, injury to the uterus, or may be a source of significant blood loss. May be a sign of sexual assault. • Penile lacerations • Priapism (prolonged erection) can indicate spinal injury • Urine colour changes (dark urine or obvious blood) that might indicate muscle breakdown or kidney injury Feel for: • Tenderness or abnormal movement in pelvis Extremities Look for: • Swelling or bruising • Deformity, which could indicate fracture • Open fractures • Amputation • Circumferential burns • Pale skin that could indicate limited blood flow Feel for: • Absent or weak pulses • Cold skin that could indicate limited blood flow • Tenderness • Abnormally firm, painful muscular compartments in the extremities can indicate compartment syndrome INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 55 Spine/back Log roll the person with assistance, then: Look for: • Bruising • Deformity Feel for: • Tenderness, crepitus and misalignment along the entire spine (upper neck to lower back) • Tenderness, crepitus or misalignment over any other areas with visible evidence of trauma Skin Look for: • Bruising • Abrasions • Lacerations • Feel for peripheral pulses in all extremities • Burns – Look for circumferential burns: depending on the location, these can cause difficulty in breathing (if on the chest) or compartment syndrome (if on the extremities) Neurologic Check for: • Decreased level of consciousness (using AVPU or GCS) and seizures/ convulsions, which may be signs of serious head injury • Movement and strength in each limb • Sensation on face, chest, abdomen, limbs; if there is a sensory deficit, identify where it begins • Priapism (persistent penile erection) • Decreased sensation, decreased strength or priapism can indicate spinal cord injury Module 2: Approach to trauma 56 Workbook question 4: Approach to trauma Using the workbook section above, list one way that you would ASSESS the following systems. Head, ears, eyes, nose, throat: Listen for: _______________________________________________________________ Look for: ________________________________________________________________ Feel for: _________________________________________________________________ Chest: Look for: ________________________________________________________________ Listen for: _______________________________________________________________ Feel for: _________________________________________________________________ Pelvis and genitals: Look for: ________________________________________________________________ Feel for: _________________________________________________________________ INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 57 DO: IMPORTANT CONDITIONS TO RECOGNIZE AND MANAGE BASED ON HISTORY AND SECONDARY SURVEY Management of specific injuries found during secondary survey CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Head injury • Headache • Altered mental status • Abnormal pupils • Scalp lacerations and/or skull fractures • Bruising to head (particularly around eyes or behind ears) • Blood or clear fluid coming from nose or ears • Weakness on one side of the body • Seizures/convulsions • Visual change • Loss of memory • Vomiting Because the brain is encased in the rigid skull, any swelling or bleeding caused by brain injury can rapidly become life-threatening. • Monitor level of consciousness (a marker of brain function) using the Glasgow Coma Scale (GCS) or AVPU scale in children. [See SKILLS] • Any patient who has significant head injuries is at risk of having spine injuries as well. [See SKILLS] • Always monitor immobilized patients for vomiting to avoid choking. • If there is concern for an open skull fracture, give IV antibiotics. • Check blood glucose and give glucose if less than 3.5 mmol/L or unable to measure. • Any patient with GCS less than 9 should be transferred for a CT scan within 2 hours of injury, if possible. Facial fractures • Deformities or unusual movement in the facial bones • Patient reports jaw not closing normally or teeth not aligned • Problems with eye movements • Give antibiotics for open facial fractures (laceration over a broken bone). • Update tetanus vaccination. • Suspect cervical spine injury and immobilize the cervical spine if needed. [See SKILLS] • Remember to position patient to keep blood from flowing into airway. • Avoid nasopharyngeal airways and nasogastric tubes when facial fracture is suspected. Penetrating eye injury • Any visible object in the eye • Painful red eye or a reported feeling of something in the eye; it may be difficult to see small objects that have penetrated the eye • Problems with vision • An abnormally shaped pupil or clear liquid draining from the eye may indicate a puncture wound • Evidence of facial trauma • Avoid any pressure on the injured eye – this could worsen the injury • Do not remove objects penetrating the eye. • Give antibiotics. • Update tetanus vaccination if needed. • Keep the head elevated and place a loose patch over both eyes (do NOT put pressure on the eye). • Plan for handover/transfer to an advanced provider. Module 2: Approach to trauma 58 Management of specific injuries found during secondary survey CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Penetrating neck wound • Small lacerations or puncture wounds may be the only sign of serious injury • Swelling (suggesting haematoma) • Look carefully for penetrating objects Patients with penetrating neck wounds are at risk of airway obstruction, so monitor the airway closely. Neck wounds may also have significant haemorrhage. • Maintain cervical spine precautions. [See SKILLS] • Stabilize, but do not remove penetrating objects. • Apply firm pressure to bleeding site, being careful not to block the airway. • Do not insert anything into wound to check the depth – this can cause further damage. • Initiate rapid handover/transfer to a unit with surgical care and advanced airway management capabilities. Chest injury • Difficulty in breathing • Crepitus or tenderness to palpation over the ribs • Uneven chest wall movement or unequal breath sounds Monitor closely for difficulty in breathing due to lung injury which can develop over time. Tension pneumothorax is treated in the primary survey; however, chest injury may also be associated with simple pneumothorax which can progress to a tension pneumothorax. • Any patient with a pneumothorax should be placed on oxygen and monitored closely for development of a tension pneumothorax. • Crepitus or tenderness may be signs of rib fractures which are often associated with underlying chest or abdominal injury. • Plan for handover/transfer for chest tube (pneumothorax) or advanced airway and breathing management. Abdominal injury • Abdominal pain or vomiting • Tender, firm or distended abdomen on examination • Sudden abdominal wall muscle contractions when the abdomen is touched (guarding) • Very few or no bowel sounds on examination • Rectal bleeding • Visible wound in the abdominal wall • Bruising around the umbilicus or over the flanks can be a sign of internal bleeding Severe pain or bruising to the abdomen is concerning for organ injury or internal bleeding. • If you suspect abdominal injuries, give IV fluids. • Do not give the patient anything to eat or drink. • If bowel is visible: – leave it outside the body; – cover it with sterile gauze soaked in sterile saline; – give antibiotics. • If there is any concern for abdominal injury, plan for rapid handover/transfer to a unit with surgical capabilities. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 59 Management of specific injuries found during secondary survey CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Spinal cord injury • Midline spinal pain/tenderness • Movement problems: paralysis, weakness, abnormal reflexes • Sensation problems: tingling (“pins and needles” sensation), loss of sensation • Loss of control of urine or stool • Priapism • May have hypotension, bradycardia • Crepitus when you touch the spinal bones • Spinal bones that are not properly aligned • Difficulty in breathing (upper cervical spine injury) • Provide spinal immobilization to any person with a history of trauma who is unconscious; or who is conscious and has neck pain, cervical spine tenderness, numbness or weakness. – Use a rolled sheet or neck collar to immobilize the cervical spine. [See SKILLS] Keep the patient lying flat in bed to immobilize the rest of the spine. [See SKILLS] When examining or moving the trauma patient, the spine should be protected by using the log-roll manoeuvre. [See SKILLS] • Give IV fluids. [See SKILLS] • Any patient with possible spinal trauma needs handover/transfer to a specialist unit. NOTES: • Spinal trauma is not always obvious. Fractured spinal bones can injure the spinal cord, causing paralysis. If the spinal cord injury is in the cervical spine, paralysis could involve the muscles that control respiration and could lead to death. Examination findings should be carefully documented so that future providers can evaluate if the patient’s condition has changed. • Spinal injuries can also cause shock. This can occur when nerves that control the contraction of the blood vessels in the body are damaged. When the walls of a blood vessel relax, the vessel dilates and pressure drops, leading to poor perfusion and shock. Risk is higher if there is also blood loss, so patients must be monitored closely. Always consider spinal injury in a patient with shock that does not improve with treatment. • Spine boards should only be used to move patients. Leaving patients on spine boards for long periods of time can cause pressure sores. Remove patients from boards as soon as they arrive at the facility and can be laid flat. Internal bleeding (not seen on primary survey) • Bruising around the umbilicus or over the flanks can be a sign of internal bleeding • Pelvic fracture • Femur fracture • Decreased breath sounds on one side in the chest (haemothorax) • Signs of poor perfusion (hypotension, tachycardia, pale skin, diaphoresis) A large quantity of blood can be lost into the chest, pelvis, thigh, and into the abdomen before bleeding is recognized. • Stop the bleeding if possible – bind pelvis or splint femur. [See SKILLS] • Give IV fluid. [See SKILLS] • Refer for blood transfusion and ongoing surgical management if needed. Module 2: Approach to trauma 60 Management of specific injuries found during secondary survey CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Pelvic fracture • Pain with palpation of the pelvis • Instability or abnormal movement of the pelvic bones • Blood at opening of the penis or rectum • Give IV fluids and pain control. [See SKILLS] • Compress pelvis gently to check for stability. • Do not open and rock pelvis or perform repeat exams as this can worsen internal bleeding. • Stabilize the pelvis with a sheet or pelvic binder. [See SKILLS] • Plan for early handover/transfer to a unit with blood transfusion capabilities. Extremity fracture with poor perfusion • Deformity or crepitus of the bone • Absent pulses beyond the fracture • Capillary refill time of greater than 3 seconds beyond the fracture • Cold extremities beyond the fracture with blue or grey skin colour Fractures can displace blood vessels and limit blood supply to the limb beyond the fracture. • Look for signs of poor perfusion beyond the fracture. Feel the pulse. Check capillary refill. Look for pale skin. [See SKILLS] If a fracture is found with weak pulses or poor perfusion, re-establish perfusion by reducing (manually re-aligning bone ends to put limb back to its normal position) and splinting the fracture. [See SKILLS] Always check and document pulses, capillary refill and sensation before and after any reduction. • Plan for urgent handover/transfer to a specialist unit. Open fracture • Deformity or crepitus of the bone with overlying laceration Consider any patient to have an open fracture if there is a wound (more than just a skin abrasion) near a fracture site. Open fractures are emergencies because they can lead to severe bone infections. • Control haemorrhage with direct pressure. [See SKILLS] • Reduce the fracture immediately if there is poor perfusion. [See SKILLS] • Irrigate the wound well. [See SKILLS] • Dress wound. • Give antibiotics and tetanus vaccination. • Splint the wound. • Plan for handover/transfer to a specialist unit. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 61 Management of specific injuries found during secondary survey CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Open wound • Laceration • Abrasion • Wounds in the underarm area, genital area, buttocks or back are easily missed • Pumping or squirting blood can indicate arterial bleeding The goal of wound care is to stop bleeding, prevent infection, assess damage to underlying structures and promote healing. • Stop bleeding. [See SKILLS] • Clean wounds thoroughly with soap and clean water or antiseptic to remove any dirt, foreign bodies or dead/dying tissue. (Give local anaesthetic before cleaning the wound if available.) • Dress wounds with sterile gauze, if available. • Check perfusion beyond the wound (capillary refill and/or distal pulses) before and after dressing wounds. • Splint extremities with large lacerations to help with wound healing and pain control. [See SKILLS] • Stabilize but do not remove penetrating objects. • For snake bite, immobilize the extremity. [See WOUND MANAGEMENT in SKILLS] • For animal bites, consult advanced provider to assess for risk of infection and rabies exposure. Depending on vaccination status, management can be extremely time-sensitive. • Give tetanus vaccination if needed. REMEMBER… Always assess, treat and monitor pain. Applying direct pressure to a wound Applying direct pressure to a wound page 15 Module 2: Approach to trauma 62 SPECIAL CONSIDERATIONS Management by injury mechanism CONDITION CONCERNING SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Crush injury • Fractures, bruising, soft tissue damage • Evidence of compartment syndrome (pain, firm muscle compartments, numbness, decreased pulses or pale skin) • Small amounts of red-brown urine Crush injuries can have serious complications. Look for compartment syndrome (a build-up of pressure within the muscle compartments that can limit blood supply to muscles and nerves) and kidney damage due to by-products of muscle injury. • It is important to monitor urine output and look for red- brown urine (a concern for possible kidney damage). • Give IV fluids to help the kidneys maintain urine output. • Splint fractures to keep bone ends from causing further damage. • Plan for early surgical referral to release the pressure if compartment syndrome develops. • Patients may have many systemic problems related to muscle damage and should always be handed over to an advanced provider. Blast injury • Injury to air-filled organs (such as lung, stomach and bowel) • Delayed symptoms of tachypnoea, hypoxia, chest pain, cough with or without blood • Abdominal pain, nausea, vomiting with or without blood • Tympanic membrane (ear drum) rupture: hearing loss, ringing in the ears, pain, ear bleeding • Other injuries, burns, exposure to chemicals or toxins An explosive blast can cause injuries in three ways: 1. Visible injuries from shrapnel (fragments of metal released by an explosive device) or burns from heat or chemicals released; 2. Internal (often hidden) injuries from the change in pressure caused by the blast. The stomach and bowel, lungs, and ears are commonly injured; and 3. Additional blunt injuries that result when the body is thrown by the blast. • Examine carefully for pneumothorax. • Give oxygen if there is difficulty in breathing. [See SKILLS] • Update tetanus. • Burns should be dressed and fluid needs calculated based on burn area. [See SKILLS] • If the patient has abdominal pain, consider bowel perforation, give IV fluids [See SKILLS] • Prepare for rapid surgical referral. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 63 Management by injury mechanism CONDITION CONCERNING SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Burn injury • Skin colour can range from pink, red, pale, or black, depending on the burn depth. The burn may or may not have blisters. • The following may suggest inhalation or airway injury. – Soot (ash) around nose or mouth, or singed (burned) nasal hairs – Swelling to lips or mouth – Voice changes Burns can affect the whole body and cause soft tissue injury, swelling and shock resulting from fluid loss due to the burn. The goal of burn management is to stop the burning process, watch for swelling and compensate for fluid loss. In significant burn injury, fluid leaks into the skin and surrounding tissue causing swelling and shock. • Burns involving the airway can rapidly cause airway obstruction. • It is crucial to replace fluid loss and anticipate ongoing losses. – In order to calculate the IV fluid requirements, it is important to determine the depth of the burn and the percentage of body surface area (BSA) that is burned. [See SKILLS] • Do not forget to give tetanus vaccination and pain relief for burn injuries. • Remove all jewelry and elevate the burned limb if possible. • Burns are at high risk for infection, even with good care. Clean and dress the wound carefully. [See SKILLS] BURNS REQUIRING RAPID HANDOVER/TRANSFER: • Serious burns to >15% of body [See SKILLS] • Burns involving the hands, face, groin area, joints, or circumferential burns • Inhalation injury • Burns with other associated trauma • Any burn in very young or elderly people • Significant pre-burn illness (such as diabetes) Module 2: Approach to trauma 64 Workbook question 5: Approach to Trauma Using the workbook section above, list what you would DO to manage the following injuries. INJURY MANAGEMENT Pelvic fracture 1. ______________________________________________________ 2. ______________________________________________________ 3. ______________________________________________________ 4. ______________________________________________________ Burn injury in an adult 1. ______________________________________________________ 2. ______________________________________________________ 3. ______________________________________________________ 4. ______________________________________________________ Abdominal injury 1. ______________________________________________________ 2. ______________________________________________________ 3. ______________________________________________________ 4. ______________________________________________________ INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 65 SPECIAL POPULATIONS TRAUMA IN PREGNANCY Any female patient aged 10–50 years should have a pregnancy test. Pregnancy causes many changes in physiology and there are added considerations for fetal well-being. Even minor trauma may cause harm to the mother and fetus. Women suffering trauma in the third trimester are at risk for placental abruption (where the placenta can separate from the uterus wall, resulting in bleeding), uterine rupture, and premature labour. Remember resuscitation of the mother resuscitates the fetus. KEY ELEMENTS OF PATIENT HISTORY Gestational age (age of the fetus or number of weeks since last menstrual period). Any pregnancy complications. PRIMARY SURVEY Airway: swelling in pregnancy can make airway obstruction more likely, so monitor closely. Breathing: the diaphragm is pushed up by the pregnant uterus, leaving less lung space for breathing. Circulation: check for vaginal bleeding; a pregnant uterus can also compress large blood vessels, causing hypotension. Place on left side with cervical spine precautions. [See SKILLS] Disability: always consider eclampsia if seizures/convulsions occur. Exposure: keep patient warm. COMMON CONDITIONS CAUSED BY TRAUMA Preterm (early) labour with or without premature rupture of membranes (loss of the fluid surrounding the baby). Placental abruption or uterine rupture: causing blood loss and shock. Seizures/convulsions. SPECIAL MANAGEMENT CONSIDERATIONS Plan early for handover/transfer to a specialist unit with obstetric care. If the uterus can be felt at the level of the umbilicus (belly button), this generally indicates that the patient is at least 20 weeks pregnant. If the woman is more than 20 weeks (5 months) pregnant, the pregnant uterus can compress the inferior vena cava, the large vessel that brings blood back to her heart, and can cause shock. When lying the pregnant patient flat, always place on the left side (on a spine board if immobilization necessary). [See SKILLS] Trauma in late pregnancy may trigger early labour. Prepare for neonatal resuscitation as well when trauma occurs in late pregnancy. Module 2: Approach to trauma 66 Workbook question 6: Approach to Trauma Using the workbook section above, list the common conditions in a pregnant woman that can be caused by trauma. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 67 SPECIAL CONSIDERATIONS IN CHILDREN Children can appear well after an injury, and yet deteriorate quickly. They have different injury patterns, and serious internal organ injuries may occur without overlying skull or rib fractures (paediatric bones are more flexible). Common management problems include over- or under-resuscitation, medication errors and failure to recognize hypothermia and hypoglycaemia. Below are special considerations for injured children. Refer also to the ABCDE module for normal paediatric vital signs and additional details. AIRWAY • When neck trauma or cervical spine injury is suspected, use jaw thrust to manually open airway while maintaining cervical spine immobilization. Children have big heads and large tongues that may easily obstruct their airways. Young children and infants may require a pad under the shoulders to align the airway. [See SKILLS] BREATHING • If the child is not breathing adequately after opening the airway, assist breathing with a bag-valve-mask, ideally with oxygen. • Give a breath every 4 seconds (15 breaths per minute) for older children and a breath every 3 seconds (20 breaths per minute) for infants. [See SKILLS] Neutral position in infants page 2 Module 2: Approach to trauma 68 CIRCULATION • For ongoing blood loss or evidence of poor perfusion in children with normal nutritional status (see also SKILLS): – place IV; – give IV fluids and re-assess. [See SKILLS] • For malnourished children, fluids MUST be adjusted. [See SKILLS] • For severe burn injury, initial bolus is with dextrose- containing fluids. [See SKILLS] • If significant haemorrhage, arrange for blood transfusion or rapid handover/transfer to a centre capable of blood transfusion. DISABILITY • Monitor child’s level of consciousness with the AVPU scale (Alert, responsive to Verbal stimuli, responsive to Painful stimuli, Unresponsive). AVPU is preferred to GCS in young children. • Assess for and manage seizures/convulsions. • Assess for and manage hypoglycaemia. EXPOSURE • Expose the entire body but watch for hypothermia. • Protect the child’s modesty at all times. • Use log-roll to assess remainder of child’s back and head. Estimate weight in children based on age Weight in kilograms = [age in years + 4] × 2 or use weight-estimation tools such as PAWPER tape, Mercy TAPE, or Broselow tape, etc. GENERAL Young children may be less able than adults to report events, even major events like being hit by a vehicle. Always consider the possibility of unwitnessed trauma in young children. Location of brachial pulse in a child page 35 Location of brachial pulse in a child INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 69 HEAD INJURIES Head injuries are a common cause of death in children, and children frequently suffer from acute brain swelling after a severe head injury. If a paediatric patient has signs of traumatic brain injury, transport urgently to a facility with critical care and/or surgical capacity. CHEST INJURIES Chest injuries can be life-threatening, and children require less force for more serious internal injuries. The ribs are more flexible than in adults, and there may be extensive chest injuries without rib fractures. ABDOMINAL INJURIES Children’s abdomens are relatively larger than adults, and the abdomen is a common site of injury in children. Injuries to the spleen and liver are especially common. Abdominal injuries should be considered in all paediatric trauma patients as they can be life- threatening and can cause severe internal bleeding. BURN INJURIES Burns in children can be difficult to manage. They require careful fluid resuscitation, close observation for airway swelling, and pain medications for dressing changes. In children who are burned, plan for rapid handover/transfer to a burn unit. Workbook question 7: Approach to Trauma Using the workbook section above, list the circulation considerations in children who suffer trauma. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ List the disability considerations in children who suffer trauma. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ Module 2: Approach to trauma 70 DISPOSITION CONSIDERATIONS Trauma patients can have complex injuries that may be hidden, and can worsen and die very quickly. Always refer seriously injured patients to a higher level of care for specialized treatment. The following high-risk conditions always require handover/transfer to a specialist unit for ongoing care: Airway problem requiring intervention. Signs of shock: – Tension pneumothorax: perform needle decompression prior to transfer (will need urgent chest tube placement). – Pericardial tamponade: ensure IV fluids started and continued on transfer. Altered mental status (drowsy, lethargic, confused or unconscious). Trauma in pregnancy: place on left side for transport (needs specialist obstetric care). Child with ABCDE problem, burn, or any head, chest or abdominal injury. Any serious burn injury: assess the burn depth and total burn surface area, commence fluid resuscitation (transfer preferably to a specialist burns unit). [See SKILLS] Other considerations for transfer: If a patient has required oxygen, arrange to continue it during transport and after handover. If an injured person is displaying signs of shock, ensure IV fluid started and continued during transfer. Ensure any external bleeding is controlled and monitored during transport. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 71 FACILITATOR-LED CASE SCENARIOS These case scenarios will be presented in small groups. The following cases WILL NOT be assessed and are for practice only. It is important that you practise these scenarios as you will be assessed on how you lead a case in the following modules. For each case scenario the group must identify the critical findings and management needed and formulate a one- line summary for handover, including assessment findings and interventions. You should use the Quick Cards for these scenarios. CASE #1: ADULT TRAUMA A taxi driver brings in a man that was severely injured. You come outside to find a 30-year-old male lying in the back seat of the taxi in severe pain. He was in a car crash a few kilometers away. His jeans are soaked with blood, with bone sticking out of the right thigh. 1. What do you need to do in your initial approach? 2. Use the primary survey to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate a short summary of this patient for handover. CASE #2: PAEDIATRIC TRAUMA A 5-year-old boy pulled a pan of boiling water off the stove at 8pm tonight. The boiling water spilled on him, burning his right side. His mother used a container of cool water to wash him down and then brought him in for evaluation. The child is crying and tells you he is in pain. He has burns to his right palm, and right inner arm up to the elbow, and the front of his chest and abdomen and the front of his right thigh. The mother does not know how much the child weighs. Module 2: Approach to trauma 72 1. What do you need to do in your initial approach? 2. Use the primary survey to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. Use the table below for your notes. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO A. Calculate the total burn surface area in this child. Try to shade in the children’s burn diagram for burn area estimation. B. Explain how you will decide if this child needs IV fluids? C. Calculate how much fluid is needed, explaining your method. D. What fluid would you use? 3. Formulate a short summary of this patient for handover. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 73 MULTIPLE CHOICE QUESTIONS Answer the questions below. Questions and answers will be discussed in the session. 1. Which of the following is a component of the trauma primary survey? A. Examine the arms for any fractures B. Check the skin color and temperature C. Examine the ears for any drainage of blood or clear liquid D. Check skin pinch 2. You are assessing a man who was in a car crash. He is very confused, but the remainder of his primary survey is normal. How do you perform a SAMPLE history if the patient is too confused to answer your questions? A. You do not need to do a SAMPLE history in a trauma patient B. Ask the patient repeatedly until he is able to answer C. Ask bystanders or family member for the information D. Assume that there is no important information 3. A 23-year-old man is carried in after diving head first into a river. He is speaking and his airway is open but he cannot walk or move his arms or legs. What is the first thing you must do? A. Place an IV line B. Examine him for other injuries C. Immobilize the cervical spine D. Give him a tetanus vaccination 4. You are evaluating a 21-year-old male who was in a motorcycle crash. He was thrown from the motorcycle and suffered injuries to his face, chest and legs. When you compress his pelvis, he screams in pain. His vital signs are: blood pressure 90/40 mmHg, heart rate 120 bpm, respiratory rate 25/min. What should be your next step? A. Place in a pelvic binder B. Administer tetanus vaccine C. Provide antibiotics D. Clean the abrasions with soap and water 5. A young woman has been brought in after an explosion. She has an open airway, a respiratory rate of 30/min, heart rate 125 bpm, blood pressure of 85/50 mmHg, has moist pale skin and she complains of abdominal pain. She has small wounds to her skin but there is no obvious bleeding. What would you do to manage this patient? A. Place two large-bore cannulae and give 1 litre of fluid B. Offer her a drink of water C. Check her temperature D. Provide antibiotics 74 Notes ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS 75 PARTICIPANT WORKBOOK Module 3: Approach to difficulty in breathing Objectives On completing this module you should be able to: 1. recognize signs of difficulty in breathing (DIB); 2. list the high-risk causes of difficulty in breathing; 3. perform critical actions for high-risk causes of difficulty in breathing. Essential skills Basic airway manoeuvres Basic airway device insertion Management of choking Oxygen administration Bag-valve-mask ventilation Needle decompression for tension pneumothorax Three-sided dressing for sucking chest wound KEY TERMS Write the definition using the Glossary at the back of the workbook. Accessory muscle use: Anaemia: Asthma: Chronic obstructive pulmonary disease (COPD): Circumferential burns: Crepitus: Module 3: Approach to difficulty in breathing 76 Cyanosis: Diabetic ketoacidosis (DKA): Diaphoresis: Difficulty in breathing (DIB): Disposition: Drowning: Haemothorax: Heart attack: Heart failure: Hives: Hyperventilation: Inflammation: Ischaemia: Large-bore IV: Needle decompression: Pericardial effusion: Pleural effusion: Pleuritic: Pneumonia: Pulmonary embolism: TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 77 Stridor: Tachycardia: Tachypnoea: Tracheal shift: Tripod position: Wheezing: Overview Difficulty in breathing (DIB) is a term used to describe a range of conditions from a feeling of shortness of breath to abnormal breathing movements, or any increased effort required to breathe. DIB can result from problems in the upper or lower airways, the lungs, the heart or the muscles used for breathing; or from conditions that may cause faster breathing (such as anaemia or chemical imbalance). DIB can be caused by: upper or lower airway obstruction (blockage by an object; by spasm of the airways, such as with asthma; by swelling due to allergy; infection or injury); fluid in the airspaces of the lung (such as from pneumonia or pulmonary oedema); air or fluid outside the lung causing lung collapse or compression (such as pneumothorax or effusion); blood clots in the vessels supplying the lungs; any other cause of decreased oxygen carried in the blood (such as anaemia); conditions that increase respiratory rate such as toxic ingestion, chemical imbalance (for example in diabetic ketoacidosis) or anxiety. The goal of INITIAL ASSESSMENT is to identify reversible causes of difficulty in breathing, and to recognize conditions that require urgent intervention or rapid transfer. The goal of ACUTE MANAGEMENT is to ensure the airway stays open and breathing is adequate to deliver oxygen to the organs. Module 3: Approach to difficulty in breathing 78 This module will guide you through: ABCDE key elements ASK: key history findings (SAMPLE history) CHECK: secondary exam findings Possible causes DO: management Special considerations in children Disposition considerations REMEMBER... • ALWAYS START WITH THE ABCDE APPROACH, intervening as needed. • Then do a SAMPLE history. • Then do a secondary exam. ABCDE: KEY ELEMENTS FOR PATIENTS WITH DIFFICULTY IN BREATHING For the patient with difficulty in breathing, the following are key elements that should be considered in the ABCDE approach. AIRWAY A person with difficulty in breathing may have airway swelling caused by a severe allergic reaction (anaphylaxis) or choking (obstruction from a foreign body). Stridor suggests serious airway narrowing. BREATHING Hypotension with absent breath sounds on one side – especially with distended (swollen or enlarged) neck veins or tracheal shift – may indicate tension pneumothorax. Wheezing may indicate asthma or severe allergic reaction. CIRCULATION Shock, heart attack, heart failure and severe infection can all present with poor perfusion and difficulty in breathing. Poor perfusion sends signals to the brain to increase the rate of breathing, which can feel and look like difficulty in breathing. Check for signs of shock by checking capillary refill, heart rate and blood pressure. Swelling in the legs or crackles in the lungs can indicate heart failure and fluid overload as a cause of difficulty in breathing. A B C TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 79 DISABILITY Patients with decreased level of consciousness may not be able to protect their airways. Drugs, infection or injury can directly affect the part of the brain that controls breathing. Assess for paralyzing conditions affecting the breathing muscles. Check level of consciousness with the AVPU scale: A: Alert V: Responds to Voice P: Responds to Pain U: Unresponsive EXPOSURE Expose the patient fully to assess for abnormal chest wall movement and any signs of trauma. Penetrating trauma to the back, chest, underarms or abdomen may cause lung injury and is often missed. ASK: KEY HISTORY FINDINGS FOR PATIENTS WITH DIFFICULTY IN BREATHING Use the SAMPLE approach to obtain a history from the patient and/or family. If the history identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it. S: SIGNS AND SYMPTOMS When did the symptoms start and was onset sudden? Do they come and go and how long do they last? Have they changed over time and has there been a similar episode previously? Sudden difficulty in breathing can suggest airway obstruction such as by a foreign body; swelling of the airway from allergic reaction or infection; trauma to the airway, lungs, heart or chest wall; or inhalation of hot gases or smoke. Acute heart problems such as heart attack, abnormal heart rhythm or valve problems can cause rapid onset DIB. A history of rapid or deep breathing may suggest poisoning, high acid levels in the blood (infection or diabetic ketoacidosis) or anxiety. DIB that starts slowly is more common with infection and chronic conditions such as a gradual build-up of fluid around the lungs (as occurs in TB and heart failure), fluid around the heart (from TB or kidney disease), lung cancer or diseases affecting the function of the chest wall. Recurrent difficulty in breathing associated with wheeze may suggest asthma or COPD. Did anything trigger the difficulty in breathing and what makes it better or worse? A history of allergies may suggest that the airway is blocked by swelling due to a severe allergic reaction. Inhaling smoke or hot gas (such as in fires) or some chemicals may cause E D Module 3: Approach to difficulty in breathing 80 DIB through upper airway injury and swelling. Exposure to some chemicals (such as certain pesticides) can cause fluid to build up in the airways and can cause weakness in the muscles involved in breathing. Difficulty in breathing that gets worse when the person lies flat can be due to fluid in the lungs. Is there any tongue or lip swelling, or voice changes? Swelling to the mouth, lips, tongue or upper throat, or a change in voice can suggest a severe allergic reaction or other inflammation of the airway. Are there abnormal sounds with breathing? High-pitched or ‘squeaking’ sounds when breathing IN may be stridor, which is caused by narrowing of the upper airway and may suggest severe allergic reaction or other airway obstruction. Wheezing – a high-pitched sound with breathing OUT – is caused by narrowing or spasm of the lower airways in the lungs and can suggest asthma, COPD, heart failure or allergic reactions. Gurgling sounds with breathing suggest that there is mucus, blood or other fluid in the airway. Is there pain associated with the difficulty in breathing? Difficulty in breathing with chest pain can suggest heart attack, pneumothorax, pneumonia or trauma to the lungs, ribs or ribcage muscles. In particular, pain that is worse with deep breaths (pleuritic pain) may suggest infection or blood clot in the lung (pulmonary embolism). Is there fever or cough? Fever suggests infection. Lung infection and any severe infection may cause fluid in the lungs. A cough may indicate fluid in the lungs from pneumonia or oedema. Cough and wheezing may suggest asthma or COPD. Is there foot or leg swelling or recent pregnancy? Difficulty in breathing with oedema of both feet or legs can suggest heart failure with fluid back-up to the lungs and body. Difficulty in breathing with swelling and pain in one leg may suggest a clot in a leg vein that has travelled to the lung (pulmonary embolism). Pregnancy is a risk factor for both pulmonary embolism and heart failure. A: ALLERGIES Any allergies to medications or other substances? Any recent insect bites or stings? Severe allergic reactions may cause difficulty in breathing due to airway swelling. People can have severe allergic reactions to almost anything, but food, plants, medications and insect bites/stings are the most common. M: MEDICATIONS Currently taking any medications? Ask about new medications and changes in doses. New medications can cause allergies with associated difficulty in breathing. Accidental overdose of some medications can stop or slow breathing. TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 81 P: PAST MEDICAL HISTORY Is there a history of asthma or chronic obstructive pulmonary disease (COPD)? Asthma and COPD often cause episodes of difficulty in breathing. A history of prior hospitalization or intubation for these conditions suggests a high-risk patient. Is there a history of heart disease or kidney disease? People with a history of heart or kidney failure may have fluid in the lungs. Heart attack may present with difficulty in breathing. Is there a history of tuberculosis (TB) or cancer? Conditions such as tuberculosis and cancer can cause build up of fluid in the sac around the heart (pericardial effusion) or build-up of fluid outside the lung (pleural effusion), both of which can cause a feeling of difficulty in breathing. Is there a history of diabetes? Diabetes can cause diabetic crisis (diabetic ketoacidosis or DKA). DKA causes fast breathing that may be reported as difficulty in breathing. Is there a history of smoking? Smoking increases the risk of asthma, COPD, lung cancer and heart attack. Is there a history of HIV? HIV infection increases the risk of other infections. L: LAST ORAL INTAKE When did the person last eat or drink? A full stomach puts the patient at risk of vomiting and possible choking. E: EVENTS SURROUNDING ILLNESS What was the person doing when the difficulty in breathing started? Always consider choking if DIB started while eating or drinking. DIB with exercise might be due to heart attack, especially when there is also chest pain. Was the patient found in or near water? Always consider drowning (inhalation of water) in a person found in or near water. Even a small amount of inhaled water can cause serious lung damage, which can worsen over time. Has there been exposure to pesticides or other chemicals? Inhaled chemicals can cause DIB by irritating the airways and lungs. Some pesticides used in farming can be absorbed through the skin, causing fluid buildup in the airways and lungs. Exposure to gases from a fire is often associated with chemical inhalation. Has there been any recent trauma? DIB with trauma is concerning for rib fractures, pneumothorax, haemothorax, and heart or lung bruising. Module 3: Approach to difficulty in breathing 82 Workbook question 1: Difficulty in breathing Using the workbook section above, list five questions about past medical history you would ask when taking a SAMPLE history. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ CHECK: SECONDARY EXAMINATION FINDINGS FOR PATIENTS WITH DIFFICULTY IN BREATHING DIB may present with changes in respiratory rate, respiratory effort, or low oxygen saturation. Always assess ABCDE first. The initial ABCDE approach identifies and manages life-threatening conditions. The secondary exam looks for changes in the patient’s condition or less obvious causes which may have been missed during ABCDE. If the secondary examination identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it. LOOK Look for signs of respiratory failure: Accessory muscle use and increased work of breathing. Difficulty speaking in full sentences. Inability to lie down or lean back. Diaphoresis (excessive sweating) and mottled skin. Confusion, irritability, agitation. Poor chest wall movement. Cyanosis (blue skin colour, especially lips and fingertips). Look at the pupils for size and reactivity: Very small pupils suggest possible opioid overdose or exposure to chemicals (including pesticides). Unequal or abnormally shaped pupils suggest head injury which can cause abnormal breathing. TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 83 Look at the face, nose and mouth: Cyanosis around the lips or nose suggests low oxygen levels in the blood. Pale inner surface of lower eyelids suggests severe anaemia. Swelling of the lips, tongue and mouth suggests an allergic reaction. Soot around the mouth or nose, burned facial hair or facial burns suggest smoke inhalation and airway burns. Bleeding or swelling of the airway may be due to trauma. Look at the neck and chest: Distended neck veins can be due to a back-up of blood due to heart failure, tension pneumothorax or pericardial tamponade. Excessive muscle use in the neck and chest (between the ribs) suggests significant respiratory difficulty. If the trachea is shifted to one side, think about tension pneumothorax or tumour. Swelling or redness of the neck suggests infection or trauma. Examine the entire neck and chest carefully for bruising, wounds or other signs of trauma. Look at the rate and pattern of breathing: People with wheeze may take longer to breathe out because of narrowing of the lower airways in the lung. Fast breathing can be due to dehydration, severe infection, chemical imbalance in the blood, poisoning or anxiety. Slow and shallow breathing might be due to opioid overdose. Look for very small pupils and altered mental status. Chest wall injury is often associated with pain that limits the ability to take deep breaths. A flail chest occurs when multiple rib fractures cause a segment of the rib cage to be separated from the rest of the chest wall. The segment may appear to be moving in the opposite direction from the rest of chest wall during breathing. Look at the legs: Swelling to the both lower legs suggests heart failure as a cause of difficulty in breathing. Swelling to one leg may be due to a blood clot in the leg. If there is also difficulty in breathing, this may mean that part of the clot has traveled to the lung. Look at the skin: Bites can be a source of allergic reaction. Rashes, such as hives, can indicate allergic reaction. When associated with difficulty in breathing, rashes can indicate widespread (systemic) infection. Pallor (pale skin) can indicate anaemia as a cause of DIB. Circumferential burns (a burn that goes entirely around a body part) to the chest can restrict chest wall expansion and limit breathing. Module 3: Approach to difficulty in breathing 84 LISTEN Listen to the breath sounds: Stridor suggests partial upper airway obstruction, which may be due to a foreign object, mass, or swelling from trauma or infection. Decreased or absent breath sounds suggest abnormal air movement in the lungs. This can be due to air or fluid around the lung (pneumothorax, haemothorax, effusion), narrowing or foreign body blockage of the airways, and infection or tumour in or around the lung. Wheezing, in particular, suggests lower airway obstruction such as from asthma, COPD, allergic reaction, foreign body or tumour. Crackles or crepitations suggest fluid in the airspaces of the lung. Listen to the heart sounds: Abnormal heart rhythms can cause the heart to pump blood abnormally, leading to poor perfusion and a feeling of difficulty in breathing. Difficulty in breathing accompanied by heart murmurs can suggest damage to the heart valves. Muffled or distant heart sounds accompanying low blood pressure, fast heart rate and distended neck veins suggest pericardial tamponade. FEEL Feel the ribs and chest wall: Deformities and abnormal movement when pressing on the chest wall suggest rib fracture. Crepitus (crackling or popping when pressing on the skin of the chest wall) may suggest underlying fracture or air under the skin (associated with pneumothorax). Unequal expansion of the chest wall suggests pneumothorax, haemothorax, or flail chest. Percuss the chest wall [See SKILLS]: Hollow sounds (hyperresonance) on one side when tapping the chest wall suggest pneumothorax. Dull sounds when tapping the chest wall may indicate fluid or blood either inside the airspaces of the lungs or between the lungs and the chest wall. TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 85 Workbook question 2: Difficulty in breathing Using the workbook section above, list three signs you should LOOK for in a patient with difficulty in breathing. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ List four things you should LISTEN for in a patient with difficulty in breathing. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ List three things you should FEEL the chest wall for in a patient with difficulty in breathing. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ POSSIBLE CAUSES OF DIFFICULTY IN BREATHING The causes of difficulty in breathing can be organized by body area: airway, lung, heart, or whole body. Key airway causes CONDITION SIGNS AND SYMPTOMS Foreign body in the airway • Acute difficulty in breathing • Visible secretions, vomit or foreign body in the airway • Abnormal sounds from the airway (such as stridor, snoring, gurgling) • Coughing • Drooling Severe allergic reaction • Swelling of lips, tongue and mouth • Stridor and/or wheezing • Rash or hives • May have tachycardia and hypotension • Exposure to known allergen Module 3: Approach to difficulty in breathing 86 CONDITION SIGNS AND SYMPTOMS Airway swelling (due to inflammation/ infection) • Stridor • Hoarse voice • Drooling or difficulty swallowing (indicates severe swelling) • Unable to lie down • May have fever (with infection) Airway burns • History of exposure to chemical or fire • Burns to head and neck (or singed facial hair or soot around nose or mouth) • Stridor • Change in voice Key lung causes CONDITION SIGNS AND SYMPTOMS Pneumonia • Fever and cough • Gradually more laboured breathing • Pain worse with breathing (pleuritic) • Abnormal lung examination (crackles) Asthma/COPD • Wheezing • Cough • Accessory muscle use • Tripod position (see figure) • May have history of smoking or allergies Pneumothorax • Decreased breath sounds on one side • Sudden onset • Hollow sounds (hyperresonance) to percussion on affected side [See SKILLS] • May have pain that worsens with breathing • May have history of trauma or evidence of rib fracture • Hypotension with distended neck veins and decreased breath sounds on one side indicate tension pneumothorax. Haemothorax • Decreased breath sounds on affected side • Dull sounds with percussion [See SKILLS] • May have a history of trauma, cancer or tuberculosis Shock (if large haemothorax) Pleural effusion • Decreased breath sounds on one or both sides • Dull sounds with percussion [See SKILLS] • May have history of cancer, tuberculosis, heart disease or kidney disease • Acute or chronic difficulty in breathing Acute chest syndrome in a patient with sickle dell disease • History of sickle cell disease • Chest pain • Fever • Hypoxia TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 87 Tripod position page 32 Key heart causes CONDITION SIGNS AND SYMPTOMS Heart attack • Pressure, tightness or crushing feeling in the chest • Diaphoresis and mottled skin • Nausea or vomiting • Signs of heart failure • History of smoking, heart disease, hypertension, diabetes, high cholesterol, family history of heart problems Heart failure • Worse with exertion • Worse when lying flat • Swelling to both legs • Distended neck veins • Crackles may be heard in the lungs • May have chest pain Pericardial tamponade • Signs of poor perfusion (tachycardia, tachypnoea, hypotension, pale skin, cold extremities, capillary refill greater than 3 seconds) • Distended neck veins • Muffled heart sounds • May have dizziness, confusion, altered mental status • History of tuberculosis, trauma, malignancy, kidney failure Tripod position Module 3: Approach to difficulty in breathing 88 Key systemic causes CONDITION SIGNS AND SYMPTOMS Anaemia • Pale skin and inner lower eyelids • Tachycardia • Tachypnoea • History of haemorrhage, malnourishment, cancer, pregnancy, malaria, sickle cell disease, renal failure Opioid overdose • Clinical or recreational opioid use • Altered mental status • Very small pupils • Slow, shallow breathing Diabetic ketoacidosis • May have known history of diabetes • Deep or rapid breathing • Frequent urination • Sweet smelling breath • High glucose in blood or urine • Dehydrated Workbook question 3: Difficulty in breathing Using the workbook section above, list the possible cause of difficulty in breathing next to the history and physical findings below. HISTORY AND PHYSICAL FINDINGS LIKELY CAUSE A 20-year-old man presents with difficulty in breathing, wheezing and: • swelling of lips, tongue and mouth • rash or hives (patches of pale or red, itchy, warm, swollen skin) • tachycardia and hypotension • history of allergies • exposure to known allergen A 50-year-old woman presents with difficulty in breathing, signs of poor perfusion (tachycardia, tachypnoea, hypotension, pale skin, cold extremities, capillary refill >3 seconds) and: • distended neck veins • muffled heart sounds • history of tuberculosis TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 89 DO: MANAGEMENT FIRST PERFORM ABCDE ASSESSMENT AND INTERVENE FOR LIFE-THREATENING CONDITIONS. Assess and manage airway and provide bag-mask-ventilation (BVM) for any patient who is not breathing or not breathing adequately (too slow for age or too shallow); any unconscious patient with abnormal (slow, shallow, gasping or noisy) breathing; or any patient with a pulse who is not breathing. For patients without a pulse, follow relevant CPR protocols. CONDITION MANAGEMENT CONSIDERATIONS Airway inflammation or burns Keep patients calm. Give oxygen if you can do this without upsetting the patient. [See SKILLS] If the patient is fully alert and no spinal injury suspected, the seated position may be more comfortable. Patients with airway burns may require early intubation as the airway can swell and block quickly; delays may make intubation more difficult. A person with airway inflammation or burns requires urgent handover/ transfer. Choking Use age-appropriate chest thrusts/abdominal thrusts/back blows. [See SKILLS] Allergic reaction Remove the allergen, if possible. For severe allergic reaction with difficulty breathing give intramuscular adrenaline as soon as possible. Give oxygen for severe cases. [See SKILLS] Asthma/COPD Administer salbutamol as soon as possible. Give oxygen if indicated. [See SKILLS] Fever Give antibiotics as soon as possible if infection might be the cause of difficulty in breathing. If the patient has signs of poor perfusion, give IV fluids with caution to avoid fluid overload. [See SKILLS] Heart attack Give aspirin. While oxygen is no longer recommended in all patients with heart attack, it should initially be given to patients with shock or difficulty in breathing. [See SKILLS] For those patients who already have nitroglycerin, you can assist them in taking it if perfusion is adequate. Chronic, severe anaemia Give IV fluids more slowly and check the lungs for crackles (fluid overload) frequently. [See SKILLS] These patients may need handover/transfer for blood transfusion. Diabetic ketoacidosis Give IV fluids. [See SKILLS] A person with diabetic ketoacidosis is extremely ill and requires urgent transfer to an advanced provider. Opioid overdose Support breathing with a bag-valve-mask as needed. Give naloxone. [See SKILLS] Pleural effusion or haemothorax Give oxygen. [See SKILLS] Arrange for handover/transfer immediately. Many of these patients will need a chest tube or other drainage. Trauma All trauma patients with difficulty in breathing should be given oxygen. IV fluid should be given to help fill the heart if either pericardial tamponade or tension pneumothorax is suspected. Needle decompression should be performed if tension pneumothorax is suspected. Treat sucking chest wounds with a 3-sided dressing. [See SKILLS] The patient will need urgent handover/transfer for a chest tube if needle decompression is performed or a 3-sided dressing is applied. Acute chest syndrome Give oxygen, IV fluids, antibiotics. May need transfer for advanced management. Module 3: Approach to difficulty in breathing 90 Workbook question 4: Difficulty in breathing Using the workbook section above, list what you would DO to manage a person who presents with: DIB, coughing. You suspect choking. 1. ���������������������������������������� 2. ���������������������������������������� DIB, high fever, cough. You suspect serious infection. 1. ���������������������������������������� 2. ���������������������������������������� DIB, hoarse voice and stridor on breathing in. You to suspect airway inflammation. 1. ���������������������������������������� 2. ���������������������������������������� 3. ���������������������������������������� SPECIAL CONSIDERATIONS IN CHILDREN The following are danger signs in children: • Signs of airway obstruction (unable to swallow saliva/drooling or stridor). • Increased breathing effort (fast breathing, nasal flaring, grunting, chest indrawing or retractions). • Cyanosis (blue colour of the skin, especially at the lips and fingertips). • Altered mental status (lethargy or unusual sleepiness, agitation). • Poor feeding or drinking. • Vomiting everything. • Seizures/convulsions. • Low temperature (hypothermia). REMEMBER... • Wheezing in children can be caused by viral infection, asthma or an inhaled object blocking the airway. • Stridor in children can be caused by an object stuck in the upper airway OR airway swelling. • Children may present with rapid breathing as the only sign of pneumonia. • Rapid breathing can also indicate diabetic crisis (DKA), which may be the first sign of diabetes in a child. TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 91 Workbook question 5: difficulty in breathing Using the workbook section above, list the paediatric danger signs. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ 6. ______________________________________________________________________ 7. ______________________________________________________________________ 8. ______________________________________________________________________ DISPOSITION CONSIDERATIONS Keep in mind that the effects of inhaled medications such as salbutamol last for only approximately 3 hours. Patients need to be monitored closely. If a patient with a severe allergic reaction is given adrenaline, the reaction can return when the adrenaline wears off. Patients need to be monitored closely. Naloxone only lasts about 1 hour. Most opioid medications last longer than this, so patients may need repeat naloxone doses. Following immersion in water (drowning), a person may develop late signs of breathing problems after several hours and should be observed closely. Never leave patients who might need definitive airway placement unmonitored during handover/transfer. Ensure that a new provider is monitoring the patient before leaving. Make transfer arrangements as early as possible for any patient who may require assisted ventilation. Module 3: Approach to difficulty in breathing 92 FACILITATOR-LED CASE SCENARIOS These case scenarios will be presented in small groups. One participant will be identified as the lead and will be assessed while the rest of the group writes the responses in the workbook. To complete a case scenario, the group must identify the critical findings and management needed and formulate a one-line summary for handover, which includes assessment findings and interventions. You should use the Quick Cards for these scenarios while being assessed. CASE #1: ADULT WITH DIFFICULTY IN BREATHING A 22-year-old man arrives by taxi. He was robbed on the street, and was stabbed in the left chest with a knife. He is now having severe difficulty in breathing. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Cards for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate one sentence to summarize this patient for handover. TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 93 CASE #2: PAEDIATRIC PATIENT WITH DIFFICULTY IN BREATHING A mother brings in her 6-year-old son for difficulty in breathing. The mother states that her son has been having difficulty breathing for the past 3 days. She says he makes funny noises when he breathes. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate one sentence to summarize this patient for handover. Module 3: Approach to difficulty in breathing 94 MULTIPLE CHOICE QUESTIONS Answer the questions below. Questions and answers will be discussed in the session 1. You are evaluating a 34-year-old female complaining of difficulty in breathing, coughing, and fever for 3 days. Which of the following actions should you do first? A. Check blood pressure B. Administer antibiotics C. Start an IV D. Check the lung sounds 2. A 67-year-old man with a history of a heart attack is complaining of difficulty in breathing that is worse whenever he lies flat. His legs are both swollen, which has become worse in the past 2 weeks. What is the most likely cause of his difficulty in breathing? A. Heart failure B. Asthma C. Pneumothorax D. Pneumonia 3. There was a fire in a nearby house and a patient is brought to you with burned nasal hairs and shortness of breath. What should you do first? A. Give oxygen B. Give intramuscular adrenaline C. Start an IV line D. Perform needle decompression 4. A 30-year-old woman was stung by a bee and now has difficulty in breathing, facial swelling, and a rash. She has a history of severe allergic reactions to bee stings. What medication should you give her? A. Naloxone B. Benzodiazepine C. Adrenaline D. Aspirin 5. You are assessing a 10-year-old boy for difficulty in breathing. You notice that the skin on his fingertips and around his mouth has a blue color. What is this finding called? A. Retractions B. Nasal flaring C. Crepitus D. Cyanosis BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 95 Module 4: Approach to shock Objectives On completing this module you should be able to: 1. recognize signs of shock/poor perfusion; 2. perform critical actions for patients with shock; 3. assess fluid status; 4. select appropriate fluid administration based on patient age, weight and condition; 5. recognize malnourishment, anaemia and burns and adjust fluid resuscitation. Essential skills Oxygen administration IV line placement Fluid status assessment IV fluid resuscitation Burn management Needle decompression Three-sided dressing Direct pressure for bleeding control Uterine massage for bleeding control Trauma secondary survey KEY TERMS Write the definition using the Glossary at the back of the workbook. Bolus: Bradycardia: Capillary refill: Cholera: Module 4: Approach to shock 96 Diaphoresis: Dehydration: Diabetic ketoacidosis (DKA): Dilation (of blood vessels): Disposition: Ectopic pregnancy: Fluid status: Fontanelle: Gastroenteritis: Large-bore IV: Lethargy: Oral rehydration solution (ORS): Perfusion: Pericardial tamponade: Resuscitation: Shock: Skin pinch testing: BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 97 Overview Poor perfusion is when the body is not able to get enough oxygen-carrying blood to vital organs. When organ function is affected, this is called shock and can lead rapidly to death. Infants, children and older adults are more likely to be affected by shock. Causes of poor perfusion which may lead to shock include: loss of blood (haemorrhage); loss of fluid due to diarrhoea, vomiting, extensive burns or excess urination (such as caused by high blood sugar); poor fluid intake. Small children, the elderly and the very ill may be unable to drink enough fluids without assistance and are at risk of dehydration; abnormal relaxation and enlargement (dilation) of the blood vessels (with the same amount of blood inside the vessel) can lower blood pressure. This can occur in severe infection, spinal cord injury and severe allergic reaction; poor filling of the heart can result from blood or other fluid in the sac around the heart (pericardial tamponade), or increased pressure in the chest that can shift and block the vessels returning blood to the heart (tension pneumothorax); failure of the heart muscle to pump effectively can be due to a heart attack (vessel blockage that causes acute heart muscle damage); inflammation or other disease of the heart muscle itself; an abnormal rhythm or valve problems. (Shock due to failure of the heart to pump effectively is sometimes called cardiogenic shock.) The goal of INITIAL ASSESSMENT is to identify shock and any reversible causes of shock. The goal of ACUTE MANAGEMENT is to restore perfusion (oxygen delivery to the organs) and address ongoing fluid loss where possible. This module will guide you through: ABCDE key elements ASK: key history findings (SAMPLE history) CHECK: secondary examination findings Possible causes DO: management Special considerations in children Disposition considerations REMEMBER... ALWAYS START WITH THE ABCDE APPROACH, intervening as needed. Then do a SAMPLE history. Then do a secondary examination. Module 4: Approach to shock 98 ABCDE: KEY ELEMENTS IN SHOCK For the person in shock, the following are key elements that should be considered in the ABCDE approach. AIRWAY Face/mouth swelling or voice changes can indicate an allergic reaction. A severe allergic reaction can cause shock. BREATHING Wheezing can indicate a severe allergic reaction which can cause shock. Shock, difficulty in breathing and absent breath sounds on one side can indicate a tension pneumothorax. Poor perfusion itself can sometimes cause rapid breathing when vital organs do not receive enough oxygen. Severe heart failure can cause poor perfusion with difficulty in breathing when fluid backs up into the lungs. Any infection severe enough to cause shock may be associated with lung inflammation that causes difficulty in breathing. CIRCULATION Shock can be caused by many types of bleeding (from the stomach or intestines, pregnancy-related, and internal and external haemorrhage from trauma). Shock can also result from the fluid loss associated with diarrhoea, vomiting, extensive burns, or excess urination (such as caused by high blood sugar). DISABILITY Confusion in a person with poor perfusion suggests severe shock. Paralysis may indicate a spinal cord injury causing shock. EXPOSURE Look for signs of bleeding, trauma, and excessive sweating (diaphoresis). Hives can indicate allergic reaction, and other rashes can indicate systemic infection. ASK: KEY HISTORY FINDINGS IN SHOCK Use the SAMPLE approach to obtain a history from the patient and/or family. If the history identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it. A B C D E BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 99 S: SIGNS AND SYMPTOMS Has there been vomiting and/or diarrhoea? For how long? Fluid losses through vomiting and diarrhoea can be severe and can lead to shock. The amount of vomiting or diarrhoea can help give a rough estimate of the risk for shock, so always ask about frequency of episodes. Has the person had blood in stool or vomit? Bleeding in the stomach and/or intestines can be severe before it is recognized. A person can lose a significant portion of his or her blood volume in the intestines. Blood may appear black in both vomit and stools. Has there been any vaginal bleeding? Vaginal bleeding may be related to pregnancy in women of childbearing years. Always ask about pregnancy status, last menstrual period, any missed periods, or known recent pregnancy. Blood loss from normal delivery or miscarriage can cause shock. A pregnancy developing outside the uterus (ectopic pregnancy) can also be life-threatening if it ruptures. Ectopic pregnancy rupture can occur before a woman even knows she is pregnant. Other causes of vaginal bleeding are masses in the cervix or uterus. Has the person had any chest pain? Chest pain may suggest the person has had a heart attack. The muscle damage to the heart from a heart attack can reduce its ability to pump blood around the body, which can cause shock. Has there been fever? Fever may suggest infection as the cause of shock. Severe infection causes both dilation of the blood vessels (which lowers blood pressure) and fluid leakage from the blood vessels (with fluid loss into the tissues). Has there been any exposure to toxins, medications, insect stings or other substances? Severe allergic reactions can lead to shock. Additionally, many medications, including blood pressure and seizure/convulsion medications, can cause shock. Has there been altered mental status or unusual sleepiness? The brain is one of the last organs to be affected by poor perfusion, so altered mental status may be a sign of severe shock. A: ALLERGIES Does the person have any known allergies? Allergic reactions can lead to shock by causing abnormal relaxation of the blood vessels. Module 4: Approach to shock 100 M: MEDICATIONS Currently taking any medications? Obtain a full medication list from the person or the family. Knowing the patient’s medication list can help understand why the patient is in shock (such as heart medications). Overdose of blood pressure or seizure/convulsion medications can cause shock, and it may be more difficult to treat shock from any cause in patients taking these medications. Medications that thin the blood can worsen bleeding. Always ask about new medications in particular and recent dose changes to evaluate for allergic reaction or unexpected side effects. P: PAST MEDICAL HISTORY History of pregnancy or recent miscarriage or delivery? Blood loss following delivery can be severe if the uterus does not contract well. Hidden blood loss leading to shock can occur with ruptured ectopic pregnancy, even in women who do not know they are pregnant. Any woman of childbearing age with shock should be evaluated for pregnancy. History of recent surgery or induced abortion? Internal bleeding or infection after surgery can lead to shock. History of heart disease (heart attack or heart valve problems)? Patients with heart disease are at risk for worsening heart function that may lead to shock or worsen shock from other causes. Is there a history of HIV? HIV increases the risk of infection. L: LAST ORAL INTAKE When did the person last eat or drink? A person who is not eating or drinking well can develop severe dehydration, leading to shock. E: EVENTS SURROUNDING ILLNESS Has there been any recent trauma? Trauma can cause hidden internal bleeding, tension pneumothorax, and bruising or bleeding around the heart, all of which may reduce blood flow and cause shock. In addition, trauma to the neck or back causing spinal cord injury can interfere with the blood vessels’ ability to maintain blood pressure. Has there been any recent illness? Any infection can cause a blood infection that can spread throughout the body and lead to shock. BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 101 Workbook question 1: Shock Using the workbook section above, list six questions about signs and symptoms you would ask when taking a SAMPLE history. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ 6. ______________________________________________________________________ CHECK: SECONDARY EXAMINATION FINDINGS IN SHOCK A person with shock will have signs of poor perfusion, which may include a fast heart rate, a low systolic blood pressure, fast breathing, pale and cool skin, slow capillary refill, dizziness, confusion, altered mental status, decreased urine output or excessive sweating. REMEMBER: Perfusion can be limited even before blood pressure falls, especially in the young. Low blood pressure with poor perfusion is a very serious sign. Always assess ABCDE first. The initial ABCDE approach identifies and manages life-threatening conditions. The secondary exam looks for changes in the patient’s condition or less obvious causes that may have been missed during ABCDE. If the secondary examination identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it. REMEMBER: Children have different normal vital signs ranges, and children with shock may not have changes in vital signs until they are very ill. Always do a careful exam for any signs of shock. Check breath sounds and respiratory rate: – Abnormal or noisy breathing can indicate pneumonia as a source for system-wide infection causing shock. – High sugar levels can result in chemical imbalance (diabetic ketoacidosis) that the body tries to address by faster or deeper breathing. This condition may also result in sweet or ‘fruity’ smelling breath. Since elevated blood glucose levels cause increased urination, severe dehydration and shock can result. Check for bleeding: – All external bleeding should be controlled with direct pressure. [See SKILLS] Arterial bleeding may appear as pulsing or high pressure bleeding, and significant blood volume can be lost in minutes. Module 4: Approach to shock 102 – Vaginal bleeding may be an important source of blood loss from pregnancy-related bleeding (even in those who think they are not pregnant) or from masses in the cervix or uterus. Check fluid status: In dehydration states, the patient may feel thirsty or may have dry lips and mouth, abnormal skin pinch, lethargy, and delayed capillary refill. Patients with heart failure can be in shock with fluid overload, and may have lower body swelling (usually in both legs), crackles on lung examination, and distended neck veins. Check for pale conjunctiva (the inside of the lower eyelid): No matter the person’s skin color, the inside of the eyelid should appear pink and moist. If the inner portion of the eyelid (conjunctiva) is pale, it may indicate significant blood loss. You can compare the patient’s conjunctiva to another healthy person or look at your own in a mirror. Check mental status: Confusion in a patient with other signs of poor perfusion suggests severe shock. Check for fever: Fever in a patient with shock suggests severe infection. Check blood sugar: Low blood glucose can sometimes look like shock. If you cannot check blood glucose, but the person has altered mental status, a history of diabetes or another reason to have low sugar (for example, is taking quinine for malaria, is very ill, or is very malnourished), give glucose. [See SKILLS] Check for severe abdominal pain or a very firm abdomen: If the person has severe abdominal pain, this can be a sign of bleeding or infection in the abdomen. In a patient who might be pregnant, this can be a sign of an ectopic pregnancy. Check urine: Check the urine colour and volume. Small amounts of darker urine may indicate substantial dehydration. Check stool: Any significant diarrhoea can cause dehydration. A large amount of watery, “rice-water” stool suggests cholera, which can rapidly cause severe dehydration and shock. Black, dark, or reddish colored stool can suggest stomach or intestinal bleeding. BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 103 Check for malnourishment [see SKILLS]: If the person appears malnourished, fluid must be adjusted [see SKILLS]. Be sure to ask about recent changes in weight. Check for swelling, rash or excessive sweating: Swelling of mouth or body can indicate an allergic reaction. Rashes can indicate allergic reaction (hives) or systemic infection. Swelling of both legs can indicate heart failure. Sweating may occur with moderate to severe shock. Workbook question 2: Shock Using the workbook section above, list what you need to check for in a person with shock. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ 6. ______________________________________________________________________ 7. ______________________________________________________________________ 8. ______________________________________________________________________ 9. ______________________________________________________________________ 10. _____________________________________________________________________ Visible severe wasting in a child page 23 Visible severe wasting in a child Assessing for pitting edema in children with malnutrition page 22 Assessing for pitt ng edema in children with malnutri ion page 2 Asse ing for pitting ed ma in children with malnutrition page 22 Assessing for pitting edema in children with malnutrition Module 4: Approach to shock 104 POSSIBLE CAUSES OF SHOCK POOR PERFUSION DUE TO DILATED BLOOD VESSELS CONDITION SIGNS AND SYMPTOMS Severe infection • Fever • Tachycardia • Tachypnoea • May have hypotension • May or may not have obvious infectious source: visible skin infection, cough and crackles in one area of the lungs (often with tachypnoea), burning with urination, urine that is cloudy or foul smelling, or any focal pain in association with fever Spinal cord injury • History or signs of trauma • May have spinal pain/tenderness, vertebrae not in line, or crepitus (crunching) when you touch the spinal bones • Movement problems: paralysis, weakness, abnormal reflexes • Sensation problems: tingling (“pins and needles” sensation), loss of sensation • Unable to control urine and stools • Priapism • May have hypotension or bradycardia • Difficulty in breathing with an upper cervical spine injury Severe allergic reaction • Swelling of the mouth • Difficulty breathing with stridor and/or wheezing • Skin rash • Tachycardia • Hypotension POOR PERFUSION DUE TO FLUID LOSS CONDITION SIGNS AND SYMPTOMS Diabetic ketoacidosis (DKA) • May have known history of diabetes • Rapid or deep breathing • Frequent urination • Sweet-smelling breath • High glucose in blood or urine • Dehydration Severe dehydration • Abnormal skin pinch • Decreased fluid consumption or increased fluid loss (vomiting, diarrhoea, excessive urination) • Dry mucous membranes • Tachycardia Burn injury • Red, white or black areas of skin depending on depth of burn • May have blistering • May have signs of inhalational injury BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 105 POOR PERFUSION DUE TO BLOOD LOSS CONDITION SIGNS AND SYMPTOMS External bleeding • History of trauma • Visible bleeding • Use of blood-thinning medications Large bone fracture • History of trauma • Pain or abnormal movement of the pelvis, blood at opening of penis or rectum (pelvic fracture) • Deformity or crepitus of the femur, shortening of the leg with the injury (femur fracture) Abdominal bleeding • Bruising around the umbilicus or over the flanks can be a sign of internal bleeding • Abdominal pain • Very firm abdomen Bleeding in the stomach or intestines • Blood in vomit or stool • Black vomit or stool • History of alcohol use Haemothorax • Difficulty in breathing • Decreased breath sounds on affected side • Dull sounds with percussion on affected side • Shock (if large amount of blood) Ectopic pregnancy • History of pregnancy, missed menstrual cycle or any woman of childbearing age • Abdominal pain • Vaginal bleeding Postpartum haemorrhage • Recent delivery • Heavy vaginal bleeding: – Pad or cloth soaked in <5 minutes – Constant trickling blood – Bleeding >250 ml – Soft uterus/lower abdomen Module 4: Approach to shock 106 POOR PERFUSION DUE TO PROBLEMS WITH THE HEART CONDITION SIGNS AND SYMPTOMS Heart failure • Difficulty breathing with exertion or when lying flat • Swelling to both legs • Distended neck veins • Crackles may be heard in the lungs • May have chest pain Heart attack • Pressure, tightness, pain or crushing feeling in the chest • Diaphoresis and mottled skin • Difficulty in breathing • Nausea or vomiting • Pain moving to jaw or arms • Signs of heart failure • History of smoking, heart disease, hypertension, diabetes, high cholesterol, family history of heart problems Abnormal heart rhythm • Very fast or very slow pulse • Irregular pulse Heart valve problem • History of rheumatic fever or heart disease • Murmur Pericardial tamponade • Signs of poor perfusion (tachycardia, tachypnoea, hypotension, pale skin, cold extremities, capillary refill greater than 3 seconds) • Distended neck veins • Muffled heart sounds • May have dizziness, confusion, altered mental status • History of tuberculosis, trauma, cancer, kidney failure Tension pneumothorax • Hypotension WITH the following: – Difficulty breathing – Absent breath sounds on affected side – Hyperresonance with percussion on affected side – Distended neck veins – May have tracheal shift away from affected side REMEMBER... hypoglycaemia can look like shock. Signs and symptoms include: • Sweating (diaphoresis) • Seizure/convulsion • Blood glucose <3.5 mmol/L • Altered mental status (ranging from confusion to unconsciousness) • History of diabetes, malaria, or a severe illness, especially in children BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 107 Workbook Question 3: Shock Using the workbook section above, list the possible cause of shock next to the history and physical findings below. HISTORY AND PHYSICAL FINDINGS LIKELY CAUSE A 35-year-old woman presents with shock, fever and: • burning with urination • cloudy urine A 20-year-old woman presents with shock, abdominal pain and: • missed menstrual cycle • vaginal bleeding A 17-year-old man presents after a motor vehicle crash with shock, bruising to the pelvis and: • a femur fracture DO: MANAGEMENT FIRST PERFORM ABCDE ASSESSMENT AND INTERVENE FOR LIFE- THREATENING CONDITIONS. Start by giving IV fluid (normal saline or Ringer’s Lactate in adults and children with normal nutritional status). Then work to address underlying causes. Place IV access rapidly (two large-bore IVs) and start IV fluids. Place IV access rapidly (two large-bore IVs), start IV fluids and assess response. Repeat with additional boluses if needed. [See SKILLS] If you cannot place an IV, immediately call for a provider who can place a nasogastric tube (a tube that goes from the nose into the stomach) or intraosseous line (a needle that is placed directly into the bone). See if the patient can safely take oral fluids in the meantime. CAUTION! For severely malnourished or severely anaemic people, or anyone with signs of volume overload, do NOT follow the fluid protocol below. Use adjusted protocol. [See SKILLS] Module 4: Approach to shock 108 Uterine massage for postpartum hemorrhage page 17 If vaginal bleeding after delivery (postpartum haemorrhage) is suspected as a cause of shock: ALL patients need rapid handover/transfer to an advanced obstetric provider. While arranging for transport and during transport, it is important to try to stop the bleeding. Give BOTH intramuscular and IV oxytocin. This is a loading dose. After these doses, continue oxytocin IV until one hour after the bleeding stops. [See SKILLS] Bleeding frequently happens if the uterus is not fully contracted (does not feel hard on palpation). Perform uterine massage [See SKILLS] until the uterus is hard. You should use BOTH oxytocin and uterine massage to stop the bleeding. If the placenta delivers, collect it in a leak-proof container and keep with the patient to allow the advanced obstetric provider to examine it. Visually check externally for a perineal or vaginal tear. If found, apply direct pressure with sterile gauze and put legs together. Even if the bleeding stops, these patients still need rapid handover/transfer to an advanced obstetric provider (see figure). IV FLUID IMMEDIATELY AVAILABLE? IV FLUID AVAILABLE NEARBY? START ORS via NG NASOGASTRIC TUBE REASSESS IMMEDIATELY AFTER BOLUS DID PERFUSION IMPROVE? TRANSFER IMMEDIATELY CONTINUE ORS VIA NG YES YES YES YES No No No No DID PERFUSION IMPROVE? IV FLUIDS REASSESS IMMEDIATELY AFTER BOLUS CONTINUE E <30 MINUTES <30 MINUTES START IV FLUIDS RE-BOLUS GIVING FLUID IN SHOCK NO malnutrition, overload or severe anaemia Uterine massage for postpartum hemorrhage BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 109 REMEMBER... fluid only addresses the immediate problem of perfusion. Patients with shock need rapid handover/transfer to a unit capable of addressing the causes of shock and providing advanced management, including transfusion. REMEMBER... fluid status assessment is critical. Patients who have signs of poor perfusion but overall volume overload can be particularly difficult to manage. Patients with malnutrition, severe anaemia, and excess fluid in the lungs due to heart, liver, or kidney failure can present this way. These patients still need fluids, but the fluids must be given cautiously and, especially in malnourished children, according to a specific protocol. [See SKILLS] Postpartum Haemorrhage 1. Arrange immediate transfer to qualifi ed obstetric provider! 2. Attempt to control bleeding while arranging and during transfer. 3. Check: 4. Transfer immediately Heavy bleeding after delivery? Has the placenta delivered? Still bleeding? Is there a perineal or lower vaginal tear? Massage uterus until it is hard. Give oxytocin IM. Give IV uids and IV oxytocin. Empty bladder. Continue uterine massage. When uterus is hard, the placenta will likely deliver. Collect placenta and keep with patient. Continue oxytocin. Continue oxytocin for at least 1 hour after bleeding stops. Apply pressure with sterile gauze, put legs together. Continue to massage uterus until hard. Continue oxytocin. Continue IV uids with oxytocin. Insert second IV line. YES YES NO NO YES Module 4: Approach to shock 110 DO: MANAGEMENT OF SPECIFIC CONDITIONS • Always perform ABCDE first. Patients in shock need oxygen. • In all forms of shock, the primary management is administration of IV fluids appropriate for age and condition. • The specific conditions below require additional considerations. CONDITION MANAGEMENT CONSIDERATIONS Burns • Burns disrupt the skin barrier and can cause significant fluid losses that can lead to shock. These patients have different fluid replacement needs. [See SKILLS] Hyperglycaemia • If concern for diabetic ketoacidosis, treat with IV fluids. [See SKILLS] A person with diabetic ketoacidosis is extremely ill and requires rapid transfer to a unit where IV infusion and close monitoring are available. Fever • Give fluids and start antibiotics. [See SKILLS] If infectious diarrhoea (like cholera) is suspected, use gloves, aprons and relevant isolation precautions and report it to the local public health agency. If signs of poor perfusion do not improve with fluids, consider rapid handover/transfer. Spinal cause • Give IV fluids and refer for ongoing management at a unit that can provide spinal care. [See SKILLS] Stomach or intestinal bleeding • Start IV fluids and refer for blood transfusion. [See SKILLS] Ectopic pregnancy • Give IV fluids and refer for blood transfusion and obstetric care. [See SKILLS] Postpartum haemorrhage • Give oxytocin and IV fluids and plan for rapid transfer to facility with blood transfusion and obstetric care capabilities. • Give IV fluids and massage uterus until it is hard. [See SKILLS] • Give oxytocin. [See SKILLS] • If the placenta has delivered, collect it in a leak-proof container and keep with patient for inspection by advanced provider. • Check for perineal and vaginal tears and apply direct pressure. Tension pneumothorax • Perform needle decompression immediately to relieve the pressure, give oxygen and IV fluids. [See SKILLS] Any patient who has had a needle decompression will need rapid handover/ transfer to a unit that can place a chest tube. Pericardial tamponade • Give IV fluids to help fill the heart against the building pressure in the heart sac. [See SKILLS] Plan for rapid handover/transfer to a provider who can drain the pericardial fluid. BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 111 CONDITION MANAGEMENT CONSIDERATIONS Suspected heart attack • Give aspirin if indicated. Place an IV and give fluids, re-assessing the patient frequently. [See SKILLS] • While oxygen is no longer recommended in all patients with heart attack, it should initially be given in patients with shock or difficulty in breathing, even when heart attack is the suspected cause. • Plan for rapid handover/transfer to advanced provider. Heart failure • Give IV fluids more slowly, checking the lungs for crackles (fluid overload) frequently. Stop IV fluids if fluid overload develops (difficulty in breathing, crackles in the lungs, increased respiratory rate, increased heart rate). [See SKILLS] • Plan for rapid handover/transfer to an advanced provider. Severe allergic reaction • Give intramuscular adrenaline [See SKILLS]. These patients will also need IV access and fluids as their condition can rapidly worsen once the adrenaline wears off. You may give a second dose if the effects wear off. [See SKILLS] If the airway is swollen or there is difficulty in breathing, patients may need rapid transfer. Traumatic injury or rapid blood loss suspected • Stop the bleeding, give IV fluids, and conduct a thorough trauma assessment. [See SKILLS] Refer for blood transfusion and ongoing surgical management. Workbook question 4: Shock Using the workbook section above, list what you would do to manage this patient. A 6-year-old boy is brought in with fever. He is in shock and does not appear malnourished. Your facility has supplies to put in an IV. 1. ________________________________________ 2. ________________________________________ 3. ________________________________________ A young man is brought in after a motorcycle crash. He has a large cut to his arm that is bleeding and there is a large pool of blood under him. He is in shock when you examine him. 1. ________________________________________ 2. ________________________________________ 3. ________________________________________ A 30-year-old woman is brought in after accidentally eating prawns. She has a known shellfish allergy, her body is covered in a red, itchy rash and she is in shock. 1. ________________________________________ 2. ________________________________________ 3. ________________________________________ Module 4: Approach to shock 112 SPECIAL CONSIDERATIONS IN CHILDREN Shock can occur quite rapidly in children and is life-threatening. Children have a relatively larger surface area (compared to their body volume) and are thus likely to become dehydrated more rapidly. Infants and young children are particularly at risk as they are unable to say when they are thirsty and cannot drink more on their own. Assessing shock in children: The clinical definition of shock in children varies. The 2016 WHO guidelines for the care of critically ill children use the presence of three clinical features: cold extremities, capillary refill greater than 3 seconds, and weak and fast pulse. There are also other important signs of poor perfusion, including low blood pressure, fast breathing, altered mental status, and decreased urination (always ask parents how much urine the child is passing). [See SKILLS] Signs of dehydration in children • Very dry mouth and lips • Lethargy (excessive drowsiness and slowness to respond), child not interactive • Sunken eyes • Small amounts of dark urine (ask about number of nappies for infants) • Sunken fontanelles in infants under 1 year • Delayed capillary refill (normal capillary refill is less than 3 seconds) • Abnormal skin pinch [See SKILLS] • Pallor (anaemia makes dehydration even more difficult to treat [See SKILLS]) Abnormal skin pinch in a child page 34 Abnormal skin pinch in a child Common causes of shock and dehydration in children include: • Vomiting and diarrhoea: Gastroenteritis causes sudden onset of vomiting and diarrhoea with some abdominal pain and fever. Large amount of watery diarrhoea may suggest cholera, and needs to be reported to public health authorities. • Vomiting without diarrhoea: Vomiting without diarrhoea or fever may suggest raised pressure on the brain (trauma, tumour, brain swelling), or intestinal blockage. It is important to examine the child for signs of trauma. Vomiting associated with fever may suggest infection. • Overwhelming infection: Fever can cause children to become dehydrated quickly. In addition, overwhelming infection can cause blood vessels to dilate, worsening shock. BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 113 Special management considerations: • Malnourishment: Malnourished children are at high risk for hypoglycaemia and will need sugar in addition to fluids. Give specialized fluids if available. [See SKILLS] Give less IV fluid more slowly, and check the lungs for crackles (fluid overload) every 5 minutes. Stop IV fluids if fluid overload develops (crackles in the lungs, increased respiratory rate, increased heart rate). Switch to oral fluids as soon as signs of poor perfusion improve. These patients need rapid handover/transfer over to an advanced provider at a centre with blood transfusion capabilities. Workbook question 5: Shock Using the workbook section above, list signs of severe dehydration in children. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ 6. ______________________________________________________________________ 7. ______________________________________________________________________ 8. ______________________________________________________________________ DISPOSITION CONSIDERATIONS People with shock can worsen and die quickly. They must be monitored very closely. Additionally, the same illnesses that cause shock interfere with the body’s ability to manage fluids, so these patients must be monitored very closely for signs of difficulty in breathing. Patients with shock may be confused and anxious. Ensure they are safe and contained during transfer. Patients with shock are often transferred for transfusion or general or obstetric surgery. Always communicate directly with the receiving facility to make sure that these resources are actually available at the time of transfer. Module 4: Approach to shock 114 FACILITATOR-LED CASE SCENARIOS These case scenarios will be presented in small groups. One participant will be identified as the lead and will be assessed while the rest of the group writes the responses in the workbook. To complete a case scenario, participants must identify the critical findings and management needed, and formulate a one-line summary for handover, including assessment findings and interventions. You should use the Quick Card for these scenarios while being assessed. CASE #1: ADULT SHOCK A 48-year-old male with a history of alcohol abuse is brought in by his wife to be evaluated for weakness. His wife states that he has been having very dark stools for the past 2 days and now cannot stand up. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 115 3. Formulate one sentence to summarize this patient for handover. CASE #2: PAEDIATRIC SHOCK The patient is a 4-year-old girl brought in by her mother. She has been having almost constant diarrhoea for the past 3 days and vomiting every time she tries to drink anything. The mother thinks she may have had a fever as well. She has no signs of malnutrition. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate one sentence to summarize this patient for handover. Module 4: Approach to shock 116 MULTIPLE CHOICE QUESTIONS Answer the questions below. Questions and answers will be discussed in the session. 1. A 7-year-old boy has had lethargy, vomiting and diarrhoea for the past 4 days. His vital signs are: blood pressure 80/40 mmHg, heart rate 140 beats per minute, respiratory rate 18 breaths per minute. The patient vomits when you try to give anything by mouth. What is your most immediate management? A. Start an IV line and give fluids B. Continue to attempt oral rehydration C. Place a nasogastric (NG) tube and hydrate through it D. Rapidly transfer to a referral hospital 2. You are taking care of a 28-year-old man who was shot in the abdomen. He is lethargic and the vital signs are as follows: blood pressure 80/40 mmHg, heart rate 130 beats per minute, respiratory rate 20 breaths per minute. There is heavy bleeding from the gunshot wound and the abdomen is rigid and tender. What is the first intervention you should give this patient? A. IV fluids B. Intraosseous line C. Surgery D. Adrenaline 3. A child that presents with sunken eyes, small amounts of dark urine, dry mucous membranes and abnormal skin pinch testing is most likely suffering from: A. Pneumonia B. Head injury C. Dehydration D. Hypoglycaemia 4. A 60-year-old man states he has been weak and dizzy for the past week. His vital signs are: blood pressure 90/50 mmHg, heart rate 125 beats per minute, respiratory rate 16 breaths per minute. His skin is cool and pale. He states that his stools have been black for the past 2 days. What is the most likely cause of his shock? A. Stomach bleeding B. Abdominal trauma C. Dehydration D. Severe infection BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 117 5. You are assessing a 23-year-old man who was stabbed in the chest. You expose the chest to find one stab wound in the right chest with minor bleeding. He is complaining of severe difficulty in breathing and there are no lung sounds on the right side. His neck veins are distended and his skin is cool and sweaty. His vital signs are: blood pressure 86/56 mmHg, heart rate 136 beats per minute, respiratory rate 28 breaths per minute. What is your next step? A. Chest tube placement B. Needle decompression C. Blood transfusion D. Start IV fluids 118 Notes ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS 119 PARTICIPANT WORKBOOK Module 5: Approach to altered mental status Objectives On completing this module you should be able to: 1. recognize key history findings suggestive of different causes of altered mental status; 2. recognize key physical findings suggestive of different causes of altered mental status; 3. list high-risk causes of altered mental status in adults and children; 4. perform critical actions for high-risk causes of altered mental status. Essential skills Glasgow Coma Scale AVPU assessment Recovery position Oxygen administration IV cannula insertion IV fluid resuscitation Snake-bite management Spinal immobilization KEY TERMS Write the definition using the Glossary at the back of the workbook. Altered mental status: Coma: Confusion: Convulsion: Cyanosis: Module 5: Approach to altered mental status 120 Delirium: Dementia: Diabetic ketoacidosis (DKA): Eclampsia: Envenomation: Human Immunodeficiency Virus (HIV): Hypoglycaemia: Hypoxia: Ingestion: Kangaroo care: Large-bore IV: Level of consciousness: Orientation: Psychosis: Rabies: Seizure: Stroke: SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 121 Overview Altered mental status (AMS) is a term used for a range of presentations, from sudden or gradual changes in behaviour to disorientation, confusion and coma. Changes in mental status and/or level of consciousness may be due to conditions that affect the brain (such as lack of oxygen or glucose; or shock causing lack of perfusion) or problems with the brain itself (such as infection, inflammation or injury). While chronic psychiatric problems and dementia can cause changes in mental status, altered mental status is often an indication of severe disease, and other life- threatening causes must always be considered. The presence of delirium – a rapidly changing state of confusion with agitation, loss of focus and inability to interact appropriately – always requires a full assessment. Always ask family/friends about baseline mental status when possible. The goal of INITIAL ASSESSMENT is to identify rapidly reversible causes of altered mental status, and to recognize dangerous conditions requiring transfer. The goal of ACUTE MANAGEMENT is to ensure that blood, oxygen and glucose reach the brain; and to protect the brain from additional injury. This module will guide you through: ABCDE key elements ASK: key history findings (SAMPLE history) CHECK: secondary exam findings Possible causes DO: Management Special considerations in children Disposition considerations REMEMBER... ALWAYS START WITH THE ABCDE APPROACH, intervening as needed. Then do a SAMPLE history. Then do a secondary exam. Module 5: Approach to altered mental status 122 ABCDE: KEY ELEMENTS FOR ALTERED MENTAL STATUS For the person with altered mental status, the following are key elements that should be considered in the ABCDE approach. AIRWAY People with altered mental status may not be able to protect their airways and may be at risk of choking on vomit. BREATHING Hypoxia (lack of oxygen) can be a cause of altered mental status. Search for any signs of difficulty breathing, or cyanosis (blue colouring of the skin). Abnormal breathing can reflect diabetic ketoacidosis or poisoning. CIRCULATION Lack of perfusion to the brain can cause altered mental status. Look for and manage signs of shock (low blood pressure, elevated heart rate, delayed capillary refill). DISABILITY Check AVPU or GCS (in trauma). Look for abnormal glucose (hypoglycaemia or hyperglycaemia can cause altered mental status). Very small pupils suggest opioid overdose or poisoning (consider pesticides). Very dilated pupils suggest stimulant drug use. Unequal pupils suggest an increased pressure on the brain. If the patient can follow commands, test for strength and sensation in face, arms and legs. Weakness or loss of sensation on one side suggests a mass, bleeding, or blocked blood vessels in the brain (stroke), though hypoglycemia can also present this way. Altered mental status with general muscle weakness may suggest salt (electrolyte) imbalance in the blood. Look for abnormal repetitive movements or shaking on one or both sides of the body (seizure/ convulsion) – this may be due to a tumour, bleeding, brain infection, hypoglycaemia, or salt (electrolyte) imbalance. EXPOSURE Remember that patients with altered mental status may not report their history accurately. Examine the entire body for infections, rashes, and any evidence of trauma, bites or stings. Needle marks on the arms may suggest drugs as a cause. ASK: KEY HISTORY FINDINGS FOR PATIENTS WITH ALTERED MENTAL STATUS Use the SAMPLE approach to obtain a history from the patient and/or family. It is important to obtain a history from bystanders, friends or family as it may be difficult to obtain accurate history from a confused patient. For example, a person with hypoglycaemia may be too confused to relate a history of diabetes. If the history identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it. A B C D E SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 123 S: SIGNS AND SYMPTOMS How does the current condition compare to baseline mental status? Always ask family/friends about baseline mental status when possible. Is there difficulty breathing? Altered mental status associated with difficulty in breathing may indicate lack of oxygen to the brain. Is there headache? Headache with altered mental status can indicate infection, tumour or bleeding. Is there vomiting/diarrhoea? Vomiting without diarrhoea can be a sign of increased pressure in the brain. Any source of dehydration, including vomiting and diarrhoea, may cause altered mental status from poor perfusion. Vomiting and diarrhoea can also cause hypoglycaemia leading to altered mental status. Has there been any dizziness or fainting? These may be signs of poor perfusion (lack of oxygenated blood) to the brain. When did the symptoms start? Do they come and go? How long do they last? Have they changed over time? Rapid onset of altered mental status may suggest infection, inflamation, bleeding or drugs/ toxic exposures. A more gradual onset (over weeks or months) may indicate a space- occupying lesion in the brain, such as a tumour or slow bleeding in the brain. Altered mental status that comes and goes with normal intervals between episodes may suggest other causes, such as seizures/convulsions or psychiatric disease. Has there been any recent fever? Any person with altered mental status and fever may have an infection. Brain infections often present with altered mental status and fever. In small children and the elderly, any serious infection, such as urine, lung, or blood infection can cause altered mental status. Also consider prolonged outdoor exposure, poisonings, medications and drugs as these may present with fever as well. Very high fever itself from any source may cause altered mental status. Is there any weakness, clumsiness or difficulty walking? Change in mental status with weakness or sensory loss in one area of the body, or problems with walking and balance, suggest that the altered mental status comes from a cause in the brain itself, such as a stroke or tumour. Is there neck pain or stiffness? Fluid that circulates around the brain also circulates around the spinal cord, meaning any bleeding, inflammation or infection in the brain (meningitis, encephalitis) can also cause neck pain and stiffness. Module 5: Approach to altered mental status 124 Is there a recent history of trauma or falls? Bleeding in or around the brain can cause altered mental status some days after an injury. Remember that chronic alcohol drinkers and the elderly are more prone to brain bleeding and may not remember falls. Always consider slow bleeding around the brain as a cause, even several days after a fall, and consider unwitnessed trauma in a patient who is found altered with no known cause. Has there been any recent depression or changes in behaviour? Drug and alcohol use or psychiatric problems can present as altered mental status. Always consider the possibility of a suicide attempt by poisoning. Does anyone else from the same family or location have symptoms? Gaseous poisoning, like carbon monoxide poisoning, can cause altered mental status in multiple people. Carbon monoxide poisoning is usually seen in cold climates when people use indoor heating. A: ALLERGIES Any allergies or recent exposure to a known allergen? Severe allergic reactions (anaphylaxis) may present with altered mental status due to low blood oxygen levels or poor blood circulation to the brain as a result of shock. M: MEDICATIONS Currently taking any medications? Many common medications can cause altered mental status as a side effect, including those for seizures/convulsions, pain and sleeping. Ask about new medications and changed doses, and consider medication interactions. A medication list should be collected and can provide clues for underlying disease (such as convulsions, liver disease, diabetes) if the person cannot communicate. Opioid medications (such as morphine, pethidine and heroin) can cause altered mental status. P: PAST MEDICAL HISTORY History of diabetes? In any patient with diabetes and altered mental status, suspect diabetic crisis, or low blood sugar caused by medications. Recent increase in urine output, increased thirst, and fast or deep breathing suggest diabetic crisis (diabetic ketoacidosis). History of heart disease? Heart attack can cause decreased blood flow and oxygen to the brain leading to confusion. Those with heart disease are also at an increased risk of stroke. SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 125 History of stroke? Altered mental status in a patient with a history of stroke may suggest an additional stroke or bleeding in the brain. Be sure to ask people who know the patient about his or her usual mental and neurological status. Symptoms of old stroke may return with severe illness of any kind. History of high blood pressure? High blood pressure increases the risk for bleeding in and around the brain (such as stroke). History of seizure/convulsion? Altered mental status in a patient with a history of seizures/convulsions may suggest that the patient is having or recovering from a convulsion. If there is a history of epilepsy (primary seizure/convulsion disorder), ask about regular medication and any recent dose changes or missed doses. With a witnessed convulsion, ask about fall or head trauma. Always ask if the convulsion was the same or different compared to prior. Remember that recovery of normal mental status after convulsions usually takes only a half hour to several hours at most, though patients may feel tired for longer. Longer altered mental status suggests another cause. History of HIV infection? Altered mental status in a person with HIV may suggest infection in or around the brain (meningitis, encephalitis). History of tuberculosis? Tuberculosis can infect the brain and cause altered mental status. History of liver or kidney failure? Liver or kidney failure can cause problems with the clearing of toxins and waste from the blood, which can lead to altered mental status. History of heavy alcohol use? Alcohol intoxication and alcohol withdrawal can present with altered mental status. People with a history of heavy alcohol use also have a high risk for head injury (and may not remember falls) and hypoglycaemia, both of which can cause altered mental status. Use of drugs of abuse? Several drugs of abuse cause altered mental status, including stimulants, sedatives and opioids. History of pregnancy? High blood pressure during pregnancy can lead to eclampsia (or seizures/convulsions and high blood pressure) during pregnancy. L: LAST ORAL INTAKE When did the person last eat or drink? Low blood glucose levels and dehydration can cause altered mental status. Module 5: Approach to altered mental status 126 E: EVENTS SURROUNDING ILLNESS Recent trauma? Both head injury and poor perfusion resulting from blood loss can cause altered mental status. Recent travel to areas where certain types of infections might be more common? Specific infections that can cause altered mental status may be more common in certain areas. Malaria is a key consideration in many areas. Recent exposures: contact with a sick person, recent bites, chemical exposures, hot or cold environments etc.? Sick contacts may suggest infectious cause. Chemical exposures (such as pesticides) or bites may suggest intoxication or envenomation. Altered mental status can be caused by both very low and very high body temperatures. Recent alcohol or drug use? Both alcohol intoxication and alcohol withdrawal can cause altered mental status. Methamphetamines and cocaine may cause severe agitation, while heroin (and other opioids) may cause lethargy and coma. See also “Past medical history” section above. Workbook question 1: Altered mental status Using the workbook section above, list seven questions about signs and symptoms you would ask about when taking a SAMPLE history. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ 6. ______________________________________________________________________ 7. ______________________________________________________________________ CHECK: SECONDARY EXAMINATION FINDINGS IN ALTERED MENTAL STATUS A person with altered mental status may be unable to answer questions, and clues to the cause may only be found during the physical examination. Always assess ABCDE first. The initial ABCDE approach identifies and manages life-threatening conditions. The secondary SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 127 examination looks for changes in the patient’s condition or less obvious causes that may have been missed during ABCDE. If the secondary examination identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it. Check for safety: Agitated and violent behaviour is a common presentation. It is very important to identify and treat the underlying cause if possible, while prioritizing the safety of the patient and providers. Keep calm and work as a team. Ensure that the space is safe from possible weapons and make sure that the patient is not between you and the door. Avoid making the patient feel threatened. Do not sit too close and speak with a calm, soft and sympathetic voice. Continually explain what is happening. Many aggressive patients will cooperate when faced with a team, so call for help and approach a patient as a group if necessary. Check vital signs, including temperature and glucose, and treat abnormalities. Call for help early and arrange handover/transfer to an advanced provider. Check and monitor level of consciousness with the AVPU scale: – A: Alert – V: Responds to Voice – P: Responds to Pain – U: Unresponsive AVPU tests the person’s ability to respond to stimuli. A person who is not intoxicated and who has no illness or injury affecting the brain will usually be alert without being prompted. Patients who only respond when prompted by voice or pain require further assessment of the neurological system. [See SKILLS] In trauma, check Glasgow Coma Scale: Check and monitor the Glasgow Coma Scale. [See SKILLS] Check the blood glucose level: Hypoglycaemia can cause altered mental status. Diabetic ketoacidosis can present with hyperglycaemia and altered mental status. Check the pupils: Very small pupils and slow breathing suggests opioid overdose. Very large (dilated) pupils suggest stimulant drug use. Unequal pupils suggest increased pressure on the brain. Check for orientation: If the patient is alert and responds to voice, ask simple questions (for example: What is your name? Where are you? What time is it? What day of the week is it?). Check for trauma: Any patient with altered mental status and history or evidence of trauma should be considered to have a possible head injury – even if the trauma occurred several days before. Bruising around the eyes, behind the ears, or leaking of clear fluid from the nose or ears suggests head injury with skull fracture. Check temperature: Fever should raise concerns about an infectious cause, and fever with stiff neck suggests an infection in or around the brain. Poisonings, medication overdoses, alcohol withdrawal Module 5: Approach to altered mental status 128 and changes in body hormones can also present with fever. Hypothermia may indicate infection, low body hormone levels (e.g., thyroid) or exposure to wet or cold environments. Check for stiff neck (Remember, if you suspect trauma, do not move the neck): Stiff neck is suggestive of infection (meningitis) or bleeding around the brain. If you suspect infection, anyone who comes in contact with the patient should wear a mask. Check strength and sensation: If the patient can follow commands, test for strength and sensation in face, arms and legs. Weakness or loss of sensation on one side suggests a mass, bleeding or blocked blood vessels in the brain (stroke), though hypoglycaemia can also present this way. Altered mental status with general muscle weakness may suggest salt (electrolyte) imbalance in the blood. Check for signs of dehydration: Dehydration can cause altered mental status. Check for dry mouth and abnormal skin pinch. Dehydration may also suggest diabetic ketoacidosis. Check the abdomen: Feel if the liver is enlarged or tender. A palpable or tender liver suggests liver disease. Check the skin: Cool, pale, and moist skin suggests shock or hypoglycaemia. Yellow skin (jaundice) suggests liver disease. Bruising suggests trauma. Rashes can indicate systemic infection. Check for bites and stings. Monitor for changes in mental status: People who are initially confused and rapidly return to normal without treatment may have had a seizure/convulsion or head trauma. People with altered mental status require close monitoring to make sure they do not worsen again. (This can happen in patients who have low blood sugar or head trauma). Workbook question 2: Altered mental status Using the workbook section above, list five secondary examination findings you would check for in a patient with altered mental status. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 129 POSSIBLE CAUSES OF ALTERED MENTAL STATUS RAPIDLY REVERSIBLE CAUSES CONDITION SIGNS AND SYMPTOMS Hypoglycaemia • Sweating (diaphoresis) • Seizures/convulsions • Blood glucose <3.5 mmol/L • History of diabetes, malaria, or severe illness, especially in children • Mental status improves quickly with glucose Severe dehydration • Signs of poor perfusion • Abnormal skin pinch • Decreased ability to drink fluids, or fluid loss • Dry mucous membranes Heat stroke • Prolonged exposure to heat and sun • High body temperature, very warm skin • May or may not be sweating (diaphoretic) Hypoxia • Shortness of breath • Low blood oxygen levels • Cyanosis INFECTION CONDITION SIGNS AND SYMPTOMS Cerebral malaria • Fever • Rapid malaria test or smear positive • In or from an area with malaria Inflammation/infection around the brain (meningitis, encephalitis, brain abscess, bleeding) • Fever • Neck stiffness • Rash • Eye pain with looking at light/sensitivity to light • Headache • Known infectious epidemic or exposure • History of HIV or TB infection Severe infection • Fever • Tachycardia • Tachypnoea • May have hypotension • Signs of infection: visible infection in the skin, cough and crackles in one area of the lungs (often with tachypnoea), burning with urination or urine that is cloudy (not clear), or any focal pain in association with fever CONDITION SIGNS AND SYMPTOMS Rabies • Agitation • Fear of drinking (hydrophobia) • Drooling • Weakness • History of animal bite Module 5: Approach to altered mental status 130 METABOLIC CONDITION SIGNS AND SYMPTOMS Diabetic ketoacidosis (DKA) • History of diabetes • Rapid or deep breathing • Frequent urination • Sweet smelling breath • High glucose in blood or urine • Dehydration TOXIC CONDITION SIGNS AND SYMPTOMS Alcohol or drug intoxication or withdrawal • Known alcohol or drug use • Injection marks, drugs found on patients • Alcohol – breath smells of alcohol, reddened face – Acutely intoxicated (drunk) – Withdrawal (convulsions, confusion, tachycardia) – Chronic use (balance problems, confusion) • Opioids: – Acutely intoxicated (lethargy, very small pupils and slow breathing) – Withdrawal (agitation, sweating, diarrhoea, vomiting) • Other drugs may cause large pupils, agitation, sweating, fever Pesticide poisoning • History of exposure • Very small pupils • Diarrhoea • Vomiting • Diaphoresis Snake bite • Snake bite history • Bite marks in a setting with venomous snakes • Oedema • Blistering of the skin • Bruising • Hypotension • Paralysis • Seizures • Bleeding from wounds Medication reaction or dosing issue • New medications or recent change in dose Gaseous poisoning • History consistent with possible exposure • Multiple people with symptoms • Headache SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 131 OTHER CAUSES CONDITION SIGNS AND SYMPTOMS Seizures/convulsions • Known history of seizures/convulsions • Bitten tongue • Urinated on self • Gradual improvement over minutes or hours • If pregnant, consider eclampsia Increased pressure on the brain (trauma, tumour, bleeding or brain swelling) • Headache • Seizures/convulsions • Nausea, vomiting • Unequal pupils • Weakness on one side of the body or speech problems Liver disease • History of alcohol abuse or liver disease • Enlarged abdomen with thin arms, yellow coloring to the skin and eyes (jaundice), or hypoglycaemia Kidney disease • High blood pressure • Oedema or swelling in the legs • Decreased or no urine if severe Head trauma • Visual changes, loss of memory, vomiting, headache • History of recent trauma • Scalp lacerations and/or skull deformity • Bruising to head (particularly around eyes or behind ears) • Blood or clear fluid coming from nose or ears • Unequal pupils or weakness on one side of the body • Seizures/convulsions ADDITIONAL CONSIDERATIONS IN CHILDREN CONDITION SIGNS AND SYMPTOMS Ingestions of chemicals or toxins • Common in younger children • History of medications or substances found around child Module 5: Approach to altered mental status 132 Workbook question 3: Altered mental status Using the workbook section above, list the possible cause of altered mental status from the history and physical findings below. HISTORY AND PHYSICAL FINDINGS LIKELY CAUSE A 15-year-old girl presents with altered mental status, fever and: • neck stiffness • eye pain when looking at light • headache A 45-year-old man presents with altered mental status, and deep, rapid breathing and: • frequent urination • sweet-smelling breath • high glucose in blood or urine • dehydration DO: MANAGEMENT FIRST PERFORM ABCDE ASSESSMENT AND INTERVENE FOR LIFE-THREATENING CONDITIONS. NOTE: If the airway is clear, and there is no evidence of trauma, place the patient in the recovery position to avoid getting fluid or vomit in the lungs. [See SKILLS] CONDITION MANAGEMENT CONSIDERATIONS Hypoxia Give oxygen. Look for underlying cause. [See SKILLS] Hypoglycaemia Treat with glucose. [See SKILLS] Hyperglycaemia If concern for diabetic ketoacidosis, treat with IV fluids. [See SKILLS] A person with diabetic ketoacidosis is extremely ill and requires rapid transfer to a unit where IV infusion and close monitoring are available. Fever (hyperthermia) with altered mental status Start antibiotics. Severe infections may require treatment by an advanced provider. Include malaria testing and treatment in endemic areas. Also consider poisoning and envenomation. Treat high fever with paracetamol. [See SKILLS] For severe temperature elevation, spray with cool water mist, fan and give IV fluids. Avoid shivering. Hypothermia Move to warm environment, remove wet clothing, warm with blankets and warm IV fluid. SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 133 CONDITION MANAGEMENT CONSIDERATIONS Bleeding or other cause of increased pressure on the brain If no trauma, raise the head of the bed to 30 degrees. If trauma is suspected ensure spinal immobilization. [See SKILLS] Opioid overdose Administer naloxone. [See SKILLS] Naloxone effects last approximately 1 hour. Most opioids last longer and patients may need repeat naloxone dosing. Consider this when planning ongoing care and re-assess the person frequently. Active seizure/convulsion Treat with benzodiazepine and monitor the person closely to check for slow breathing. Check glucose or give glucose if you are unable to check. Place patient in recovery position if no trauma suspected. [See SKILLS] If the patient continues to seize or does not wake up between seizures, arrange for rapid transfer to an advanced provider and monitor the airway. Pregnant with active seizure/convulsion This could be eclampsia. Arrange rapid handover/transfer to a specialist unit and give magnesium sulphate. Monitor the patient closely for signs of toxicity. [See SKILLS] If any of these occur, do not give additional doses of magnesium. Alcohol withdrawal Always check glucose and give as needed. Treat withdrawal with a benzodiazepine. [See SKILLS] Monitor the airway closely. Poisoning or envenomation Try to identify the poison and refer to an advanced provider for specific treatments. If pesticide poisoning, make sure the patient has been decontaminated, and monitor the airway closely as the secretions can cause obstruction. Snake bites should be treated as described in the “Wound Management” section [see SKILLS] and referred as soon as possible for antivenom. Rabies There is no specific treatment for rabies. Symptomatic rabies is almost always fatal. See TRAUMA for management of suspected exposure from animal bite. Violent or very agitated patient Protect the patient from harming self or others. Ensure that staff have a clear exit path (do not place the patient between staff and the door). Remove potential weapons and unsafe objects. Call for help from colleagues, family members, and security if needed. Speak in a calm, soft, non-threatening tone. Explain what is happening at each stage of care. Do not confront or judge. Consider other causes: check glucose and vital signs including temperature and oxygen saturation. Treat abnormalities. Arrange for safe handover/transport to advanced provider. Trauma Assess GCS, immobilize the spine and evaluate for signs of increased pressure on the brain. [See SKILLS] Module 5: Approach to altered mental status 134 SPECIAL CONSIDERATIONS MANAGEMENT OF ACTIVE CONVULSIONS • Check ABCDE. • Maintain the airway – do not put anything in the mouth. • Give oxygen if concern for hypoxia or prolonged seizure/convulsion. • Place patient on his/her side, if possible. • Protect the patient from harm or further injury. • Check glucose or give glucose (if unable to check). • Give a benzodiazepine. • If pregnant and seizing, give magnesium sulphate. • If no response, give another dose of benzodiazepine (repeat three times if needed) and monitor for low blood pressure and slow breathing. • If the patient does not wake between seizure/convulsions, consider this a life-threatening condition. Arrange for rapid handover/transfer to an advanced provider. • If the seizures/convulsions stop, place patient in recovery position and monitor closely. Workbook question 4: Altered mental status Using the workbook section above, list what you would do to manage these patients. CONDITION MANAGEMENT A 3-year-old child presents with altered mental status and a blood glucose of 2 mmol/L. 1. ____________________________________________ A 25-year-old woman is brought in with jerky movements and you suspect an active seizure/ convulsion. 1. ____________________________________________ 2. ____________________________________________ 3. ____________________________________________ A 50-year-old man is brought in following a fall from a roof. He has a headache and altered mental status. 1. ____________________________________________ 2. ____________________________________________ SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 135 SPECIAL CONSIDERATIONS IN CHILDREN Children with altered mental status may have seemingly mild signs such as sleeping more than usual or being less interactive. Manage ABCDE first, and then look for and manage causes of altered mental status. Remember that very ill or injured children may have normal vital signs until they rapidly deteriorate. Hypoglycaemia occurs frequently in severely ill children and is a common cause of altered mental status in children. Check blood glucose (or give glucose if you are unable to check) in any child with altered mental status. Hypoxia can occur as a result of many conditions, including respiratory infections and shock; birth hypoxia is a consideration in newborns. Hyperthermia with altered mental status suggests infection, but can also be seen with excessive heat exposure, exercise, seizure/convulsion, hormonal imbalance and some medications and poisons. Hypothermia with altered mental status can also suggest infection, particularly in infants, but can be due to drug intoxication, exposure to cold or hormonal imbalance. Young infants are more affected by variation in temperature. Keep the child warm by using blankets and a hat to prevent heat loss and using skin-to-skin contact (also called “kangaroo care”) with a family member 24-hours per day while ill. Seizures/convulsions can be due to fever alone but (as in adults) can also suggest infection, hypoglycaemia or hyponatremia (low sodium). Do not delay antibiotics in patients with suspected serious bacterial infection. Always consider trauma. Infection in or around the brain can cause altered mental status. Look for a bulging or swollen fontanelle (in a child under 1 year) and/or rash to the legs and lower abdomen, which can indicate infection or increased pressure on the brain. Do not delay antibiotics in children with suspected serious bacterial infection. Flat fontanelle Bulging fontanelle page 31 Flat fontanelle Bulging fontanelle Poor perfusion can cause altered mental status. Children can become dehydrated very quickly. Check for signs of dehydration: abnormal skin pinch, dry mucous membranes (the inner, pink part of the mouth), irritability, sunken or depressed fontanelle (in a child under 1 year), slow capillary refill (greater than 3 seconds), cold extremities, tachycardia, and hypotension. Give IV fluids and re-assess frequently. [See SKILLS] Module 5: Approach to altered mental status 136 Malaria may be more severe in children than adults. Children with severe malaria may present with severe anaemia, seizure/convulsions, coma, and hypoglycaemia. Ingestion of chemicals or drugs is common in children. Try to identify the poison (talk to parents) and try to get a photograph of the package. Consult advanced provider immediately for management. Consider unwitnessed ingestions in children aged under 6 years (especially aged 1–3): • Ask about signs and symptoms depending on the substance ingested. • Take a thorough history from the family. • Examine the bottles of the ingested substance or medicine. • Determine what time it took place. • Ensure that no other children were involved. • Check for signs of burns in or around the mouth • Check for stridor (high-pitched noises) suggesting ingestion of chemicals that burned or damaged the airway and are causing swelling. • Children with ingestion of drugs or chemicals need to be monitored closely and may require handover/transfer to a referral unit for further management. Workbook question 5: Altered mental status Using the workbook section above, answer the following questions about altered mental status in children: How would you assess for brain infection in a child? ________________________________________________________________________ ________________________________________________________________________ Why does hypoglycaemia occur frequently in severely ill children? ________________________________________________________________________ Seizures/convulsions in young children can be a sign of what? ________________________________________________________________________ SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 137 DISPOSITION CONSIDERATIONS Disposition depends on the cause of altered mental status. Causes of altered mental status that cannot be rapidly corrected or which might return after medications wear off need management in a hospital setting. Any patient with altered mental status must be closely monitored for airway problems. Consider handover/transfer to a provider with advanced airway capabilities. If the underlying cause of the low blood glucose is not identified and treated, patients with hypoglycaemia who improved with glucose may develop low blood glucose again and may require repeat treatments. These patients need to be monitored closely. Naloxone (opioid reversal agent) effects only last approximately 1 hour. Many opioid medications are longer-acting and may need more doses of naloxone to reverse the opioid effects. Any patient treated with naloxone must be monitored closely. Make sure the new provider knows the patient has been given naloxone and may need additional doses. FACILITATOR-LED CASE SCENARIOS These case scenarios will be presented in small groups. One participant will be identified as the lead and will be assessed, while the rest of the group writes the responses in the workbook. To complete a case scenario, the group must identify the critical findings and management needed, and formulate a one-line summary for handover, including assessment findings and interventions. You should use the Quick Card for these scenarios while being assessed. CASE #1: ADULT WITH ALTERED MENTAL STATUS A 42-year-old man is brought in after he was found slumped over at a bus stop. When the bystanders went to him he was awake but very confused. They do not know him, but because he is so confused they brought him to you for care. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTION TO PERFORM: AIRWAY YES NO BREATHING YES NO Module 5: Approach to altered mental status 138 ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTION TO PERFORM: CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate one sentence to summarize this patient for handover. CASE #2: PAEDIATRIC PATIENT WITH ALTERED MENTAL STATUS A mother brings her 3-year-old child to you for evaluation after she had two seizures/ convulsions today. The child is wrapped in multiple blankets. The mother states that the child has been increasingly confused over the past 2 days and has had high fevers. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTION TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate one sentence to summarize this patient for handover. SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 139 MULTIPLE CHOICE QUESTIONS Answer the questions below. Questions and answers will be discussed in the session. 1. You are evaluating ABCDE on a 4-year-old boy who has a fever and a cough. He is not responding to you calling his name, but if you pinch the sole of his foot, he moans. What is his level on the AVPU scale? A. Alert B. Verbal C. Pain D. Unresponsive 2. A 37-year-old male is brought in by his wife with fever and confusion. She says since the fever began 3 days ago he has become increasingly confused. There has been no trauma. On examination you notice that his neck is stiff. What is the most likely cause of his altered mental status? A. Pneumonia B. Infection around the brain C. Stroke D. Drug use 3. A 46-year-old man comes in to check his blood pressure. His vital signs are: blood pressure 160/90, heart rate 120, respiratory rate 18, and blood glucose is 5 mmol/L. While you are examining him he has a seizure/convulsion. What treatment should you give? A. Benzodiazepine B. Glucose C. Antibiotics D. Naloxone 4. A 36-week pregnant woman is having a seizure/convulsion. She has a recent history of high blood pressure as well. What treatment should you give? A. Magnesium sulphate B. Glucose C. Nitroglycerin D. Nothing, the seizure/convulsion will stop on its own 5. You are assessing a 6-month-old infant and find a depressed fontanelle. What does this physical examination finding suggest? A. Infection in the brain B. Dehydration C. Pneumonia D. Hypoglycaemia 140 Notes ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS 141 PARTICIPANT WORKBOOK WHO BASIC EMERGENCY CARE [SKILLS]
AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 143 TABLE OF CONTENTS: SKILLS 1. AIRWAY SKILL STATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 BASIC AIRWAY MANOEUVRES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 • Adult head-tilt and chin-lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 • Paediatric head-tilt and chin-lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 • Adult and paediatric jaw thrust . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 MANAGEMENT OF CHOKING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 AIRWAY SUCTIONING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 BASIC AIRWAY DEVICE INSERTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Airway skill station assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 2. BREATHING SKILL STATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 BREATHING EXAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 GIVING SUPPLEMENTAL OXYGEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 BAG-VALVE-MASK VENTILATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 EMERGENCY NEEDLE DECOMPRESSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 MANAGEMENT OF OPEN PNEUMOTHORAX (SUCKING CHEST WOUND) . . . . . . . . . . . . . . . . . 157 HOW TO MAKE A SPACER FROM A PLASTIC BOTTLE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 Breathing skill station assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 3. CIRCULATION SKILL STATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 CIRCULATION EXAM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 EXTERNAL BLEEDING CONTROL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 • Direct pressure for external bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 • Deep wound packing for external bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 • Tourniquet technique for uncontrolled external bleeding . . . . . . . . . . . . . . . . . . . . . . . . 162 UTERINE MASSAGE FOR POSTPARTUM HAEMORRHAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 IV CANNULATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 • ADJUSTING FLUID VOLUME FOR SPECIAL CONDITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . 167 • IV FLUID ADMINISTRATION FOR SHOCK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 Circulation skill station assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 TABLE OF CONTENTS: SKILLS 144 4. EXTENDED PHYSICAL EXAMINATION SKILL STATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . 176 NEUROLOGIC EXAM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 • Glasgow Coma Scale (GCS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 • AVPU Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 SECONDARY SURVEY TRAUMA ASSESSMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 Extended physical examination skill station assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . 177 5. IMMOBILIZATION SKILL STATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 CERVICAL SPINE IMMOBILIZATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 LOG ROLL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 FULL SPINAL IMMOBILIZATION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 POSITIONING OF THE PREGNANT PATIENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 RECOVERY POSITION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 FRACTURE IMMOBILIZATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 • FRACTURE IMMOBILIZATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 • FRACTURE IMMOBILIZATION: OPEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 APPLYING A PELVIC BINDER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 Immobilization skill station assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 6. WOUND MANAGEMENT SKILL STATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 GENERAL WOUND MANAGEMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 BURN MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 • DETERMINE TOTAL BODY SURFACE AREA (TBSA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 • ESTIMATE DEPTH OF BURN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190 • FLUID RESUSCITATION IN BURN INJURY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 SNAKE BITE BANDAGING AND IMMOBILIZATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192 Wound management skill station assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192 7. Medication administration skill discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194 AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 145 SKILLS SKILL STATIONS are designed to allow you to practise new skills and demonstrate life- saving techniques. REMEMBER...ALWAYS WEAR PROPER PPE PRIOR TO CARING FOR A PATIENT AND PERFORMING ANY SKILL. 1. AIRWAY SKILL STATIONS AIRWAY SKILL STATION: BASIC AIRWAY MANOEUVRES Opening the airway: adult head-tilt and chin-lift To be used for patients with altered mental status who may not be able to protect the airway, with NO history of trauma: • Place person face up on flat, firm surface. • Tilt the head back with one hand and lift the chin with your fingers. – To do this, place one hand on the patient’s forehead and then place two fingers of the other hand on the chin. Rotate your hands, tilting the chin up away from the chest. • Remove foreign bodies if visible. • Use suction to remove any liquids or secretions from the airway if needed. • Hold the airway open – do not let the head drop back as this will close the airway. Opening the airway: paediatric head-tilt and chin-lift To be used with patients with altered mental status who may not be able to protect the airway, with NO history of trauma: • Remember, children’s heads are bigger than adults’ heads compared to body size, and their airways are softer and easier to block when the neck is bent. In older children, the airway can be opened by tilting the head backwards slightly (see figure). • Babies have the largest heads relative to their body size. Their heads should be placed in neutral (sniffing) position (see figure). • Inspect the mouth and remove visible foreign bodies. Take care not to push the foreign body deeper into the airway. Adult head-tilt and chin-lift page 1 Adult head-tilt and chin lift SKILLS 146 • Use suction to remove any liquids or secretions from the airway. • Hold the head as below in position to keep the airway open. Neutral position in infants Head-tilt and chin-lift in children (no trauma) Opening the airway: adult and paediatric jaw thrust Use when the patient has altered mental status and may not be able to protect the airway and there IS a history of trauma (cervical spine fracture is possible): • Ask an assistant to immobilize the cervical spine while you perform the jaw thrust. [See SKILLS] • Place fingers behind the angle of mandible (the curve on the jaw bone) on both sides of the jaw and push up so that the lower jaw moves. The head and neck should NOT move. • Inspect the mouth and remove foreign bodies if visible. • Use suction to remove any liquids or secretions from the airway if needed. • Hold the jaw in place to keep the airway open – do not let the jaw drop back as this will close the airway. Jaw thrust in children Jaw thrust in adults Head-tilt and chin-lift in children (no trauma) page 3 N utral position in infants page 2 Modified _02 Pediatric jaw thrust page 4_A AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 147 AIRWAY SKILL STATION: MANAGEMENT OF CHOKING Managing choking in an adult or larger child If respiratory distress occurs suddenly while eating, a person is clutching the throat, or there is silent coughing, cyanosis (skin turns blue in colour), stridor or noisy breathing, suspect a foreign body obstructing the airway. Encourage the person to speak or cough if possible and observe if the obstruction is removed. Do not perform the manoeuvres described below if the person is audibly coughing and/or able to make sounds. A person who is unable to speak or cough has complete airway obstruction and needs immediate help: • Tell the person that you are going to provide help. • Deliver five abdominal thrusts (see below for modifications for pregnant women). – Stand behind the person and lean the person forward. – Form a fist with one hand and place it in the centre of the abdomen between the umbilicus (belly button) and the bottom portion of breastbone. – Place your other hand over your fist. – NOTE: If the patient is pregnant, place the side of your fist in the center of the chest and pull sharply inward. – Pull in and up five times using hard, quick thrusts. This forces the air out of the patient’s lungs to try to “blow out” the obstruction. – If the obstruction persists, have the person bend at the waist and give five back blows (with the heel of your hand, strike the back between the shoulder blades in the direction towards the head). – Re-assess. – Repeat abdominal thrusts followed by back blows until patient speaks, coughs or becomes unconscious. – If the choking person becomes unconscious, lie him/her face up on a firm surface. Performing chest thrusts may relieve the obstruction. If a series of chest thrusts is not successful, continue with rescue breaths and chest compressions based on relevant CPR protocols. Chest thrusts for choking in late pregnancy page 6 Abdominal thrusts for choking adult page 5 Abdominal thrusts for choking adult Chest thrusts for choking in late pregnancy SKILLS 148 Managing choking in an infant or small child • Lay the infant on your arm or thigh in face down position with the head lower than the abdomen. • Give five back blows (with the heel of your hand, striking the back sharply between the shoulder blades in the direction towards the head). • If obstruction persists, turn the infant over. • Give five chest thrust with two fingers, just below the nipple line in the midline of the chest. • If obstruction persists, check infant’s mouth for any visible obstruction that can be removed. (Caution for biting.) • If necessary, repeat entire process until the foreign body is removed. Chest thrusts for choking in infants page 7 Back blows for choking in infants page 8 Chest thrusts for choking in infants Back blows for choking in infants AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 149 AIRWAY SKILL STATION: AIRWAY SUCTIONING The purpose of suctioning is to remove any liquids or secretions from the upper airway. Suctioning may be necessary to maintain an open airway if a person cannot clear secretions without help. • Check to see if your suction canister or handheld device is working. • Attach a rigid or soft suction catheter to the end of the suction tubing. • Explain what you are doing. • Insert the suction catheter into the back of the mouth (only as far back as you can see), cover the side hole on the catheter (NOT the tip of the catheter) to create suction. Suction only while pulling the catheter out and release suction when advancing the catheter forward (advancing the catheter further into the mouth while suctioning can cause injury). Repeat to suction all of the fluid in the back of the mouth. • Do not suction for more than 10 seconds at a time unless the airway is completely blocked with fluid. • To avoid trauma to the mouth, do not place the end of the suction tip directly against the soft tissue or hold it in just one place. Suction only in the oral cavity, do not suction up the nose. AIRWAY SKILL STATION: BASIC AIRWAY DEVICE INSERTION Oropharyngeal airway (OPA) insertion • An oropharyngeal airway (OPA) should only be inserted when the person is unconscious. A conscious person will not tolerate an OPA and will push it out. If the person resists, gags or vomits, remove the device immediately. • Always protect the cervical spine when there is a history of trauma. • Measure the appropriate size of the OPA by measuring from the tip of the earlobe to the corner of the mouth. • Open the person’s mouth using care not to insert your fingers between the teeth (to avoid accidentally being bitten). • Insert the OPA with the curved portion sideways and the tip pointing towards the cheek. • Push the OPA gently into the mouth and, when you can push no further, rotate the OPA 90 degrees, so that the tip now points down the throat and follows the curve of the tongue (see figure). • Push the OPA the remainder of the way in if necessary so that the flange (the wide, flat end) rests on the person’s lips. If you have to do this, be sure that the tip of the OPA does not push the tongue down to obstruct the back of the throat. • Check again to make sure the OPA did not push the tongue down and obstruct the airway. • Give oxygen if available. Oropharyngeal airway (OPA) insertion page 10 Oropharyngeal airway (OPA) insertion SKILLS 150 Nasopharyngeal airway (NPA) insertion Nasopharyngeal airways (NPA) are better tolerated in people who are semi-conscious or when there is a possibility of gagging with oropharyngeal airways. DO NOT use an NPA in people with head and facial trauma. • Assess the nasal passage for any obvious airway obstruction. • Determine the appropriate size NPA to insert. Measure from the base of the nostrils to the earlobe. The diameter of the NPA itself needs to be smaller than the person’s nasal passage. • Lubricate the NPA well and insert it into the nostril, directing it along the floor of the nose posteriorly towards the throat until the wide, flat portion (flange) of the tube rests against the nostril. • Give oxygen if available. Nasopharyngeal airway (NPA) insertion page 9 Nasopharyngeal airway (NPA) insertion Airway skill station assessments Skills station marking criteria 1st pass 2nd pass 3rd pass Safety: Personal protective equipment used or verbalized. BASIC AIRWAY MANOEUVRES Skill 1 – Open the airway: head-tilt and chin-lift List the indications for use – non-trauma cases only. Tilt the head with one hand on the forehead and lift chin with fingers. State that a baby must be placed in a neutral (sniffing) position. Remove foreign bodies if visible. Suction airway if required. Hold the airway open. Do not let the head drop back as this will close the airway. Comments: Skill 2– Open the airway: jaw thrust List the indications for using jaw thrust versus head-tilt and chin-lift (trauma with possible cervical spine injury). Ask for an assistant to immobilize the cervical spine. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 151 Place fingers behind the angle of mandible (the curve on the jaw bone) on both sides of the jaw and push up so that the lower jaw moves. Note that the head and neck should NOT move. Remove any visible foreign bodies. Hold the airway open – do not let the jaw drop back as this will close the airway. Comments: MANAGEMENT OF CHOKING Skill 3 – Choking: adult and larger child Be able to give the indication for abdominal thrusts (the person is unable to speak or cough). Tell the person what you are going to do. Stand behind the person and lean the person forward. Form a fist with one hand and place it in the centre of the abdomen between the umbilicus and the bottom portion of breastbone. Cover one fist with your other hand. Pull in and up five times using hard quick thrusts. This forces the air out of the patient’s lungs to try to “blow out” the obstruction. Assume the victim is still choking: have the person bend at the waist. Deliver five back blows with the heel of one hand between the shoulder blades, striking the back in the direction towards the head. State that you will re-assess the patient Repeat abdominal thrust then back blows until patient speaks or coughs or becomes unconscious. State how this would be modified for a pregnant woman: • Rather than abdominal thrust, place the side of fist in the centre of the chest, cover fist with other hand, and pull sharply inward. Comments: Skill 4 – Management of the choking infant and small child Lay the infant over your arm or thigh in the face down position with the head lower than the abdomen. Give five back blows to the infant’s back between the shoulder blades with the heel of one hand. If obstruction persists, turn the infant over. SKILLS 152 Give five chest thrusts with two fingers placed just below the nipple line in the middle of the chest. If obstruction persists, check infant’s mouth for any obstruction that can be removed. Repeat until obstruction is removed. Comments: Skill 5 – Suctioning the airway Check your suction canister or handheld device to make sure it is working. Attach a hard (yankauer) or soft suction catheter to the end of the suction tubing. Tell the person what you are doing. Insert the suction catheter into the back of the mouth (ONLY as far back as you can see) and cover the side hole on the catheter (NOT the tip of the catheter). Do not suction while inserting the catheter into the mouth. Suction only while pulling catheter out. State how long the patient should be suctioned for (no more than 10 seconds at a time unless the airway is completely covered with fluid). State the need to constantly move the suction catheter and not put the suction tip against the soft tissue. Comments: BASIC AIRWAY DEVICE INSERTION Skill 6 – Oropharyngeal airway (OPA) List the indication for using an oropharyngeal airway (person is unconscious with no gag reflex). Determine the appropriate size OPA to insert: (participant should explain how to do this out loud). • Measure from the earlobe to the corner of the mouth on that side. Open the mouth using care not to insert your fingers between the teeth (to avoid accidentally being bitten). Insert the OPA with the curved portion sideways and the tip pointing to the cheek. Once the OPA is in as a far as it will go, rotate the oropharyngeal 90 degrees so that the tip now points down the throat and the curve follows the tongue. Push the OPA the remainder of the way in so that the flange (the flat end) rests on the person’s lips. Check to make sure the OPA did not push the tongue down to obstruct the airway. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 153 State that oxygen will be given if available. Comments: Skill 7 – Nasopharyngeal Airway (NPA) List the indications for an NPA. (Better tolerated in a person who is semi-conscious or who may still have a gag reflex). State that NPAs should not be used in people with head and facial trauma. Assess the nasal passage for any obvious airway obstruction. Explain how to determine the appropriate size NPA to insert: • Measure from the external portion of the nostril to the bottom of the earlobe. • The diameter of the tube should not be bigger than the nostril (nasal passage). Lubricate the NPA. Lift up the tip of the nose. Insert the lubricated NPA into the nostril and gently push it along the floor of the nose until the flared-out base (flange) rests against the nostril. State that oxygen will be given if available. Comments: Competency demonstrated YES NO Remediation required YES NO Signature of facilitator: SKILLS 154 2. BREATHING SKILL STATIONS BREATHING SKILL STATION: BREATHING EXAM • Assess and count the rate of breathing (normal is between 10–20 breaths per minute in an adult. See ABCDE module for normal paediatric values). • Look for increased work of breathing (nasal flaring, retractions or chest in-drawing). • Feel for chest rise and chest wall tenderness. • Percuss the chest wall: – Place one hand on the chest with fingers separated (the middle finger should lie between the ribs). – With the other hand, tap on the middle finger of the first hand and listen for changes in tone (hollow or dull). • Listen to the chest: – Always expose the chest. Never listen through clothes. – Make sure your stethoscope is not too cold. – Place your stethoscope lightly on the chest wall. Ask the patient to open his or her mouth and take a complete deep breath in and out. Listen to the sounds of the breathing and compare the left side to the right. Listen in the upper zone, middle zone and lower zones and listen to the front of the chest and the back. – Normal breath sounds like wind moving in and out, while abnormal breathing sounds like air going through water, crumpling paper bags, or no air moving at all. [See DIB] – Respect modesty and avoid placing the stethoscope directly on the breasts when possible. BREATHING SKILL STATION: GIVING SUPPLEMENTAL OXYGEN Supplemental oxygen should be given when the patient has signs and symptoms of hypoxia – fast breathing, anxiety, excessive sweating, cyanosis or chest pain. Where available, a pulse oximeter should be used to measure oxygen saturation. • If hypoxia does not appear severe, lower levels of oxygen (24–40% oxygen) can be provided to children and adults through nasal cannula (nasal prongs), but monitor closely in case a mask is needed. (Remember, regular air is approximately 21% oxygen) – Nasal cannula should be about half the size of the nostril. – Position the cannula in each nostril, making sure that it does not extend too far back or press on the tissues. – Secure the tubing to the cheeks or loop the tubing over the ears so that the nasal prongs and the tubing are both on the front side of the patient’s body (never put the head through the loop in the tubing – if patients become confused and hypoxic, they can accidentally strangle themselves). – Oxygen is delivered at a low rate: max 5 L/min. • If hypoxia appears more severe (or if signs of hypoxia continue with maximum oxygen flow via nasal cannula), a simple facemask may be used. Simple facemask is usually used with oxygen flow rates of 6–10 L/min and can deliver approximately 40–60% oxygen. – The facemask is applied to the face, ensuring the bridge of the nose is covered and as little as possible leaks along the side. The mask should rest below the lower lip, but not past the chin. The elastic strap should be placed over the head to secure the mask. • For patients who appear extremely hypoxic or who still have signs of hypoxia with a simple facemask, oxygen can be delivered through a non-rebreather facemask. This provides close to 100% oxygen if the reservoir bag is full. – To prepare the non-rebreather facemask, put one finger over the valve at the top of the reservoir bag inside the mask to inflate the bag. Then apply the non-rebreather facemask in the same way as the simple facemask, ensuring as little leakage as possible. – Make sure that the oxygen is attached to the wall or cannister and that the flow rate is between 10–15 L/min depending on the pressure in your oxygen system and how fast and deep the patient breathes. If the patient is still hypoxic or the non-rebreather facemask bag does not fill, increase the oxygen flow rate. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 155 – NEVER put a non-rebreather facemask on before it is connected to oxygen. A true non- rebreather mask will not allow outside air in and can worsen difficulty in breathing and hypoxia if there is no oxygen flowing through the tubing. Nasal cannula/prongs Simple facemask Non-rebreather BREATHING SKILL STATION: BAG-VALVE-MASK VENTILATION Assess and manage airway and provide bag-mask-ventilation (BVM) for any patient who is not breathing or not breathing adequately (too slow for age or too shallow), any unconscious patient with abnormal breathing (slow, shallow, gasping or noisy), or any patient with a pulse who is not breathing (for patients without a pulse, follow relevant CPR protocols). CAUTION! Avoid over-aggressive ventilation (using bag-valve-mask too fast or with too much pressure) as this will damage the lungs. Children have smaller lungs that are especially fragile. When ventilating a child, be particularly careful to only give enough pressure to make the chest rise and be sure to allow enough time between breaths for exhalation (for the air to escape). Large volumes of air or high pressures may result in pneumothorax or irreversible lung damage. Bag-mask-ventilation steps: • If you have oxygen available, attach the BVM tubing and set the flow to the highest rate available. DO NOT DELAY bag-mask-ventilation to prepare oxygen. (Oxygen can be attached later.) • Place the mask over the patient’s mouth and nose (if you have two people available one person squeezes the bag and other holds the mask on the patient’s face and keeps the airway open). • Create a seal so that air does not leak out. Put your hand or hands in the “EC” position – your thumb and first finger should make a “C” around the top of the mask and push down evenly, your last three fingers should reach just under the bony part of the jaw (looking like an “E”) and pull the jaw upward to open the airway. – Think about pulling the face up to the mask (thus opening the airway) and pushing the mask down onto the face (creating a seal). – If you push down too hard without pulling the face up to the mask, you will block the airway and the patient will be difficult to bag. If you have problems ventilating, reposition your hands and the mask and try again. • If the patient is breathing on his or her own, deliver breaths when the patient takes a breath (during inspiration). Do not attempt to deliver a breath as the patient exhales. • If you are still unable to ventilate the person after repositioning the mask, consider the possibility of foreign body obstruction or air leak. Insert an oral or nasopharyngeal airway device if not already in place (See SKILLS). Nasal cannula/prongs Simple facemask Non-rebreather page 11 SKILLS 156 • Hold the bag in one hand and depress the bag enough to make the chest rise (to about one third of its volume for an adult – make sure you are using the appropriate-sized bag: an adult bag should have a volume of about 2 litres). • Squeeze bag over 1–2 seconds to provide chest rise (giving the breath faster can cause lung damage). • Give one breath every 6 seconds (10 breaths per minute) in an adult; one breath every 4 seconds (15 breaths per minute) in older children; or one breath every 3 seconds (20 breaths per minute) in infants. CAUTION with volume of breaths given in small children (see SKILLS). Giving large volume breaths can cause pneumothorax. • After each breath allow the chest to fall before giving another breath. • Watch the chest rising and falling evenly with each breath. BVM: One provider BVM: Two providers BVM: Child BREATHING SKILL STATION: EMERGENCY NEEDLE DECOMPRESSION Needle decompression of the chest is a life-saving emergency procedure for suspected tension pneumothorax (presence of air or gas in the cavity between the lungs and the chest wall causing excessive pressure on the opposite lung, the great vessels, and the heart). Patients can die very quickly from a tension pneumothorax. These patients need an emergent chest tube, but emergency needle decompression will relieve the immediate pressure and allow time for handover/transfer for chest tube. Emergency needle decompression should only be performed for tension pneumothorax. • Expose the chest and assess breathing. • A tension pneumothorax is identified if shock and the following are present: – Difficulty in breathing – Absence of lung sounds on the affected side – Hypotension – Distended neck veins – Hyperresonance with percussion on the affected side – Tracheal shift away from affected side • Insert a large-bore (14–16G preferred) IV cannula along the upper edge of the third rib through the second rib (intercostal) space in line with the midpoint of the clavicle on the affected side. – In tension pneumothorax, there will be a gush of expelled air • Give oxygen at high concentration (non-rebreather mask). • Start IV lines and give IV fluids. • Refer and transport to definitive care immediately. BVM: One provider BVM: Two providers BVM: Child page 12 AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 157 Chest tube should be placed as soon as possible following needle decompression (even if there was no rush of air) or for any suspected haemothorax. Needle decompression BREATHING SKILL STATION: MANAGEMENT OF OPEN PNEUMOTHORAX (SUCKING CHEST WOUND) An open pneumothorax is an open chest wall wound that sucks air in when the patient breathes in. Normally, when the chest wall is expanded, air is drawn into the lungs through the airway (through a vacuum effect). If there is another hole in the chest wall (due to trauma) air will also be drawn in that hole, but, rather than going into the lungs, it goes into the space between the chest wall and lungs, creating a pneumothorax. A 3-sided dressing is placed to prevent more air from coming in during inhalation, but to allow air from the pneumothorax to escape during exhalation to avoid developing a tension pneumothorax. To manage a sucking chest wound (open pneumothorax): • Give high flow oxygen. • Cover the sucking chest wound with petroleum gauze or other non-adhesive dressing such as the plastic wrapper from gauze packaging. • Tape three sides of the dressing, leaving one side un-taped to act as a flap valve. • These patients need to be transferred as soon as possible to a centre where a chest tube can be placed. (DO NOT place a chest tube through the injury.) Caution! There is a danger of the dressing becoming stuck to the chest wall with clotted blood. When this happens, air cannot escape from the chest cavity and pressure can build up, leading to a tension pneumothorax. Remove the dressing completely if there is worsening respiratory status or evidence of worsening perfusion. If the patient cannot be observed continuously, a three-sided dressing should NOT be placed. Needle decompression page 13 SKILLS 158 BREATHING SKILL STATION: HOW TO MAKE A SPACER FROM A PLASTIC BOTTLE The purpose of a spacer is to hold the medication (salbutamol) released from a metered dose inhaler so the person has time to effectively inhale the medication. (Without experience and proper training, it can be difficult to use a metered dose inhaler effectively and medication is often lost into the mouth or throat). Spacers should be made in advance, however. Do not delay salbutamol delivery to make a spacer. Spacer made from a plastic bottle • Use a clean 300–500ml plastic bottle (wash with detergent and rinse and dry well). • Take the cap off the metered dose inhaler and trace the shape of the opening of the inhaler on the base of the bottle directly opposite the mouth of the bottle. • Cut an opening into the base of the bottle slightly smaller than the traced shape. You can cut this with scissors or a heated paper clip. • Insert the inhaler into the spacer to check the size (the inhaler should fit tightly into the cut opening). • Always remember to prime the spacer with five puffs before use to clear the dead space. Breathing skill station assessments Skills station marking criteria 1st pass 2nd pass 3rd pass Safety: Personal protective equipment used or verbalized use. Skill 1– Assess breathing Assess and count rate of breathing. Look for increased work of breathing (nasal flaring, retractions). Feel for chest rise and chest wall tenderness. Percuss the chest wall. Listen to the chest (auscultate). Comments: Skill 2 – Supplemental oxygen administration State the indication for oxygen (hypoxia, indicated by fast breathing, anxiety, excess sweating, cyanosis (blue tinted skin), or chest pain). Spacer made from a plastic bottle page 14 AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 159 Explain when nasal cannula should be used (mild hypoxia). Demonstrate applying a nasal cannula with a nasal prong in each nostril. Secure the tubing to the cheek or loop over the patient’s ears. (The participant should NOT put the patient’s head through the loop in the tubing.) State that the oxygen flow rate should be no more than 5 l/min. If the patient still has signs of hypoxia, explain which oxygen delivery method should be used next. (Simple facemask) Apply simple facemask – mask over nose bridge and below lower lip. Ensure minimal air leak – adjust elastic to hold in place. Explain that the oxygen flow rate should be between 6–10 L/min. If the patient still has signs of hypoxia, explain which oxygen delivery method should be used next. (Non-rebreather facemask) To prepare the non-rebreather facemask, put one finger over the valve at the top of the reservoir bag inside the mask to inflate the bag. Ensure that the bag is inflated. Apply non-rebreather facemask – mask over nose bridge and below lower lip. Ensure minimal air leak – adjust elastic to hold in place. Turn on oxygen to 10–15 L/min depending on patient’s breathing. Adjust non-rebreather mask, and adjust flow to ensure bag is filled partially. Comments: Skill 3 – Bag-valve-mask ventilation State the indication for bag-valve-mask ventilation. State that if oxygen is available, connect it to the bag – but do not delay BVM to prepare oxygen. Ensure adequate mask-face seal. State correct rate of ventilation. State relevant cautions when ventilating a child. Verbalize that over-aggressive ventilation can damage lungs and cause vomiting. State or demonstrate correct volume of ventilation. Assess chest rise. If no chest rise, reposition airway. Consider OPA or NPA. Comments: SKILLS 160 Skill 4 – Emergency needle decompression State the indication for this procedure. Explain procedure to patient. Expose the chest and clean the skin. Identify landmark: second intercostal space (between the 2nd and 3rd ribs) in the midclavicular line. Insert 14–16G IV cannula into the identified location. Slide cannula over needle, and remove needle. State plan to handover/transfer for chest tube Give oxygen and assess respiratory rate, vital signs and oxygen saturation (if available). Start IV line and give IV fluids. Comments: Skill 5 – Management of open pneumothorax (sucking chest wound) Give high flow oxygen. Cover with petroleum gauze. Tape 3 sides of gauze. State the need for a chest tube to be inserted. Describe the risk of a clotted dressing blocking outflow of air. Comments: Competency demonstrated YES NO Remediation required YES NO Signature of Facilitator: AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 161 3. CIRCULATION SKILL STATIONS CIRCULATION SKILL STATION: CIRCULATION EXAM • Check for anxiety, confusion or altered mental status. • Feel for a pulse, assessing rate and quality (normal range is 60–100 beats per minute in adults. See ABCDE for normal paediatric values). • Assess capillary refill (checked by pushing on the fingernail, palms, or soles and releasing to see how long it takes for the colour to return to the skin). The normal range is less than 3 seconds. • Assess the skin colour and touch the skin to assess the temperature. • Measure other vital signs: respiratory rate and blood pressure (normal adult values: RR 10–20 breaths per minute and systolic BP greater than 90 mmHG. See ABCDE for normal paediatric values). CIRCULATION SKILL STATION EXAM: EXTERNAL BLEEDING CONTROL Direct pressure for external bleeding A wound that is deep and bleeding heavily may not stop bleeding on its own. Applying direct pressure with a clean dressing such as gauze can help to slow or stop the bleeding (see figure). • Put on gloves. • Use gauze or another clean non-adherent dressing. • Do not use bulky dressings as they can make it difficult to put enough pressure in the right place. • Apply firm pressure as directly as possible to the source of bleeding, usually with two or three fingers. • If the wound is on a limb, elevate the limb above the heart. • If the first dressing becomes soaked with blood, do not remove as this will dislodge any clots that have formed. Instead add another pad and apply firm pressure. • When bleeding stops, apply a bandage to keep the gauze/pad in place. • If bleeding does not stop, consider deep wound packing or tourniquet (see next section). Applying direct pressure to a wound Applying direct pressure to a wound page 15 SKILLS 162 Deep wound packing for external bleeding If the wound is deep or gaping and simple pressure does not stop the bleeding, deep wound packing may help. However, deep wound packing is a temporary procedure to stop the bleeding since it can lead to infection if left for more than 24 hours. • Put on gloves. • Always assess pulses, capillary refill and sensation before and after dressing or splinting any wound. • Thoroughly wash out the wound by flushing with at least a litre of clean water (under pressure when possible; see next section). • Use gauze or another clean, compact material to completely fill the space within the wound. • Use additional gauze on top of the wound surface and apply direct pressure with your gloved hand or a bandage wrapped firmly around the wound/limb. • For limb wounds requiring packing, apply a splint to reduce the risk of re-bleeding. • A deep wound pack should not be left in place for more than 24 hours because of the risk of infection. • If bleeding does not stop, consider tourniquet (see next section). Tourniquet technique for uncontrolled external bleeding You will not be expected to perform the tourniquet technique BUT you will be expected to know what life-threatening conditions it can be used for, the special considerations around use of a tourniquet and the ongoing care of the patient. Use this technique ONLY if all other bleeding control measures have failed AND haemorrhage is life-threatening. If you place a tourniquet, there is a possibility that tissues below the tourniquet will be permanently damaged and even require amputation. If you are considering using a tourniquet, CALL FOR HELP IMMEDIATELY and plan for handover/transfer to a unit where surgery is possible. • If available, use a pneumatic tourniquet (like a blood pressure cuff) over padded skin and inflate until bleeding stops. If not, use a thick band or piece of cloth or belt (the wider, the better), over padded skin. • Apply as close to wound as possible, but do not place over a wound or a fracture. • Apply enough pressure to make distal pulses disappear and re-assess bleeding. • If bleeding stops, leave dressing in place if already present or dress the wound and prepare for handover/transfer to a surgical care unit. • If the bleeding does not stop, increase tourniquet pressure until major bleeding ceases. • Record the exact time the tourniquet was applied in the notes AND write it on the patient’s skin or the tourniquet itself. • Consult advanced provider as soon as possible (and never more than 2 hours) after placing a tourniquet. • The tourniquet should be released every 2 hours for at least 10 minutes. Hold direct pressure to the bleeding area during this time. Do not re-apply the tourniquet unless evidence of continued active bleeding. • Location of the tourniquet: tourniquets should only be placed on extremities and should be placed above the level of the bleeding. Because of the relationship between the bones and blood vessels, tourniquets on the upper arm or leg are often more effective than tourniquets placed below the elbow or knee. • Make sure the tourniquet is clearly visible. • Remember tourniquet should be placed as a last resort. If you place a tourniquet, you are cutting off blood supply to the limb, so only do this for life-threatening bleeding. When tourniquet use is absolutely necessary, use a wide, yet constrictive, band. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 163 CIRCULATION SKILL: UTERINE MASSAGE FOR POSTPARTUM HAEMORRHAGE Some bleeding will occur with every delivery. After delivery, the uterus should contract, which compresses vessels and limits bleeding. Failure of the uterus to contract is the top cause of abnormal bleeding after delivery (postpartum haemorrhage). Call for help, arrange for rapid handover/transfer, start uterine massage and give oxytocin immediately. Postpartum Haemorrhage 1. Arrange immediate transfer to qualifi ed obstetric provider! 2. Attempt to control bleeding while arranging and during transfer. 3. Check: 4. Transfer immediately Heavy bleeding after delivery? Has the placenta delivered? Still bleeding? Is there a perineal or lower vaginal tear? Massage uterus until it is hard. Give oxytocin IM. Give IV uids and IV oxytocin. Empty bladder. Continue uterine massage. When uterus is hard, the placenta will likely deliver. Collect placenta and keep with patient. Continue oxytocin. Continue oxytocin for at least 1 hour after bleeding stops. Apply pressure with sterile gauze, put legs together. Continue to massage uterus until hard. Continue oxytocin. Continue IV uids with oxytocin. Insert second IV line. YES YES NO NO YES SKILLS 164 Performing uterine massage for postpartum haemorrhage • Explain to the woman what you will do and why. • The goal is to compress the uterus between your hand and bony structures behind the uterus (e.g. sacrum/lower back). • Place your hand on the woman’s abdomen. Through the abdominal wall, feel for the uterus and cup it with your hand. This will ensure it stays under your hand whilst you are massaging it. Do not simply squeeze the uterus, but ensure that you are applying strong pressure toward the patient’s back while massaging with a circular motion. • Massage the uterus until it is very firm. It should feel like a 10 cm rock in the lower abdomen when contracted. • Do not stop massaging until the uterus is contracted (hard). • Make sure the uterus does not become relaxed (soft) after you stop uterine massage. If it becomes relaxed, resume massage. • Continuously re-assess for vaginal bleeding. • Perform frequent vital signs. Uterine massage for postpartum hemorrhage Uterine massage for postpartum hemorrhage page 17 AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 165 CIRCULATION SKILL: IV CANNULATION Insertion of IV cannula (adult) Inserting an IV cannula is an essential skill required for the treatment of shock. If an adult displays any signs and symptoms of shock, insert two large-bore cannulae (14 or 16 gauge). • Prepare cannula, IV fluid of choice, tourniquet, gloves, dressing to cover the cannula and alcohol swab. • Put on gloves. • Place an elastic band or glove around the arm to function as a temporary tourniquet to help the veins engorge (this “tourniquet” is different from the one above and should not be so tight as to cut off arterial blood flow). Avoid placing an IV in any arm that might have a fistula for treatment of kidney disease. • Look and feel for a vein that is straight. Avoid blood vessels that have a pulse. If a person is in shock, it may be difficult to find a vein. In this case search for a vein in the antecubital fossa (where the elbow bends, see figure). IV in antecubital fossa • Use alcohol or other appropriate skin cleanser to wipe the skin around the vein you plan to use. • DO NOT insert an IV through skin that is broken or appears infected. • Prepare the cannula. Preparation may vary depending on local resources and types of cannula. • Tell the patient what you are doing. • Remove the safety covering over the cannula (the only thing that should be inserted is the needle with overlying plastic cannula). • Insert the needle directly over and in line with the vein as flat and parallel to the skin as possible. Watch for flashback (flash of blood in the cannula) when you enter the vein. – If blood has a regular pumping pattern, you have likely hit an artery and you should remove the needle/catheter and apply firm pressure to the site for at least 5–10 minutes. • After seeing the flash of blood, insert the needle a few millimeters further, then advance the plastic cannula over the needle fully into the patient’s vein. (Do NOT let the needle move forward when you start to move the plastic cannula.) • Hold the cannula in place, applying pressure to the base of the cannula (to occlude it and stop the flow of blood) and withdraw the needle, leaving the cannula positioned in the vein. If needed, withdraw blood to send for laboratory testing. • Remove the IV tourniquet and flush the cannula with normal saline. • Place a cap on the end of the cannula, secure the cannula well and dress the site. Document the date the cannula was inserted in the notes. • Ensure the needle is placed into a sharps container. Check IV site daily for signs of infections such as skin redness, pain and swelling. Ensure the cannula is still in the vein and not sitting in the skin next to the vein allowing fluid to be infused under the skin creating pain and swelling. If any sign of swelling or infection, remove the IV cannula and re-assess. IV in antecubital fossa page 16 SKILLS 166 Insertion of IV cannula (paediatric) Attempt to place the cannula in the hand of the child first. Other sites that can be used to insert a cannula include: • Scalp veins • External jugular veins • Antecubital veins • Femoral veins When preparing for IV cannulation in children ask another assistant or parent to help keep the child’s arm still. Veins in infants • Prepare a 21 or 23 gauge cannula. • When inserting the cannula into the back of the hand, keep the hand bent to obstruct venous return and make the veins visible. Place an “IV tourniquet” (as above) if needed. If you use an IV tourniquet, be sure you don’t forget to remove it. • Insert the cannula using the same technique used in adults. Again, be sure that the blood flows smoothly from the catheter and is not pumping. After insertion, withdraw blood if required for laboratory investigation. Remove the tourniquet and flush the cannula with a small amount of normal saline after insertion. • Secure the cannula well. Children will attempt to remove the cannula and will undo dressings. Avoid placing a single piece of tape (plaster) that goes all the way around an extremity as this may limit blood flow. • If the IV is placed near a joint (hand, antecubital fossa, femoral area) splint the joint to stop it from bending and preventing the IV fluid flowing in, and lightly bandage the IV site with bulky dressings to prevent the child from pulling at the adhesive dressing underneath. Veins in infants Scalp veins External jugular veins Antecubital veins Veins on dorsum of hand Femoral veins Ankle veins page 18 AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 167 Securing an IV in a child page 20 Securing an IV in a child Inserting IV in a small child's hand page 19 Inserting IV in a small child’s hand Check IV site daily for signs of infections such as skin redness, pain and swelling. Ensure the cannula is still in the vein and not sitting in the skin next to the vein allowing fluid to be infused into the skin creating pain, swelling and another source of infection. If any sign of infection, remove the IV cannula and re-assess. CIRCULATION SKILL: IV FLUID – ADJUSTING FLUID VOLUME FOR SPECIAL CONDITIONS Shock should be treated with IV fluids. Fluid volume must be adjusted for patients with three conditions: malnutrition, severe anaemia and fluid overload. When administering IV fluid to any patient, look for signs of new or worsening fluid overload: difficulty in breathing, crackles in the lungs, increasing respiratory rate or increasing heart rate. Stop IV fluids if there are any of these signs and plan for immediate handover to an advanced provider. Recognizing conditions needing IV fluid adjustment in patients with shock – fluid overload, malnutrition, and severe anaemia. 1. Is there fluid overload? In some patients, such as those with heart or kidney failure, there may be extra fluid in the tissues (for example, in the lungs or the soft tissues of the legs). These patients can be fluid “overloaded” even when they have poor perfusion (because the extra fluid is not in the blood vessels). These patients still need IV fluid if they are in shock, but IV fluid must be given more slowly with careful monitoring so that the fluid overload does not get worse. SKILLS 168 CHECK FOR: Signs of fluid overload. • Difficulty in breathing with crackles on chest exam • Lower body swelling (usually in the legs) • Unable to lie flat • Distended neck veins – If signs of fluid overload are present, you must adjust fluids: Small amount of fluids may be given (250–500 ml boluses in adults). Slow the rate of fluid administration. Monitor closely for worsening signs of fluid overload (increasing respiratory rate or heart rate, new or worsening difficulty breathing and increasing crackles in the chest). Stop IV fluids if any of these signs develop. REMEMBER: It is important to go slowly so you can stop for early signs of fluid overload. If you don’t stop IV fluid when these early signs develop, too much IV fluid can cause a patient’s lungs to fill with fluid and create severe difficulty in breathing, or even death. 2. Does the patient have severe anaemia? In patients with severe anaemia, IV fluid can dilute the blood and lower its capacity to carry oxygen to dangerous levels. Additionally, patients with severe anaemia tend to show signs of fluid overload more quickly with IV fluid administration. Remember: you should only give IV fluids to someone with severe anaemia if there are signs of shock (see figure). CHECK FOR: Signs of severe anaemia. • Severe pallor to the palms of the hands (compare to your own palm) or the mucous membranes. • Fast breathing or fast heart rate • Confusion or restlessness • May also have signs of heart failure/fluid overload • If these signs of severe anaemia are present, you must adjust fluids: Slow the rate of fluid administration. Monitor closely and stop IV fluids for worsening. Rapid handover/transfer to a centre capable of blood transfusion. 3. Is the patient severely malnourished? • IV fluid can cause life-threatening swelling and heart failure in malnourished patients and must be adjusted very carefully. Malnourished patients are also at very high risk of hypoglycaemia. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 169 CHECK FOR: Signs of malnourishment. • Visible wasting: a child with severe wasting does not look just thin, but is visibly bony with skin that appears too large for the body. The arms, legs and buttocks may be thin, and the head may appear relatively large because of wasting of the body. • Oedema of both feet: take shoes or socks off and assess both feet for oedema. Press the top of the foot gently with your thumb for a few seconds to see if a dent remains in the tissues. Remember that a severely malnourished child may not appear very thin if there is a lot of oedema. – If these signs of severe malnutrition are present, you must adjust fluids. [See FLUID ADMINISTRATION IN SHOCK (CHILD WITH SEVERE MALNUTRITION) for detailed fluid choice and administration rates] Oral fluid is preferred if the patient can tolerate it. Add dextrose: use dextrose-containing fluids or give a dose of dextrose with IV fluids. Slow the rate of fluid administration. Monitor closely and stop IV fluids for any signs of fluid overload. Switch to oral fluid as soon as possible. Visible severe wasting in a child: Assessing for bilateral oedema in severe malnutrition in children: • Skin looks too large for the body • There is no fat on the child • Outlines of ribs can be seen • Severe muscle wasting of the arms, legs and buttocks • The head may appear relatively large because of wasting of the body (see figure) Visible severe wasting in a child • Use your thumb to press gently for a few seconds on the top of each foot – the child has oedema if there is an impression when you lift your thumb • Repeat on the other foot (see figure) Assessing for pitting edema in children with malnutrition Visible severe asting in a child page 23 Assessing for pitting edema in children with malnutrition page 22 SKILLS 170 CIRCULATION SKILL: IV FLUID – ADMINISTRATION Fluid administration for shock in adults • Attach normal saline or Lactated Ringer’s solution to the cannula. • In adults give 1 litre over less than 30 minutes. • Assess response to fluid immediately after the fluid bolus. Assess perfusion (capillary refill, mental status, urine output), and check for pulse rate and blood pressure. If improving, the pulse rate should lower and the blood pressure should increase. Mental status may also improve. • Assess for fluid overload (see signs above). • If still in shock with no evidence of fluid overload, give another 1 litre bolus. • If still in shock after 2 litres of IV fluid, re-assess for ongoing blood loss (external and internal) or spinal injury, and call for advanced provider. If there is evidence of severe malnutrition, severe anaemia or fluid overload: • Patients with shock still need IV fluids, but it is important to re-assess frequently for signs of worsening overload. – For these adult patients who are at high risk for fluid overload, bolus with 500 ml IV fluid initially, then re-assess. If no signs of fluid overload or fluid in the lungs, give additional 500 ml. Fluid administration for shock in children The appropriate amount of fluid for critically ill children is controversial given recent evidence that bolus fluids can worsen outcomes in some children. In addition, relevant criteria for poor perfusion and shock may vary by context. The 2016 WHO guidelines for the care of critically ill children (see WHO Sources section) use the presence of three clinical features to define shock requiring bolus fluids: cold extremities, capillary refill greater than 3 seconds, and weak and fast pulse. For children with poor perfusion that is due to loss of fluid, such as those with bleeding, burns or severe diarrhoea/vomiting, bolus fluids are also recommended. For other children with evidence of poor perfusion, smaller amounts of fluids given more slowly may be safer. Country teams should consider the clinical presentation of the child, the capacity of providers to detect signs of fluid overload, and the availability of monitoring and support equipment when adapting recommendations to the national context. To give IV fluid resuscitation to a child in shock WITHOUT severe malnutrition, severe anaemia or overload: • Insert IV cannula as described above. • Weigh the child or ask the parents for a recent weight. • Give normal saline or Lactated Ringer’s: 10–20 ml per kilogram of body weight over 30 minutes. Re-assess the child after the first infusion. • If no improvement, repeat 10 ml per kilogram of body weight over 30 minutes. Call for help and plan to handover to an advanced provider and unit with the capacity for blood transfusion. IV fluid resuscitation for a child in shock WITH severe malnutrition Children that are in shock AND have severe malnutrition require specialized fluids (if available) with different rates of infusion. Children with severe malnutrition and shock are at very high risk of hypoglycaemia and will need sugar in addition to fluids. [See MEDICATIONS] If the child can take oral fluids, give oral rehydration with ReSoMal (unless the child is in shock due to cholera, then use ORS). If the child is lethargic, unconscious or not capable of taking oral fluids, then give IV fluids. CAUTION! Intravenous fluid administration can be dangerous in malnourished children. While giving fluid in any way, you must check every 5 minutes for the following danger signs: new or worsening DIB, respiratory rate increase of >5 per minute or heart rate increase of >15 beats per minute. Stop fluids if any danger sign develops. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 171 • Insert IV line as above. • Weigh the child. • Give 10–15 ml per kilogram of IV fluid over 1 hour. If specialized fluids are available, give one of the following according to availability: – Ringer’s Lactate with 5% glucose (dextrose) – Half-strength Darrow’s solution with 5% glucose (dextrose) – 0.45% normal saline with 5% glucose (dextrose). • If you do not have dextrose-containing fluids, then give one of the following: – Ringer’s Lactate AND give a separate oral or IV dose of dextrose [See MEDICATIONS] – Normal saline AND give a separate oral or IV dose of dextrose. [See MEDICATIONS] Re-assess the child after the first 5–10 minutes of the infusion and then every 5 minutes: If the child worsens during rehydration (increased difficulty in breathing, breathing rate increases by 5/min and pulse rate increases by 15/min or lung crackles develop): • Stop the fluids. • Call for help and plan for handover to an advanced provider. If there is no improvement after the first infusion: • Call for help. Plan for handover to an advanced provider at a centre with blood transfusion capabilities. • Give fluid at 4 ml per kilogram over 1 hour while awaiting transfer to the advanced provider. If the child displays signs of improvement (improved capillary refill, lower pulse rate and respiratory rate): • Switch to oral or nasogastric rehydration with ReSoMal (low sodium oral rehydration solution) 10 ml per kilogram per hour for up to 10 hours. • Transfer to a malnutrition unit. SPECIAL CONSIDERATIONS: Children with severe anaemia and poor perfusion need urgent handover to an advanced provider and unit with the capacity for blood transfusion. Children who need IV fluids, but in whom bolus fluids are not indicated should be given maintenance fluids. See the WHO Child Health publications page (www.who.int/maternal_child_adolescent/ documents/child/) for recommended maintenance fluid rates in children. Circulation skill station assessments Skills station marking criteria 1st pass 2nd pass 3rd pass Safety: Personal protective equipment used or states intent to use Skill 1 – Assess circulation Look for anxiety, confusion, AMS Feel for pulse: rate, quality Assess capillary refill: >3 seconds indicates poor perfusion Assess skin colour and temperature Verbalize to measure other vital signs: respiratory rate and blood pressure Comments: SKILLS 172 Skill 2 – Bleeding control: direct pressure Put on gloves Uses gauze or another clean, non-adherent dressing, apply firm pressure to the wound Verbalize to not use bulky dressings Apply firm pressure as directly as possible to the source of bleeding, usually with two or three fingers Demonstrate how to elevate a limb with a wound above the heart Verbalize to not remove the first dressing Apply second dressing with firm pressure when wound continues to bleed Apply bandage when bleeding ceased Verbalize the need to call for help Comments: Skill 3 – Bleeding control: deep wound packing Put on gloves Identify deep or gaping wound as an indication for deep wound packing Assesses pulses, capillary refill and sensation after dressing or splinting any wound Irrigate with 1L clean water before packing. Use gauze or another clean, compact material to pack the space within the wound Put additional gauze on top of the wound surface and apply direct pressure with your gloved hand or a bandage wrapped firmly around the wound/limb If a wound is on a limb and requires packing, consider applying a splint to reduce the risk of re-bleeding Assesses pulses, capillary refill and sensation after dressing or splinting any wound State that a deep wound pack should not be left in place for more than 24 hours because of the risk of infection Comments: Skill 4 – Bleeding control: tourniquet Identify continued bleeding as an indication for a tourniquet States intent to use a blood pressure cuff or thick band or piece of cloth or belt (the wider, the better) after padding skin Identifies appropriate location for tourniquet States to tighten tourniquet until the distal pulses disappear. Then re-assess the bleeding to see if it has stopped AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 173 States to secure tightened tourniquet in place States plan to release for 10 minutes every 2 hours. Only re-apply if bleeding resumes States documentation time of tourniquet placement States will not leave tourniquet on for more than 2 hours without consulting advanced provider Comments: Skill 5 – Uterine massage for postpartum haemorrhage States to call for help and initiate handover/transfer States the indication for performing uterine massage States the need to prepare oxytocin and IV fluid States that the goal is to compress the uterus between the hand and bony structures behind the uterus (e.g. sacrum/lower back) Demonstrates how to cup the uterus through the abdominal wall to ensure that it stays under the hand Demonstrates how to apply strong pressure toward the patient’s back while massaging with a circular motion States that massaging should not stop until the uterus is contracted (feels hard) States that the uterus should not become relaxed (soft) after uterine massage has stopped. If it does, resume uterine massage States to continuously re-asses for vaginal bleeding and perform frequent vital signs Comments: Skill 6 –Inserting an iv cannula Prepare equipment: gloves, IV cannula, administration set , fluids, IV tourniquet, swab Tell the patient what you are about to do Place IV tourniquet on limb Identify a straight vein Clean the skin over the vein Remove the safety covering and insert the cannula, keeping cannula flat and in line with vein When flashback is achieved, advance needle slightly and then slide cannula over needle into the vein Hold this in place and withdraw the needle while putting pressure over base of cannula Remove the IV tourniquet Flush with saline or connect IV line SKILLS 174 Secure with tape or dressing States to check IV site daily to assess for redness or signs of infection Disposes of any sharps appropriately Comments: Skill 7 – Recognizing conditions requiring IV fluid re-adjustment State the special considerations for fluid resuscitation: malnutrition/severe anaemia/fluid overload State how to assess for fluid overload: difficulty in breathing with crackles on chest exam, lower body swelling (usually in the legs), unable to lie flat due to shortness of breath, distended neck veins State ways to adjust fluids in patients in shock with fluid overload: • Small amounts of fluids (250–500 ml boluses in adults) • Slow the rate of fluids • Monitor closely for signs of worsening fluid overload Verbalize how to assess for signs of severe anaemia State ways to adjust fluids in patients with severe anaemia: • Slow the rate of fluids • Monitor closely for signs of fluid overload State need for rapid handover/transfer to a centre capable of blood transfusion Verbalize how to assess muscle wasting in severe malnutrition Demonstrate how to assess for bilateral oedema in the feet State ways to adjust fluids in patients with severe malnutrition: • Give oral fluids if possible • Add dextrose to IV fluids or give dextrose with IV fluids • Slow the rate of fluids • Monitor closely for signs of fluid overload Comments: Skill 8 – IV fluid resuscitation for shock Verbalize caution in administering IV fluid in a malnourished, anaemic or fluid-overloaded patient Insert an IV cannula as described above Attach the IV cannula to the correct fluid for administration Fluid administration for an adult should be normal saline or Ringer’s Lactate States fluid administration for shock in an adult should be 1L given over <30 minutes AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 175 Assess perfusion, if still in shock, give another 1L bolus over <30 minutes State that, if still in shock after 2 L IV fluids, suspect ongoing blood loss and plan for handover to higher-level care Give mechanism for modifying fluid for an adult if severe malnutrition, severe anaemia or fluid overload is present: give fluid in smaller boluses and re-assess frequently for signs of worsening fluid overload Signs of fluid overload are: Fluid in the lungs and difficulty in breathing • Oedema • Patient is unable to lie flat • Distended neck veins For a child in shock (WITHOUT severe malnutrition, anaemia or overload): • Obtain the child’s weight • Give 10–20 ml/kg normal saline or Lactated Ringer’s over 30 minutes • Re-assess after the bolus, if no improvement, repeat bolus • If shock persists, transfer For a child in shock (WITH severe malnutrition, anaemia or overload): • Weigh the child • State that these children need specialized IV fluids – Ringer’s Lactate with 5% glucose – Half-strength Darrow’s solution with 5% glucose – 0.45% (HALF) normal saline with 5% glucose • Give 10–15ml/kg IV fluid over 1 hour • Re-assess the child every 5–10 minutes while receiving fluids • State if no improvement, transfer Verbalize to stop IV fluid in any patient if signs of fluid overload develop Dispose of any sharps appropriately Comments: Competency demonstrated YES NO Remediation required YES NO Signature of Facilitator: SKILLS 176 4. EXTENDED PHYSICAL EXAMINATION SKILL STATIONS EXTENDED PHYSICAL EXAMINATION SKILL STATION: NEUROLOGIC EXAM Glasgow Coma Scale (GCS) The GCS is a 15-point scale for assessing and monitoring people with head injury. The person is assessed for eye opening, verbal and motor response, and given a score for the highest level of function in each area. The totals are combined to determine the overall score. The lower the score, the more severe the head injury may be. Please note that the lowest score a patient can receive is 3. Severe head injury – GCS 8 or less Moderate head injury – GCS 9–12 Mild head injury – GCS 13–15 Calculating The Glasgow Coma Score (GCS) Glasgow Coma Score (GCS) Function Response Score Eyes (4) Open spontaneously 4 Open to command 3 Open to pain 2 None 1 Verbal (5) Normal 5 Confused talk 4 Inappropriate words 3 Inappropriate sounds 2 None 1 Motor (6) Obeys command 6 Localizes pain 5 Flexes limbs normally to pain 4 Flexes limbs abnormally to pain 3 Extends limbs to pain 2 None 1 AVPU Scale The AVPU scale is a simplified assessment that can give you an indication of level of consciousness by assessing response to stimuli. The AVPU scale is particularly useful for children and infants. • A= Alert. People who are fully awake and interactive (even if not fully oriented) are alert. • V= Voice. Those who are not fully alert before stimulus (may have eyes closed or appear sleepy), but do respond to voice without being touched (the response may be words, moaning or movement). • P= Pain. Those who do not respond to voice, but do respond to pain: hard chest (sternal) rub in adults, pinch to the sole of the foot in children, or pinch to bridge of nose in suspected spinal injury. The response may be words, moaning or movement. • U= Unresponsive. Those who do not make any movement or verbal response to painful stimuli are unresponsive. • For any patient who is P or U on the AVPU scale, stop and return to the ABCDE as rapid intervention may be needed to protect the airway. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 177 EXTENDED PHYSICAL EXAM SKILL STATION: SECONDARY SURVEY TRAUMA ASSESSMENT A secondary survey (head-to-toe assessment) of an injured person is conducted ONLY when the ABCDE has been completed and life-threatening complications have been addressed. The purpose of a head-to-toe assessment is to identify all injuries, plan ongoing management and plan the appropriate disposition. If the person deteriorates during the head-to-toe assessment, stop and re-assess the ABCDE immediately. Ensure clothes have been removed but the person is kept warm with gown, sheet or blanket. For this session use the workbook section on secondary survey from the TRAUMA module. Extended physical examination skill station assessment Skills station marking criteria 1st pass 2nd pass 3rd pass Safety: Personal protective equipment used or verbalized use HEAD-TO-TOE TRAUMA ASSESSMENT Skill 1 – HEENT examination Look at scalp, face, eyes, and in mouth, nose, ears Listen for stridor, gurgling or other airway sounds Feel for abnormal facial bone or jaw movement, loose teeth, or crepitus. Comments: Skill 2 – Neck examination Look for neck wounds, trauma, haematoma or distended neck veins Feel for air in tissue or pain/deformity of the cervical spine Check for reduced ability to move neck or pain Comments: Skill 3 – Chest examination Look for bruising, uneven chest movement, burns Listen for breath sounds, muffled heart sounds Feel for crepitus Comments: Skill 4 – Abdominal examination Look for distension, wounds, bruising, burns Feel for rebound tenderness, guarding, location of pain Comments: SKILLS 178 Skill 5 – Pelvis and genitourinary examination Look for bruising, lacerations, blood, priapism, urine colour Feel for pelvis instability or tenderness Comments: Skill 6 – Extremity examination Look for swelling, bruising, deformity or open fractures, wounds, pale extremity Feel for pulses, cold extremity, tenderness, firm/painful muscle compartments Comments: Skill 7 – spine/back examination Log roll patient with assistance Look for bruising or deformity Feel for tenderness, deformity in spine and scapulae Comments: Skill 8 – Skin examination Look for bruising, abrasions, lacerations, burns Comments: Skill 9 – Neurologic examination Check level of consciousness (AVPU or GCS) Check movement and strength in each limb Check for priapism Check sensation on face, chest, limbs Comments: Competency demonstrated YES NO Remediation required YES NO Facilitator’s signature: AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 179 5. IMMOBILIZATION SKILL STATIONS Approach to spinal immobilization There are two types of spinal immobilization: cervical spine and thoracic/lumbar spine. Together, these are called full spine immobilization. Immobilization stabilizes the bones to avoid further injury to the spine. Provide spinal immobilization to any person with a history of polytrauma who is unconscious; or who is conscious and has neck pain, spine tenderness, numbness or weakness. Remember, immobilized patients cannot move normally and are at a higher risk of airway blockage (by secretions or vomit) and pressure sore development. Monitor closely. IMMOBILIZATION SKILL STATION: CERVICAL SPINE IMMOBILIZATION To immobilize the cervical spine: • Keep the patient flat on his or her back and face up on a level surface such as a bed. • Tell the patient what you are doing. • Hold the patient’s head in line with the spine with two hands on either side of the head. • Prevent the patient’s neck from moving with locally available materials (towel rolls, newspaper, sandbags, or bags of IV fluids) or cervical collar if available. These can be secured to the head with tape (plaster) but should never be secured to the bed. (If the patient vomits, you will not be able to turn him or her and if the patient falls, the tape (plaster) could cause a cervical spine injury.) • If the patient vomits, use the log-roll technique (see below) to turn the whole patient onto his or her side, keeping the head in line with the body. • Keep someone with the patient at all times to watch the airway. • Remember, a patient who has severe pain/injury elsewhere may not be able to feel neck pain, even if there is a fracture. A concerning mechanism should raise suspicion. SKILLS 180 IMMOBILIZATION SKILL STATION: LOG ROLL To move any immobilized patient or anyone with a suspected spine injury (e.g. if the patient has to vomit or needs to be transferred), use the log-roll technique (see figure): • Ask for assistance. Ideally, have one person at the head to hold the neck, one or two people to hold the body and one for the legs. • The provider at the head must keep the head, neck and torso aligned with the rest of the spine. The provider should place their forearms tightly alongside the head with hands gripping the shoulders to keep the head and neck in line with the rest of the spine. Keep this alignment when turning the patient. • The person controlling the head and neck leads the team and will say, “1–2-3 roll” to guide timing of the roll for all assistants. • Working together, roll the patient onto his or her side, keeping the spine in line. • During the roll, the person providing head and neck control must ensure the cervical spine remains aligned with the rest of the spine. The people rolling the body should also ensure that the rest of the spine stays in as straight a line as possible. • When the patient is turned onto one side, a provider can examine the back, place or remove a backboard and/or manage back wounds as needed. • To lie the patient flat again, the person controlling the head and neck uses the “1–2–3 roll” command to ensure coordinated movement. • Always remove a backboard as soon as possible using the log-roll technique. Time on a backboard increases the risk of pressure sores. Check pressure areas frequently using the log roll. Preparing for log roll page 24 Preparing for log roll AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 181 IMMOBILIZATION SKILL STATION: FULL SPINAL IMMOBILIZATION To immobilize the thoracic and lumbar spine (see previous section for cervical spine immobilization): • Immobilize the cervical spine as in previous section. • Keep the person on a flat surface with instructions to lie flat and not to move. • For transport, log roll the patient onto a flat surface (such as a backboard) to prevent movement of the spine. Do not attach the backboard to the bed, as you will be unable to log roll (see above) if needed. • Before immobilizing, be sure there is no glass or debris on or under the patient’s back. Use the log roll to check. Immobilized patients must be checked regularly to avoid pressure point wounds. • If the person needs to vomit, use the log-roll technique to roll the person to the side so that no vomit enters the airway. • Spine boards should ONLY be used to move patients. Leaving patients on spine boards for long periods of time can cause pressure sores. Remove patients from boards as soon as they arrive at the facility and can be laid flat. Spinal immobilization for moving a patient page 25 Spinal immobilization for moving a patient IMMOBILIZATION SKILL STATION: POSITIONING OF THE PREGNANT PATIENT • If a patient is over 20 weeks pregnant and needs spinal immobilization, immobilize the spine as above. Then place padding under the side of the board near the back and hips to tilt the patient onto her left side. This helps to prevent compression of the large internal blood vessels by the pregnant uterus which could decrease blood returning to the heart. SKILLS 182 IMMOBILIZATION SKILL STATION: RECOVERY POSITION • If the patient is unconscious or semiconscious and if there is NO TRAUMA, place the patient on his or her left side. Stabilize the patient by bending the top leg forward. The left arm should be straight with the patient’s head resting on the arm to elevate the head and position the mouth downward. This position will allow for vomit and other secretions to drain from the mouth with less risk of airway obstruction. This is called the recovery position (see figure). Recovery position page 26 Recovery position AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 183 IMMOBILIZATION SKILL STATION: FRACTURE IMMOBILIZATION FRACTURE IMMOBILIZATION Splints are used for immobilizing suspected fractured limbs, preventing pain caused by movement of broken bones and minimizing further bleeding and damage. Always assess and record perfusion of the limb beyond the fracture by assessing pulses and capillary refill time. Always assess pulses, capillary refill and sensation before AND after dressing or splinting any wound. • If no perfusion (limb cold, pale, no pulse, slow or no capillary refill), rapid re-alignment (reduction) of the limb is required to restore circulation. • If there is still no perfusion after re-alignment of the limb, splint and plan for rapid handover/ transfer to a specialist unit. • If you cannot re-align the limb, rapidly handover/transfer to an advanced provider. Goal of fracture management: • Restore circulation • Treat and reduce pain • Prevent further injury and bleeding • Re-align bony fragments so that healing and union can take place and normal function is restored Splinting materials include: • Padding to protect the skin and allow swelling • Pre-formed splint for base or modified local resources • Bandages to secure the splint • Adhesive tape (plaster) Before applying a splint, tell the person what you are doing and give pain relief. • Remove clothing to clearly see the injury. • Remove all jewelry. • Check pulses, capillary refill, sensation and movement of the limb. Document this before and after application of the splint. • Size the splint to immobilize the joint above and below the fracture site. • If the limb is visibly deformed and pulses beyond the fracture are weak or absent, first straighten (reduce) the fracture prior to applying the splint. Do not force realignment of a deformed limb if the limb has a good pulse. • Place the joint in the desired position and if the injury involves fingers or toes, pad between toes and fingers. • If stocking gauze is available, place it over the limb without wrinkles to avoid skin damage. • Pad the side of the splint that will be in contact with the skin, and pad the limb, especially bony protrusions (like the elbow). • Wrap the limb and splint with a bandage to hold the splint. Ask the patient how it feels to ensure it is not too tight. The splint should be secure, but remember that the limb will swell, so it is important that the splint and bandaging are not too tight. • Check pulses, sensation and movement of the limb following the application of the splint and every hour afterward. SKILLS 184 FRACTURE IMMOBILIZATION: OPEN Consider an open fracture if there is a wound near a fracture site. Open fracture sites can often be contaminated and will require cleaning and potentially surgical debridement before the fracture can be fixed. If an open fracture is suspected, plan for handover/transfer to a surgical or orthopaedic unit after splinting. • Give pain relief prior to splinting. • Control haemorrhage with direct pressure. In limb amputation, if bleeding is uncontrolled apply tourniquet (see above), commence fluid resuscitation and plan for rapid handover/transfer. • Straighten (reduce) the limb if there are signs of poor perfusion or absent pulses in the limb. • Remove any dirt, grass, obvious glass or other debris from the wound and irrigate the wound with 2 litres of normal saline. • Cover the wound with saline-soaked gauze. • Splint as above, but leave a window so you can continue to monitor the wound. • In amputation, cover wound with sterile, saline-soaked gauze or towel. • Give tetanus vaccination. • Begin IV antibiotics. IMMOBILIZATION SKILL STATION: APPLYING A PELVIC BINDER Pelvic fractures can cause life-threatening haemorrhage by damaging blood vessels adjacent to the fractures. If a person has been injured and has pain in and around the pelvis, apply a binder (see figures). As the pelvis is shaped in a ring, the binder will bring together the displaced bones and help limit internal bleeding. Signs of pelvic fractures include pain or abnormal movement of the pelvis on exam; bruising around the hips, at the top of legs, or to the genitals; and signs and symptoms of shock. • Place bed sheet or similar under the pelvis. If the bed sheet is wide, fold it over so that it spans from the lower back to the end of the buttocks. • You may need to log roll the patient in order to get the binder in position. • The sheet should be centered over the greater trochanters (hip bones, as demonstrated by the instructor) and firmly cross-over at the front. • Pull firmly and tie, but do not cause the person undue pain. It should feel firm but not overly painful. • Document what time the pelvic binder was applied. • Check the binder each hour. Confirm that the binder is still applying pressure around the pelvis. Ensure that that skin is intact where the binder has been applied and around the genitals. Normal pelvis Open pelvic fracture page 27 Normal pelvis Open pelvic fracture AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 185 Pelvic immobilization page 28 Pelvic immobilization Immobilization skill station assessments Skills station marking criteria 1st pass 2nd pass 3rd pass Safety: Personal protective equipment used or verbalized use Skill 1 – Cervical spinal immobilization Keep the patient lying flat. Tell the patient what you are doing. Hold the patient’s head in line with the spine using your two hands on either side of the head. A partner should use rolled sheets, shoes, or IV fluid bags on either side of the head. May be secured with tape (plaster) but do not secure to the bed. State that if the patient vomits, log-roll technique will be used to protect the airway, keeping the head aligned with the rest of the body. Comments: Skill 2 – Log roll State indications for a log roll. Ask for assistance. Place one person at the head to hold the neck, one or two people to hold the body and one for the legs. The person with head control must hold the cervical spine firmly aligned with the rest of the spine before and during the roll. When the provider at the head and neck instructs, roll the patient onto the side. Use “1–2–3 roll” to guide the roll. The person controlling the head and neck uses the “1–2–3 roll” to return the patient to his or her back. SKILLS 186 State that the patient should be removed from the backboard as soon as possible to prevent pressure sores. Comments: Skill 3 – Full spine immobilization State indication for full spine immobilization. Ask for assistance to help with the movement. Perform log roll on to backboard for transfer. Ensure no glass or debris on or under the patient’s back. Secure patient to backboard device for transfer (Do NOT attach backboard or patient to bed). State to log roll if patient needs to vomit. Skill 4 – Positioning of the pregnant patient Verbalize the indications for positioning (greater than 20 weeks pregnant and needs spinal immobilization). Left lateral position with cervical spine immobilization and a pillow or wedge under the backboard or bed. Comments: Skill 5 – Recovery position Verbalize the indications. Controlled manoeuver into left lateral position ensuring open airway. Appropriately position the patient (top leg bent forward, left arm straight with the patient’s head resting on the arm to elevate the head and position the mouth downward). Comments: Skill 6 – Fracture immobilization Remove clothing to clearly see the injury, remove all jewelry. Check pulses, sensation and movement of the limb and document findings. Size the splint against the limb. Immobilize the joint above and below the injury. Identify special considerations: • Straighten the limb if signs of poor perfusion or absent pulses in the limb. • Control haemorrhage as needed. • Remove debris and irrigate an open fracture wound with 2 L of normal saline. • Cover open fractures with sterile saline gauze. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 187 Place the joint in the desired position. Pad in between toes and fingers if injury involves digits. If stockinette is available, place it over the limb without wrinkles or pad the side of the splint that will be in contact with the skin. Pad the patient’s limb, especially bony prominences. Wrap the limb and splint with a bandage to hold the splint. Check pulses, sensation and movement of the limb following the application of the splint. State patients with an open fracture will require tetanus vaccination, if not up to date, and antibiotics. Comments: Skill 7 – Applying a pelvic binder Identify pelvic pain after trauma. Place bed sheet under the pelvis. If bed sheet is wide, fold it over so that it is the size of the pelvis (lower back to end of buttocks). Push the binder under the small of the back and pull it into position or log roll patient onto binder. Centre over the great trochanters (hip bones) and firmly cross over at the front. Pull firmly and tie, but do not cause the person undue pain. It should feel firm but not overly painful. Document the time the pelvic binder was applied. Comments: Competency demonstrated YES NO Remediation required YES NO Signature of facilitator: SKILLS 188 6. WOUND MANAGEMENT SKILL STATIONS WOUND MANAGEMENT: GENERAL WOUND MANAGEMENT • Haemorrhage control: stop bleeding as above. • Prevent infection: – Clean wound of blood clots, dirt, dead or dying tissue, foreign bodies. – Clean skin around the wound thoroughly with soap and water or antiseptic. – Thoroughly wash out wound by flushing with at least 1 litre of clean water. The water should be under pressure to thoroughly clean the wound. To create a high pressure stream, use a syringe (with 14 g needle or IV catheter attached) or poke a small hole in a clean bottle and squeeze the bottle. Be sure to use the entire litre. – If not vaccinated or not up to date, give tetanus vaccination. • Dressing wounds: – Dress wound with sterile gauze if available. – Use a pressure dressing if the wound is still bleeding. – Check perfusion (capillary refill and/or distal pulses) and sensation beyond the wound before AND after dressing wounds. • Pain management: – Give local anaesthetic before cleaning the wound if staff and equipment are available. – Splint large lacerations and fractures. WOUND MANAGEMENT: BURN MANAGEMENT It is important to cover burns early in order to keep the area moist and reduce the risk of infection. Burns can be very painful so ensure you give pain relief. • Use sterile technique and normal saline to clean the burn. • Carefully remove any loose, dead skin and broken, tense or infected blisters. • Apply a non-adherent dressing to the burn to provide a moist healing environment. Clean clear plastic wrap can be used over the burn as an interim measure and if you are transferring the person to a surgical unit shortly. • Ensure the entire burn is covered with the dressing. • If the person has presented with an old burn that is now infected, apply a topical antibiotic (such as bacitracin or silver sulfadiazine). This person may also require IV or intramuscular antibiotics. • If there is delay in handover or transfer, ensure the dressings are changed daily. Always give pain control with dressing changes. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 189 ADULT BURN MANAGEMENT: DETERMINE TOTAL BODY SURFACE AREA (TBSA) This is used to calculate the fluids needed using the Parkland Formula. Use the Rule of Nines body chart for adults and modified chart for children and infants (see figure). The body is divided into portions that each make up 9% of the total body surface. Children have different percentages due to the different body proportions, such as a larger head and smaller limbs (see figures). • Assess the person using the diagram below. • Note the areas of burn and shade them in on the diagram. • Next to where you are shading, write the burn depth (see burn depth estimate below). • Once you have marked the diagram (front and back) with all the burns you have assessed on the person, add the percentages. • This will give you the total burn surface area (TBSA). Burn surface area in adults 4.5%4.5% 18% 18% 9% 9%9% 9% 4.5%4.5% 4.5% 4.5% 1% page 29 Burn rface area in adults SKILLS 190 Burn surface area in children 13% A D C B C B F E F E 2% 2% 2% 2% 13%2% 2% 2% 2% 1% 2% 2% 2% 2% 1% 1% 1% 1% page 30 Area Head (A/D) Thigh (B/E) Leg (C/F) 10% 3% 2% 7% 4% 3% 6% 5% 3% 9% 3% 3% By age in years 0 1 5 10 Burn surface area in children PAEDIATRIC BURN MANAGEMENT: DETERMINE TOTAL BODY SURFACE AREA (TBSA) Area By age in years 0 1 5 10 Head (A or D) 10% 9% 7% 6% Thigh (B or E) 3% 3% 4% 5% Leg (C or F) 2% 3% 3% 3% BURN MANAGEMENT: ESTIMATE DEPTH OF BURN The best way to estimate burn depth is by gently pressing two fingers onto the burn to assess capillary refill. • Put gloves on. • With care, press down on the centre of the burn with two fingertips for 3–4 seconds, and then let go. The faster the capillary refill the more superficial the burn is. • Now assess the outer edge of the burn (burn depth can vary for different areas of the burn). • Use the chart below to guide your assessment findings. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 191 Burn type Skin findings Superficial (formerly first degree) • Red or pink • Painful, skin intact, no blisters • When pressed, skin is pink with quick capillary refill Partial thickness (formerly second degree) • Red or mottled red • Intact or broken blisters, wet • Painful • May temporarily turn white when pressed then red colour returns Full thickness (formerly third degree) • White or black • Leathery and dry • No sensation • When pressed, no change in colour BURN MANAGEMENT: FLUID RESUSCITATION IN BURN INJURY As discussed in the TRAUMA module, an adult or child with a burn injury may require fluid resuscitation. Start fluid resuscitation in the following cases: • Full or partial thickness burns greater than or equal to 15% total burn surface area in adults. • Full or partial thickness burns greater than or equal to 10% total burn surface area in children. BURN MANAGEMENT: PARKLAND FORMULA CALCULATION FOR THE FIRST 24 HOURS 4 ml IV fluid X weight in kilograms X % total burn surface area* *% total burn surface area = % partial thickness burn area + % full thickness burn area (% superficial burn area is NOT used in the calculation) The Parkland Formula is a fluid resuscitation management strategy for the initial 24 hours following a burn. Patients presenting beyond 24 hours after the initial burn will also need fluid resuscitation, but the Parkland Formula is not used beyond 24 hours. • The first half of the fluid should be given within the first 8 hours after the burn (NOT after arrival to care). • The second half is to be given over the subsequent 16 hours. • For adults, give normal saline or Ringer’s Lactate. • For children, use a dextrose-containing fluid (Ringer’s Lactate with 5% dextrose or normal saline with 5% dextrose for initial resuscitation). If no dextrose-containing fluids are available, give an additional dose of dextrose (either IV or orally) with IV fluids (see MEDICATIONS). For ongoing care of children, the Parkland emergency resuscitation fluids calculated above MUST BE ADDED to any required maintenance fluids based on hospital care protocols (see WHO Pocket book of hospital care for children, 2013). Your facilitator will review examples using the Parkland Formula. REMEMBER: Patients with serious burns to >15% of their body, burns involving the hand, face, groin area, joints, or burns that go completely around the body or a body part need to be transferred/ handed over for specialized care. SKILLS 192 WOUND MANAGEMENT: SNAKE BITE BANDAGING AND IMMOBILIZATION Note: When possible, take a picture of the snake and send with the patient. Immobilizing a limb after a snake bite is important to reduce movement and absorption of venom. • Always assess pulses, capillary refill and sensation before and after dressing or splinting any wound. • You may choose to use a broad pressure bandage and wrap upwards from the lower portion of the bite. The bandage should be firm, but should not cut off pulses in the limb. Extend the bandage as high up the limb as possible. – This is recommended if the snakes in your area produce a toxin that damages the nerves, causes paralysis, causes the person to become very ill or if there will be prolonged transport time. – This is NOT recommended if the snakes in your area produce toxins that primarily cause tissue damage near the wound and do not cause body-wide symptoms. • Bind a splint to the limb to immobilize as much of the limb as possible. • Note the time the bandage was placed. • Keep the person still and lying down. • DO NOT put a tourniquet around the snake bite or limb. • DO NOT cut the bite out as this will lead to unnecessary bleeding. • DO NOT suck on the bite to remove the venom. Wound management skill station assessments Skills station marking criteria 1st pass 2nd pass 3rd pass Safety: Personal protective equipment used or verbalized use SKILL 1– General wound management Haemorrhage control: stops bleeding as per earlier taught skill. Preventing infection Cleans wound of blood clots, dirt and foreign bodies. Cleans skin around the wound thoroughly with soap and water or antiseptic. Thoroughly washes out wound by flushing with water (state 1 litre of clean water or more). Gives tetanus vaccination as needed. Dressing wounds Assesses pulses, capillary refill and sensation before dressing or splinting any wound. Dresses wound with sterile gauze if available. Applies pressure dressing if the wound is still bleeding. Checks perfusion beyond the wound (capillary refill and/or distal pulses) before and after dressing wounds. Pain management AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 193 Gives local anaesthetic before cleaning the wound if staff and equipment are available. Splints large lacerations and fractures. Assesses pulses, capillary refill and sensation after dressing or splinting any wound. Comments: BURN MANAGEMENT Skill 2 – Burn wound management Uses a sterile technique and normal saline to clean the burn. Removes any loose, dead skin and broken, tense or infected blisters. Applies a non-adherent dressing to the burn to provide a moist healing environment. Ensures the entire burn is covered with the dressing. Considers antibiotics. States transfer or handover plan. Comments: Skill 3 – Fluid resuscitation in burn injury Correctly states indications: • Partial or full thickness burns greater than or equal to 15% total burn surface area in adult. • Partial or full thickness burns greater than or equal to 10% total burn surface area in children. Estimates depth of burn. Determines total body surface area (TBSA). Calculates Parkland Formula. Explains delivery of fluids. (First half in first 8 hrs; second half in next 16 hrs) Chooses correct fluid for initial bolus. (Children weighing less than 20 kg: Ringer’s Lactate with 5% dextrose, normal saline with 5% dextrose) Comments: Skill 4: Snake bite bandaging and immobilization Uses a broad pressure bandage and wrap upwards from the lower portion of the bite. Extends the bandage as high up the limb as possible. SKILLS 194 Immobilize as much of the limb as possible with a splint. Notes the time the bandage went on. Keeps the person still. States DO NOT put a tourniquet around the snake bite or limb. States DO NOT cut or suck on the bite wound. Comments: Competency demonstrated YES NO Remediation required YES NO Facilitator’s signature: 7. Medication administration skill discussion The table below summarizes the medications discussed in this course, which represent only a very basic set of treatments for emergency conditions. They have been included based on their wide availability, their appropriateness for use by all of the frontline providers targeted by this course, their feasibility of use in pre-hospital or facility settings, and for their potential importance as early treatments for emergency conditions. Be sure to check locally available drug concentrations, as these can vary. The most common concentrations are used in this table for dosing reference. Almost every condition discussed will require additional treatments beyond these, and many important emergency treatments that may be used by advanced providers are not included here. Table: Medications used in the Basic Emergency Care course Drug indication Dosage Adverse effects Adrenaline (Epinephrine) Anaphylaxis/severe allergic reaction and severe wheezing [see ABCDE, DIB] Solution: 1 mg in 1 ml ampoule (1:1000) Note: • The doses below are for intramuscular not IV administration. • The preferred site for injection is the outer mid-thigh. Adults: Intramuscular(IM): 50 kg or above: 0.5 mg IM (0.5 ml of 1:1000) 40 kg: 0.4 mg IM (0.4 ml of 1:1000) 30 kg: 0.3 mg IM (0.3 ml of 1:1000) • May repeat at 5-minute intervals Paediatrics: Anaphylaxis: 0.15 mg IM (0.15 ml of 1:1000), repeat every 5–15 minutes as needed Severe asthma: 0.01 mg/kg IM up to 0.3 mg, repeat every 15 minutes as needed • Anxiety/fear • Palpitations • Tachycardia (elevated heart rate) • Dizziness • Sweating • Nausea • Vomiting • Hyperglycaemia (elevated blood glucose) • Chest pain • High blood pressure • Tissue necrosis at injection site AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 195 Drug indication Dosage Adverse effects Antibiotics Specific drugs in this category will be determined by local treatment protocols and availability. These should include a broad-spectrum regimen for life-threatening infections that can be used empirically (before the infectious source is definitively identified) in very ill patients. • Allergic reactions • Gastrointestinal upset • Other specific effects vary by antibiotic Acetylsalicylic acid (Aspirin) Suspected heart attack Tablet: 100 mg, 300 mg Oral: 300 mg (preferably chewed or dispersed in water) given immediately as a single dose. Do NOT give aspirin until evaluated by an advanced provider if there is: 1. any active bleeding, or 2. chest pain that is sudden, maximum at onset, sharp and tearing, and radiating to the back (can indicate a tear in the aorta). • Gastrointestinal irritation with blood loss • Tinnitus • Anaphylaxis Benzodiazepines – Diazepam Seizures/convulsions [see AMS] Tablet: 2 mg, 5 mg Solution: 5 mg/1 ml ampoule Adults: First dose: 10 mg slow IV push OR 20 mg rectally Second dose after 10 minutes: 5 mg slow IV push or 10 mg rectally Maximum IV dose: 30 mg Children: First dose: 0.2 mg/kg slow IV push or 0.5 mg/kg rectally. Can repeat half of first dose after 10 minutes if seizures/convulsions continue. Maximum IV dose: 20 mg Do not give second dose if respiratory rate is less than 10 breaths per minute. Do not give diazepam intramuscularly (unpredictable absorption). How to give rectal diazepam: • Draw up the dose from an ampoule of diazepam into a small syringe (tuberculin if available). Base the dose on the weight of the child, when possible. • Remove the needle. • Insert the syringe 4–5 cm into the rectum, and inject the diazepam solution. • Hold the buttocks together for a few minutes. • Sedation • Respiratory depression • Low blood pressure • Bradycardia (low heart rate) • Nausea and vomiting • Abdominal cramps SKILLS 196 Drug indication Dosage Adverse effects Glucose (dextrose) Hypoglycaemia (low blood sugar) [see ABCDE, ALTERED MENTAL STATUS] Solution: 50% dextrose (D50), 25% dextrose (D25), 10% dextrose (D10) NOTE: Dextrose should NEVER be given intramuscularly as it may cause serious tissue damage. Adults and children greater than 40 kg: 25–50 ml IV of D50, or 125–250 ml IV of D10 Children up to 40 kg: 5 ml/kg IV 10% dextrose (D10) • Hyperglycaemia (high blood glucose) • Dizziness • Skin necrosis if injected outside the vein D10 is preferred in children under 40 kg. If D10 is not available, you can use the Rule of 50 to remember the equivalent amount of dextrose in another solution. All of the following contain the same amount of dextrose: 5 ml of D10 2 ml of D25 1 ml of D50 If no IV access: Place 2–5 ml of 50% dextrose in buccal space (inside the cheek) OR Give sugar solution (1 level teaspoon of sugar moistened with water every 10–20 minutes) in buccal space AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 197 Drug indication Dosage Adverse effects Magnesium sulphate Eclampsia or pregnant with seizure/convulsion [see ALTERED MENTAL STATUS] Solution forms: 1 g in 2 ml ampoule (50%) 5 g in 10 ml ampoule (50%) To give IV, make a 20% solution: *add 3 ml of sterile saline to the 2 ml ampule OR *add 15 ml of sterile saline to the 10 ml ampoule. Loading dose (IV + IM): * 4 g IV (dilute to a 20% solution and give 20 ml slowly over 20 minutes) AND *10 g IM (intramuscular): 5 g (10 ml of 50% solution) with 1 ml of 2% lidocaine in upper outer quadrant of each buttock. Magnesium can cause low blood pressure; monitor carefully. IF unable to give IV, give 10 g IM injection only (as above, 5 g in each buttock). If seizures/convulsions recur: after 15 minutes give an additional 2 g (10 ml of 20%) IV over 20 minutes. If transport delayed, continue treatment: Give 5 g of 50% solution IM with 1 ml of 2% lidocaine every four hours in alternate buttocks. • Low blood pressure • Respiratory depression • Drowsiness • Confusion • Loss of reflexes • Muscle weakness • Nausea • Vomiting • Flushed skin • Thirst STOP if: • Respiratory depression (respiratory rate <16) develops. Toxicity: • Low blood pressure • Respiratory depression • Loss of knee jerk • Urine output <100 ml/4 hours Naloxone Opioid overdose [see ABCDE, ALTERED MENTAL STATUS, DIFFICULTY IN BREATHING] Solution: 400 mcg/ml (hydrochloride) in 1 ml ampoule IV: 100 mcg single dose OR IM: 400 mcg in single dose May repeat every 5 minutes as needed. May require continuous infusion at 0.4 mg/ hour for several hours for long-acting opioids. • Hypertension (high blood pressure) • Cardiac arrhythmias • Hyperventilation • Difficulty in breathing • Agitation *** Naloxone effects only last 1–3 hours. Many opioid medications are longer- acting and may need more doses of naloxone or a naloxone infusion. Any patient treated with naloxone must be monitored closely*** SKILLS 198 Drug indication Dosage Adverse effects Oxytocin Treatment of postpartum haemorrhage Solution: 10 IU in 1 ml ampule Initial dose: Give 10 IU IM AND start IV fluids with 20 IU/L at 60 drops/minute. Once the placenta is delivered, continue IV fluids with 20 IU/L at 30 drops/minute if still bleeding. If placenta has to be manually removed or uterus does not contract: Repeat 10 IU IM. Continue IV fluids with 20 IU/L at 20 drops/ minute for 1 hour after bleeding stops. Max Dose: 3 L of IV fluids containing oxytocin. • Nausea/vomiting • Headache • Rash • Anaphylaxis • Uterine spasm (at low doses) • Uterine hyperstimulation (at high doses) Paracetamol (acetaminophen) Mild to moderate pain, fever and headache Tablet: 250 mg, 500 mg Rectal suppositories: 250 mg, 500 mg Adults: 500mg – 1 g every 6 hours Max 4 g daily or max 2 g daily if liver impairment, cirrhosis Children: 10–15 mg/kg up to six times a day • Rash • Liver damage following overdoses Salbutamol (albuterol) Severe wheezing [see ABCDE, DIFFICULTY IN BREATHING] Where available, can use nebulizer with appropriate dose. Inhaler: 100 mcg per puff Inhaler with spacer Adult: Prime with five puffs and give two puffs via spacer every two minutes until improved. Child: Prime with five puffs and give two puffs into spacer. Keep spacer in the child’s mouth for three to five breaths. Repeat until six puffs of the drug have been given to a child < 5 years or 12 puffs for > 5 years of age. Repeat regularly until condition improves. In severe cases, 6 or 12 puffs can be given several times in an hour. • Palpitations • Fine tremor • Headache • Tachycardia (high heart rate) Remember: child must be able to seal mouth around spacer opening. Babies will likely require spacer mask or nebulizer. Nebulizer: (ADULT) 5mg in 5 ml sterile saline. (CHILD) 2.5mg in 3 ml sterile saline. For severe wheezing, above doses can be given several times in an hour. Tetanus vaccination Solution: 5 units per 0.5 ml IM 0.5 ml Give to all injured children whose vaccinations are not up to date and in all adults who have not had this vaccination in the past 5 years. If immunization status is unknown, give vaccination. • Pain to injection site • Allergic reaction • Fever • Nausea AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 199 8. Transfer and handover skills discussion This course is intended for providers working in the field, on ambulances and in health-care facilities. Transferring patients from the scene to first facility, or between facilities, require special attention to destination planning, ongoing management and handover. DESTINATION PLANNING Many patients treated on the scene will require transport to a health-care facility for further management. Additionally, patients already at a facility may require transfer to a different facility for more advanced care. For example, a pregnant woman with seizures will need handover for advanced care and emergency delivery; a patient with severe burns will require transfer for advanced airway management and surgical care; a patient in shock from blood loss will require handover to a centre capable of blood transfusion. When planning any transport, make sure that: the level of services at the destination facility matches the needs of the patient (e.g. there is an operating theatre if surgery is needed); that the expected resources are currently available (e.g., the operating theatre is running, and there is blood for transfusion); and that the destination can be reached in the necessary time frame given the patient’s condition. Do not delay transport for tests or interventions that are not critical to patient safety if they can be performed at the receiving facility. Follow local transfer and destination protocols where they exist. Where there are no clear protocols, balance transport times with facility capabilities – the goal is to reach needed care as soon as possible. It is usually better to have a longer initial transport time than to arrange a second transfer because appropriate care was not available at the first destination. Once the appropriate facility has been determined, communication with a provider at the receiving facility is essential (see ‘Handover’ below). This will allow the receiving centre to prepare for the patient’s arrival and arrange resources (e.g. blood, operating theatre preparation). Follow specific local communication protocols where they exist. Wherever possible, formal protocols for both pre-hospital transport and transfer between facilities should be in place. These should include explicit criteria for when a patient should be transferred. TRANSPORT Transfer includes two aspects: transporting the patient and caring for the patient at all times during transport. One person cannot do both jobs. During transport, at least one provider should always be in the same part of the vehicle as the patient to allow for ongoing monitoring, assessment and management. The ABCDE approach should be used to assess and re-assess ALL patients during transportation; vital signs (including AVPU or GCS) should be checked every 15 minutes, and patients should be closely monitored for response to treatments and for signs of worsening. Remember to plan overall transportation time and route, and check road conditions and weather. This is essential in order to anticipate the patient’s needs during transport (e.g. IV fluid and medication needs). Ensure that the patient and family are aware of the transport plan. Allow a family member to accompany children whenever possible. SKILLS 200 HANDOVER Formal handover should be given any time care is transferred to a new provider, including: between providers within a facility, to or from transport providers, or remotely from a sending facility to a receiving facility provider. In addition to a verbal report at the time a patient is handed over to a new provider, written documentation of the clinical condition and treatment should accompany the patient at all times. You will practise handover summaries throughout the course in the case scenarios. The Situation, Background, Assessment, Recommendations (SBAR) format is a structured way of communicating key information and can be used for all of the handovers mentioned above. SBAR components and examples are: SITUATION Basic patient information (e.g. age, sex). Chief complaint (the patient’s initial description of the problem, such as difficulty in breathing for 3 days, or arm pain after a fall, etc.). BACKGROUND The 2–4 most important and relevant aspects of the patient’s case and/or condition (these may be elements of the history, physical exam, or testing results, depending on the case). Include any important ABCDE findings/interventions. ASSESSMENT What you think is wrong with the patient. The reason for the handover/transfer. RECOMMENDATIONS Specific things the new provider should prepare for: – next steps in the treatment plan; – potential worsening of the patient’s condition (e.g. need for close airway observation if inhalation burn is suspected); – cautions regarding prior therapies or interventions (e.g. time of last adrenaline dose to anticipate return symptoms, need to monitor mental status if sedating medications have been given, need to monitor 3-way dressing for clotting, etc.). Examples: Case 1: A 22 year-old man was riding a motorcycle when he crashed into another vehicle at high speed. He was thrown from his motorcycle and was not wearing a helmet. His airway is open; he has normal breath sounds on both sides of his chest; his pulses are strong and around 90 beats per minute; he is only responsive to pain and has a femur fracture with bone visible in an open wound; there are abrasions on his forehead. You have immobilized his spine, started an IV and splinted the fracture. You and your colleague have transported him from the scene of injury and are handing him over to a hospital provider. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 201 Handover summary: This is a 22-year-old man who was in a motorcycle crash, was not wearing a helmet and was thrown from his motorcycle; he is only responsive to pain and has an open femur fracture, but is currently protecting his airway and has no evidence of shock. We are concerned for his altered mental status, and open femur fracture, but are unable to tell if he has a spinal injury. He needs transfer for surgical management and further neurological assessment. Spinal immobilization should be maintained and he should be monitored for worsening bleeding and mental status changes. Case 2: A 14-year-old girl had a seizure/convulsion at school. She was brought to you by her teachers because she did not stop seizing. You administered a benzodiazepine, which caused the seizures to stop. After, you were able to perform the ABCDE survey and then a complete head-to-toe exam. She does not have a fever; she has a normal heart rate, blood pressure, and respiratory rate. She responds to voice. Her tongue is bitten and she urinated on herself; she has no other injuries or rashes. Handover summary: This is a 14-year-old girl who had a prolonged convulsion and was convulsing on arrival; her seizures were stopped with one 10 mg dose of diazepam and now she remains sleepy, has normal vital signs and no fever. She is being transferred for further evaluation of her seizure. Monitor the airway as she has received sedating medications (diazepam). Case 3: A 75-year-old man had chest pain while walking home from the market. He was brought to you by taxi. He says that the chest pain started 30 minutes ago and felt like a lot of pressure in the centre of his chest. He has no allergies. He takes a blood pressure medication, but cannot recall the medication’s name. He had a heart attack 2 years ago that felt very much like the pain he was having today. His last meal was 6 hours ago. The pain started while he was walking home carrying several heavy bags, though he now has no pain. His vital signs, ABCDE survey, and head-to-toe examination are normal. You have given aspirin and started an IV line and will now handover to an inpatient provider. Handover summary: This is a 75-year-old man with a history of a heart attack who has had chest pain similar to his prior heart attack. The pain started while he was walking and lasted for more than 30 minutes, but is now gone. He has received aspirin and has an IV line. I am concerned he might have problems with his heart. He should be monitored for change in ABCDE or return of the chest pain. 202 Notes ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE GLOSSARY REFS & QUICK CARDS 203 PARTICIPANT WORKBOOK GLOSSARY ABCDE The initial steps of any patient assessment, which includes assessing and treating Airway, Breathing, Circulation, Disability and Exposure. Accessory muscle use Use of muscles other than the diaphragm to assist in breathing (commonly the neck, chest wall, and abdominal muscles). May appear as indrawing/retractions between the ribs, or in the neck muscles. Altered mental status (AMS) Term used for a range of presentations from changes in behaviour or memory, to disorientation, confusion and coma. AMS See altered mental status. Anaemia Decreased concentration of red blood cells, leading to a decreased ability to carry oxygen. Anaphylaxis A severe allergic reaction that can cause shock. Asthma A condition causing mucus production and intermittent spasm in the bronchial airways, resulting in narrowing that causes wheezing. AVPU A system to assess level of consciousness: Alert, Verbal, Pain, and Unresponsive. Bag-valve-mask (BVM) device A manual handheld device consisting of an air-filled bag connected to a mask. The bag is compressed by hand to deliver a breath as the mask is held to the patient’s face. Bolus A defined volume of fluid or other substance given rapidly, usually intravenously. Bradycardia Heart rate lower than normal range. BVM See “bag-valve-mask device”. GLOSSARY 204 Capillary refill A marker of perfusion, checked by pushing on the fingernail, palms or soles and releasing to see long it takes for the colour to come back to the skin (blood flow to return). The normal range is less than 3 seconds. Cardiopulmonary resuscitation (CPR) Performing chest compressions and ventilation with the goal of resuscitating a patient with no pulse. Cervical spine (C-spine) The part of the spine in the neck, containing the first seven vertebrae. Circumferential burn Burns that extend around a body part can act like a rigid band and may limit blood supply (to a limb) or breathing (burn around the chest or abdomen). Cholera Bacterial infection causing a profound watery diarrhoea, often described as rice-water stools. Chronic obstructive pulmonary disease (COPD) Term describing breakdown of lung structure (emphysema) and chronic inflammation causing spasm of the lower airways and wheezing. Coma Prolonged state of unconsciousness. Compartment syndrome A condition of increased pressure from swelling in an area of the body that cannot expand, such as compartments in the forearm or lower leg. Compartment syndrome reduces blood flow to the area and may result in severe pain as well as damage to nerves and other tissues. Confusion Problems with clarity, recall and organization of thought. Convulsion See Seizure. CPR See cardiopulmonary resuscitation. Crackles High pitched sound, like crumpling of a paper bag, heard with a stethoscope. Crackles are caused by fluid in the airspaces of the lungs. Also called rales or crepitations (creps). SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 205 Crepitations See “Crackles”. Crepitus Crackling or popping when pressing on the skin or bones. Cyanosis Blue colouring to the skin or lips, resulting from low blood oxygen levels. Decontamination Removing a dangerous substance, such as chemicals, toxins or infectious materials, from a person’s skin or clothes. Depending on the substance, this is done by brushing off the substance or irrigating with water. Deep wound packing Tight packing of a large or gaping wound with clean, compact gauze to ensure that external pressure can effectively compress an area of bleeding that is too large or too deep to compress otherwise. Defibrillator Machine that delivers high-energy electrical current to convert abnormal heart rhythms. Dehydration Decreased fluid in the body. Delirium Rapidly changing state of confusion, characterized by agitation, loss of focus and inability to interact appropriately. Dementia Chronic condition characterized by abnormal mental state, including loss of memory and problems with thinking. There is often no change in ability to focus on the present. Destination planning Planning the choice of destination facility for transport or transfer in order to best match transport time and the level of services available at the receiving facility to the patient’s clinical needs. Diabetic ketoacidosis (DKA) A condition occurring in diabetics in which lack of insulin causes elevated blood sugar, leading to severe dehydration and build-up of acid in the blood. Diaphoresis Sweating. DIB See difficulty in breathing. GLOSSARY 206 DKA See Diabetic Ketoacidosis. Dilation (of blood vessels) The enlargement or stretching of a part of the body (e.g. blood vessels). Difficulty in breathing (DIB) The feeling of difficulty in breathing (sometimes also called shortness of breath, or SOB) can result from many causes, including problems with the lungs, problems with oxygen, airway blockage, fast breathing, weak respiratory muscles. Direct pressure A way to control external bleeding (haemorrhage) from a wound by applying firm pressure with two or three fingers at the site of bleeding. Disposition The next step in care of a patient – this may be handover of care to another provider through admission or transfer, or discharge to home. Drowning Compromise of breathing from water in the lungs, usually resulting from prolonged time under water. Eclampsia A condition when a pregnant or newly delivered woman has seizures, high blood pressure, and protein in the urine. It can progress to coma and is life-threatening. (“Pre-eclampsia” is diagnosed based on specific criteria and identifies a woman at high-risk of progression to eclampsia.) Ectopic pregnancy A pregnancy outside of the uterus, most often in the fallopian tubes. As an ectopic embryo grows, it may damage the surrounding structures, causing sudden severe bleeding. Ruptured ectopic pregnancy is a surgical emergency. Envenomation The process by which venom is injected by the bite (or sting) of a venomous animal. Escharotomy A surgical procedure to cut and release burned tissue that may restrict breathing or blood supply to a limb. Flail chest When multiple rib fractures in more than one place cause a segment of the rib cage to be separated from the rest of the chest wall and prevent normal breathing movement. SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 207 Fluid status The level of fluid in the body. It can be low (dehydration), normal, or high (fluid overload and/ or oedema). Fontanelle A gap (soft spot) between the developing bones of the skull in babies – changes in the volume of fontanelles may reflect fluid status. Fontanelles normally close between 12 and 18 months of age. Foreign body An object from outside the body (e.g. a foreign body in the airway). Fracture A broken or cracked bone. GCS See Glasgow Coma Scale. Gastroenteritis Infection or inflammation of the stomach and intestine that can cause vomiting, diarrhoea and abdominal pain. Glasgow Coma Scale (GCS) A system of assessing the neurologic function of a trauma patient. It is a score ranging from 3 (unresponsive) to 15 (normal) that assesses responsiveness based on eye movement, verbal response and motor response. Guarding Voluntary or involuntary contraction of the abdominal wall muscles when pressing on the abdomen. Handover A brief summary of critical patient information given by the current provider any time a patient is transferred to a new provider. Handover summarizes the clinical presentation, the care the patient has received, and alerts the new provider of any potential complications. Handover should always be given to transport providers, in addition to receiving-facility providers. Handover should also be given even when care is transferred to a new provider within the same facility. Haemorrhage Large volume bleeding. It may occur externally or within the body. Haemorrhagic shock A state of poor perfusion due to substantial blood loss. GLOSSARY 208 Haematoma Bleeding or a collection of blood within the tissues, outside of the vascular space. Also called bruising. Haemothorax Blood in the space between the chest wall and the lungs. Heart attack (Also called myocardial infarction). Death of heart muscle due to a lack of oxygen-rich blood getting to the heart. Heart failure When the heart fails to pump enough blood to perfuse the organs, usually resulting in oedema in the lungs or extremities. Hives Multiple itchy, red and raised areas on the skin suggestive of an allergic reaction. Human Immunodeficiency Virus (HIV) A virus that weakens the immune system and can lead to AIDS, a syndrome of multiple infections. Hyperthermia High body temperature. Hyperventilation Increased (fast) rate of breathing. Hyperresonance Hollow sounds with percussion. Hypoglycaemia Low blood sugar. Hypothermia Low body temperature. Hypotension Blood pressure lower than the normal range. Hypovolaemic shock Poor perfusion due to low blood volume, which may result from decreased fluid intake or severe fluid or blood loss. Hypoxia Low levels of oxygen in the blood. SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 209 Inflammation Redness and swelling that may result from trauma, infection, allergy or other causes. Ingestion Swallowing a substance – generally used for dangerous substances or doses. Inhalation injury Inflammation or oedema of the airways or lungs resulting from breathing hot gases or irritating chemicals (most commonly smoke inhalation in the setting of fire). Intubation Placing a breathing tube through the mouth, down the throat, and through the vocal cords to allow ventilation of the lungs by bag device or ventilator. Ischaemia Inadequate oxygen and blood supply to tissues that can lead to tissue death (myocardial ischaemia, or lack of oxygen to the heart muscle, is an example). IV (abbreviation for intravenous) Often used to refer to an intravenous catheter, or for the intravenous route of administration of a medication or fluid. Kangaroo care Using skin to skin contact between a newborn infant and mother and covering the child’s head and exposed body, to prevent hypothermia and promote bonding. Laceration A cut or slice to the tissues. Large-bore IV A large IV catheter is needed for rapid volume resuscitation. Ideally, these catheters should be placed in larger blood vessels (that tend to be closer to the heart, like the antecubital fossa in the arms or large veins in the neck). In adults, this is usually defined as 14- or 16-gauge, though in some settings, 18 may be the largest available gauge. Level of consciousness Describes the level of responsiveness or alertness to the environment. Lethargy Excessive drowsiness and slowness to respond. Log roll A method of rolling a person to the side while preventing the spine from bending. Usually performed when spinal injury is suspected to prevent additional damage. GLOSSARY 210 Nasal flaring The widening of nostrils during breathing – it results from increased effort, and is a sign of difficulty in breathing. Nasopharyngeal airway (NPA) A rubber tube inserted through the nostril that reaches to the opening of the throat to allow air to pass. Needle decompression Insertion of a needle into the chest wall to relieve the pressure of a tension pneumothorax. Oedema Abnormal swelling or fluid build-up in the body tissues, outside the vascular space. Oral rehydration solution (ORS) A water, glucose, and salt mixture given by mouth or nasogastric tube to dehydrated patients to replace fluid losses. Orientation Describes a person’s relationship to the surrounding world, including the ability to accurately identify one’s own name and location, as well as the current time and date. Oropharyngeal airway (OPA) A plastic device inserted through the mouth that reaches to the opening of the throat to prevent the tongue from blocking the airway and allows air to pass. ORS See “Oral rehydration solution”. Oxygen (O2) saturation Percent of oxygen in the blood. Parkland Formula A formula used to estimate the amount of IV fluid needed for resuscitation of a burn patient over the first 24 hours after the burn. It is: 4 ml fluid X weight in kilograms X total burn surface area. Half should be given over the first 8 hours, and half over the next 16 hours. Percussion Tapping on the chest wall to assess the lungs. The quality of the sound on tapping may indicate fluid or air in the lungs. Perfusion The delivery of blood to body tissues. Pericardial effusion Fluid in the sac around the heart (the pericardium). SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 211 Pericardial tamponade A critical build-up of fluid in the sac around the heart (the pericardium) that compresses the heart and interferes with normal pumping of blood to the body, leading to shock. Personal protective equipment (PPE) Equipment meant to be worn by a person to protect from infection or injury. This can include gloves, goggles, and protective clothing such as aprons or fluid resistant gowns. Pleural effusion Abnormal fluid collection around the lung that can cause difficulty in breathing and even lung collapse. Common causes include tuberculosis and other infections, heart failure and cancer. Pleuritic pain Pain that is worse with breathing, usually caused by inflammation. Pneumonia Infection of the lungs. Pneumothorax Air in the space between the lungs and the chest wall (pleural space) that causes the lung to collapse. Pre-eclampsia See Eclampsia. Priapism Persistent, abnormal erection of the penis. Psychosis Broadly defined as loss of contact with reality. Pulmonary embolism Blood clot travelling to and blocking the vessels of the lungs. The most common source is the legs. Pulse oximeter Device that detects oxygen saturation (the percentage of red blood cells saturated with oxygen). Rabies A virus that is transmitted through animal bites that affects the brain and nerves and can cause altered mental status. Rebound tenderness Pain that occurs when releasing pressure on the abdomen (as opposed to when pressing on the abdomen). GLOSSARY 212 Resuscitation Time-sensitive interventions performed in an attempt to manage life-threatening conditions. Retractions (sometimes also called “in-drawing” or “recessions”) The visible pulling in of tissues between the ribs or around the collarbones with strained inspiration. Retractions are a sign of serious difficulty in breathing. SAMPLE history An approach to asking key history findings for all patients. SAMPLE stands for: S – Signs and Symptoms, A – Allergies, M – Medications, P – Past history, L – Last oral intake, E – Events surrounding the illness or injury. Seizure Also called convulsions or fits. Abnormal electrical activity in the brain, often seen as altered mental status with abnormal repetitive movements. Seizures may be a primary condition or may be caused by infection, injury, toxins or chemical balance problems. Shock A state where organs do not get enough blood and oxygen (poor perfusion), leading to organs not working properly. Skin pinch testing An easy way to check hydration status in children by pinching the skin, usually on the abdomen. Well-hydrated skin should return to normal in less than 2 seconds. Sprain A stretched, pulled, or torn ligament. Stridor A high pitched sound on breathing in that is caused by swelling or a physical obstruction of the upper airway. Stroke Death of brain tissue due to ischaemia from either blood clot or haemorrhage. Sucking chest wound A wound in the chest wall that allows air in and out of the chest cavity, indicating an open pneumothorax. Tachycardia Heart rate faster than normal range. Tachypnoea Rapid breathing. SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 213 Tension pneumothorax Occurs when a pneumothorax causes sufficient pressure inside the chest cavity that blood vessels collapse (reducing the amount of blood that can return to the heart, and the heart cannot fill or pump enough blood to maintain perfusion of the organs). Tracheal shift Describes a change in the position of the trachea to either side of midline, a finding sometimes associated with tension pneumothorax. Trauma primary survey The trauma primary survey is another term for the ABCDE approach in injured patients. It includes initial assessment of an injured person and management of all immediately life- threatening injuries, in order of priority. The primary survey consists of the ABCDE: Airway, Breathing, Circulation, Disability and Exposure. Trauma secondary survey The head-to-toe (front and back) examination of the trauma patient that includes taking a SAMPLE history. The purpose of this survey is to identify and treat all injuries, with priority given to any hidden life-threatening conditions that were missed by the primary survey. Tripod position Sitting upright with neck extended but leaning slightly forward with hands on knees. People with severe difficulty in breathing will often sit in this position. Wheezing A whistling sound made when breathing out due to inflammation in the lungs, suggestive of lower airway swelling. WHO sources 214 WHO sources Emergency Triage Assessment and Treatment (ETAT). Geneva: World Health Organization; 2005. June 2016 update. Integrated Management of Adolescent and Adult Illness (IMAI) District Clinician Manual. Volume 1 and 2. Geneva: World Health Organization; 2011:Chapter 2–4; 6–8. Pocket book for hospital care of children. Second edition. Geneva: World Health Organization; 2013. GLOSSARY SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE REFS & QUICK CARDS PARTICIPANT WORKBOOK 215 Basic Emergency Care Quick Cards
217 ABCDE APPROACH REMEMBER... Always check for signs of trauma [see also TRAUMA card] ASSESSMENT FINDINGS IMMEDIATE MANAGEMENT Airway A Unconscious with limited or no air movement If NO TRAUMA: head-tilt and chin-lift, use OPA or NPA to keep airway open, place in recovery position or position of comfort. If possible TRAUMA: use jaw thrust with c-spine protection and place OPA to keep the airway open (no NPA if facial trauma). Foreign body in airway Remove visible foreign body. Encourage coughing. • If unable to cough: chest/abdominal thrusts/back blows as indicated • If patient becomes unconscious: CPR Gurgling Open airway as above, suction (avoid gagging). Stridor Keep patient calm and allow position of comfort. • For signs of anaphylaxis: give IM adrenaline • For hypoxia: give oxygen Breathing B Signs of abnormal breathing or hypoxia Give oxygen. Assist ventilation with BVM if breathing NOT adequate. Wheeze Give salbutamol. For signs of anaphylaxis: give IM adrenaline. Signs of tension pneumothorax (absent sounds / hyperresonance on one side WITH hypotension, distended neck veins) Perform needle decompression, give oxygen and IV uids. Will need chest tube Signs of opiate overdose (AMS and slow breathing with small pupils) Give naloxone. Circulation C Signs of poor perfusion/shock If no pulse, follow relevant CPR protocols. Give oxygen and IV uids. Signs of internal or external bleeding Control external bleeding. Give IV uids. Signs of pericardial tamponade (poor perfusion with distended neck veins and mu ed heart sounds) Give IV fl uids, oxygen. Will need rapid pericardial drainage Disability D Altered mental status (AMS) If NO TRAUMA, place in recovery position. Seizure Give benzodiazepine. Seizure in pregnancy (or after recent delivery) Give magnesium sulphate. Hypoglycaemia Give glucose if <3.5 mmol/L or unknown. Signs of opiate overdose (AMS with slow breathing with small pupils) Give naloxone. Signs of life-threatening brain mass or bleed (AMS with unequal pupils) Raise head of bed, monitor airway. Will need rapid transfer for neurosurgical services Exposure E Remove wet clothing and dry skin thoroughly. Remove jewelry, watches and constrictive clothing Prevent hypothermia and protect modesty. Snake bite Immobilize extremity. Send picture of snake with patient. Call for anti-venom if relevant. If cause unknown, remember trauma: Examine the entire body and always consider hidden injuries [see also TRAUMA card] REMEMBER: PATIENTS WITH ABNORMAL ABCDE FINDINGS MAY NEED RAPID HANDOVER/TRANSFER. PLAN EARLY. 218 SPECIAL CONSIDERATIONS IN THE ASSESSMENT OF CHILDREN A • Children have bigger heads and tongues, and shorter, softer necks than adults. Position airway as appropriate for age. • Always consider foreign bodies. B • Look for signs of increased work of breathing (e.g. chest indrawing, retractions, nasal aring). • Listen for abnormal breath sounds (e.g. grunting, stridor, or silent chest). AGE RESPIRATORY RATE (breaths per minute) <2 months 40–60 2–12 months 25–50 1–5 years 20–40 C • Signs of poor perfusion in children include: slow capillary re ll, decreased urine output, lethargy, sunken fontanelle, poor skin pinch • Look for signs of anaemia and malnourishment (adjust uids). • Remember that children may not always report trauma and may have serious internal injury with few external signs. AGE (in years) NORMAL HEART RATE (beats per minute) <1 100–160 1–3 90–150 4–5 80–140 D • Always check AVPU • Hypoglycaemia is common in ill children. • Check for tone and response to stimulus. • Look for lethargy or irritability. E INFANTS AND CHILDREN HAVE DIFFICULTY MAINTAINING TEMPERATURE • Remove wet clothing and dry skin thoroughly. Place infants skin-to-skin when possible. • For hypothermia, cover the head (but be sure mouth and nose are clear). • For hyperthermia, unbundle tightly wrapped babies. DANGER SIGNS IN CHILDREN • Signs of airway obstruction (unable to swallow saliva/ drooling or stridor) • Increased breathing e ort (fast breathing, nasal aring , grunting, chest indrawing or retractions) • Cyanosis (blue colour of the skin, especially at the lips and ngertips) • Altered mental status (including lethargy or unusual sleepiness, confusion, disorientation) • Moves only when stimulated or no movement at all (AVPU other than “A”) • Not feeding well, cannot drink or breastfeed or vomiting everything • Seizures/convulsions • Low body temperature (hypothermia) ESTIMATED WEIGHT in KILOGRAMS for CHILDREN 1–10 YEARS OLD: [age in years + 4] x 2 NORMAL ADULT VITAL SIGNS Pulse rate: 60–100 beats per minute Respiratory rate: 10–20 breaths per minute Systolic blood pressure >90 mmHg Estimating systolic blood pressure (not reliable in children and the elderly): Carotid (neck) pulse SBP ≥ 60 mmHg Femoral (groin) pulse SBP ≥ 70 mmHg Radial (wrist) pulse SBP ≥80 mmHg SAMPLE History Signs & Symptoms Allergies Medications PMH Last oral intake Events APPROACH TO THE PATIENT WITH TRAUMA Key findings from the Trauma Primary Survey [see also ABCDE card] ASSESSMENT FINDINGS IMMEDIATE MANAGEMENT Airway A Not speaking, with limited or no air movement Use jaw thrust with c-spine protection. Suction if needed, remove visible foreign objects. Place OPA to keep the airway open. Signs of possible airway injury (neck haematoma or wound, crepitus, stridor) Give oxygen. Monitor closely-- swelling can rapidly block the airway. Will need advanced airway management Signs of possible airway burns (soot around the mouth or nose, burned facial hair, facial burns) Give oxygen. Monitor closely-- swelling can rapidly close the airway. Will need advanced airway management Breathing B Signs of tension pneumothorax (hypotension with absent breath sounds/hyperresonance on one side, distended neck veins) Perform needle decompression. Give oxygen, IV uids. Will need chest tube Open (sucking) chest wound Give oxygen, place 3-sided dressing, monitor for tension pneumothorax. Will need chest tube Breathing not adequate Give oxygen, assist ventilation with BVM. Large burns of chest or abdomen (or circumferential burn to limb) Give IV uids per burn size, give oxygen, remove constricting clothing/jewelry. May need escharotomy Signs of ail chest (section of chest wall moving in opposite direction with breathing) Give oxygen. May need advanced airway management and assisted ventilation Signs of haemothorax (decreased breath sounds on one side, dull sounds with percussion) Give oxygen, IV uids. Will need chest tube Circulation C Signs of shock (capillary re ll >3 sec, hypotension, tachycardia) Give oxygen, IV uids, control external bleeding, splint femur/pelvis as indicated. Uncontrolled external bleeding Apply pressure, deep wound packing or tourniquet as indicated. Signs of tamponade (poor perfusion, distended neck veins, mu ed heart sounds) Give IV uids, oxygen. Disability D Signs of brain injury (AMS with wound, deformity or bruising of head/face) Immobilize cervical spine, check glucose, give nothing by mouth. Will need neurosurgical care Signs of open skull fracture (as above, with blood or uid from the ears/nose) As above, and give IV antibiotics per local protocol. REMEMBER: INJURED PATIENTS WITH ABNORMAL ABCDE FINDINGS MAY NEED RAPID HANDOVER/TRANSFER TO A SURGICAL SERVICE. PLAN EARLY. 219 APPROACH TO THE PATIENT WITH TRAUMA Key fi ndings from the Trauma Primary Survey [see also ABCDE card] ASSESSMENT FINDINGS IMMEDIATE MANAGEMENT Airway A Not speaking, with limited or no air movement Use jaw thrust with c-spine protection. Suction if needed, remove visible foreign objects. Place OPA to keep the airway open. Signs of possible airway injury (neck haematoma or wound, crepitus, stridor) Give oxygen. Monitor closely-- swelling can rapidly block the airway. Will need advanced airway management Signs of possible airway burns (soot around the mouth or nose, burned facial hair, facial burns) Give oxygen. Monitor closely-- swelling can rapidly close the airway. Will need advanced airway management Breathing B Signs of tension pneumothorax (hypotension with absent breath sounds/hyperresonance on one side, distended neck veins) Perform needle decompression. Give oxygen, IV uids. Will need chest tube Open (sucking) chest wound Give oxygen, place 3-sided dressing, monitor for tension pneumothorax. Will need chest tube Breathing not adequate Give oxygen, assist ventilation with BVM. Large burns of chest or abdomen (or circumferential burn to limb) Give IV uids per burn size, give oxygen, remove constricting clothing/jewelry. May need escharotomy Signs of ail chest (section of chest wall moving in opposite direction with breathing) Give oxygen. May need advanced airway management and assisted ventilation Signs of haemothorax (decreased breath sounds on one side, dull sounds with percussion) Give oxygen, IV uids. Will need chest tube Circulation C Signs of shock (capillary re ll >3 sec, hypotension, tachycardia) Give oxygen, IV uids, control external bleeding, splint femur/pelvis as indicated. Uncontrolled external bleeding Apply pressure, deep wound packing or tourniquet as indicated. Signs of tamponade (poor perfusion, distended neck veins, mu ed heart sounds) Give IV uids, oxygen. Disability D Signs of brain injury (AMS with wound, deformity or bruising of head/face) Immobilize cervical spine, check glucose, give nothing by mouth. Will need neurosurgical care Signs of open skull fracture (as above, with blood or uid from the ears/nose) As above, and give IV antibiotics per local protocol. REMEMBER: INJURED PATIENTS WITH ABNORMAL ABCDE FINDINGS MAY NEED RAPID HANDOVER/TRANSFER TO A SURGICAL SERVICE. PLAN EARLY. 220 MANAGEMENT OF SPECIFIC CONDITIONS Facial fracture Immobilize cervical spine if indicated, give IV antibiotics for open fractures, avoid nasal airway/ nasogastric tubes. Penetrating eye injury Avoid pressure on the eye, stabilize but do not remove foreign objects, give antibiotics and tetanus, elevate head of bed. Open abdominal wound Give IV uids, nothing by mouth. Cover visible bowel with sterile gauze soaked in sterile saline, give antibiotics. Pelvic fracture Give IV uids, stabilize with sheet or pelvic binder. Fracture with poor limb perfusion Reduce fracture, splint. Open fracture Irrigate well, dress wound, splint, give antibiotics, rapid handover for operative management. Penetrating object Leave object in place and stabilize it to prevent further injury. Crush injury Give IV uids, monitor urine output, monitor for compartment syndrome. Burn injury Assess size and calculate uid needs, give IV uids and oxygen, monitor for airway oedema. Blast injury Give oxygen, treat burns as below, give IV uids, monitor closely for delayed e ects of internal injury. REMEMBER: INJURED PATIENTS WITH WOUNDS, INCLUDING BURNS AND OPEN FRACTURES, NEED TETANUS VACCINATION. HIGH-RISK MECHANISMS AND INJURIES High-Risk Mechanisms High-Risk Injuries • Pedestrian or cyclist hit by a vehicle • Motorcycle crash or any vehicle crash with unrestrained occupants • Falls from heights greater than 3 metres (or twice a child’s height) • Gunshot or stabbing • Explosion or re in an enclosed space. • Penetrating injuries to head, neck or torso • Blast or crush injuries • Flail chest • Two or more large bone fractures, or pelvic fracture • Spinal injury • Limb paralysis • Amputation above wrist or ankle SPECIAL CONSIDERATIONS IN CHILDREN • Children can look well but then deteriorate quickly. • Children have more exible bones than adults and can have serious internal injuries with few external signs. • Use caution when calculating uid and medication dosages. Use exact weight whenever possible. • Watch carefully for hypothermia and hypoglycaemia. DISPOSITION Conditions that require handover or transfer to a specialist unit include: • ABCDE nding that has required intervention • Evidence of internal bleeding • Any pneumothorax or sucking chest wound • Shock, even if treated successfully • Altered mental status • Trauma during pregnancy • ABCDE abnormalities or any chest /abdomen injury in a child • Signi cant burn injuries Considerations for transfer: • Any patient who has required oxygen should have oxygen during transport and after handover. • For signs of shock, ensure IV uid started and continued during transfer. • Control any external bleeding and monitor site closely during transport. APPROACH TO THE PATIENT WITH DIFFICULTY IN BREATHING Key ABCDE Findings (Always perform a complete ABCDE approach rst!) IF YOU FIND... REMEMBER... Choking, coughing Foreign body Stridor Partial airway obstruction due to foreign body or in ammation (from infection, chemical exposure or burn) Facial swelling Severe allergic reaction, medication e ect Drooling Indicates a blockage to swallowing Soot around the mouth or nose, burned facial hair, facial burns Smoke inhalation and airway burns – rapid swelling can block the airway Signs of chest wall trauma Rib fracture, ail chest, pneumothorax, contusion, tamponade Decreased breath sounds on one side Pneumothorax (consider tension pneumothorax if with hypotension and hyperresonance to percussion), haemothorax, large pleural e usion/pneumonia Decreased breath sounds and crackles on both sides Pulmonary oedema, heart failure Wheezing Asthma, allergic reaction, COPD Fast or deep breathing DKA Low blood pressure, tachycardia, mu ed heart sounds Pericardial tamponade Altered mental status with small pupils and slow breathing Opioid overdose Key Findings from the SAMPLE History and Secondary Exam IF YOU FIND... REMEMBER... DIB worse with exertion or activity Heart failure, heart attack DIB that began with choking or during eating Foreign body, allergic reaction History of fever, cough Pneumonia, infection Pesticide exposure Poisoning Recent fall or other trauma Rib fracture, ail chest, pneumothorax, contusion, tamponade Known allergies, allergen exposure, bite or sting Allergic reaction Recent medication or dose change Allergic reaction or side e ect History of opioid or sedative drug use Overdose History of wheezing Asthma or COPD History of diabetes DKA History of tuberculosis or malignancy Pericardial tamponade, pleural e usion History of heart failure Pulmonary oedema History of sickle cell disease Acute chest syndrome 221 APPROACH TO THE PATIENT WITH DIFFICULTY IN BREATHING Key ABCDE Findings (Always perform a complete ABCDE approach rst!) IF YOU FIND... REMEMBER... Choking, coughing Foreign body Stridor Partial airway obstruction due to foreign body or in ammation (from infection, chemical exposure or burn) Facial swelling Severe allergic reaction, medication e ect Drooling Indicates a blockage to swallowing Soot around the mouth or nose, burned facial hair, facial burns Smoke inhalation and airway burns – rapid swelling can block the airway Signs of chest wall trauma Rib fracture, ail chest, pneumothorax, contusion, tamponade Decreased breath sounds on one side Pneumothorax (consider tension pneumothorax if with hypotension and hyperresonance to percussion), haemothorax, large pleural e usion/pneumonia Decreased breath sounds and crackles on both sides Pulmonary oedema, heart failure Wheezing Asthma, allergic reaction, COPD Fast or deep breathing DKA Low blood pressure, tachycardia, mu ed heart sounds Pericardial tamponade Altered mental status with small pupils and slow breathing Opioid overdose Key Findings from the SAMPLE History and Secondary Exam IF YOU FIND... REMEMBER... DIB worse with exertion or activity Heart failure, heart attack DIB that began with choking or during eating Foreign body, allergic reaction History of fever, cough Pneumonia, infection Pesticide exposure Poisoning Recent fall or other trauma Rib fracture, ail chest, pneumothorax, contusion, tamponade Known allergies, allergen exposure, bite or sting Allergic reaction Recent medication or dose change Allergic reaction or side e ect History of opioid or sedative drug use Overdose History of wheezing Asthma or COPD History of diabetes DKA History of tuberculosis or malignancy Pericardial tamponade, pleural e usion History of heart failure Pulmonary oedema History of sickle cell disease Acute chest syndrome 222 CRITICAL ACTIONS FOR HIGH-RISK CONDITIONS CHOKING unable to cough, not making sounds STRIDOR high pitched sounds on breathing IN WHEEZING high pitched sounds on breathing OUT SEVERE INFECTION TRAUMA Remove any visible foreign body Perform age- appropriate chest/ abdominal thrusts or back blows CPR if becomes unconscious Keep patient calm and allow position of comfort IM adrenaline for suspected allergic reaction Oxygen if concern for hypoxia Early handover/ transfer for advanced airway management Give salbutamol IM adrenaline for suspected allergic reaction Oxygen if concern for hypoxia Oxygen Antibiotics Oral/IV uids as appropriate Oxygen Needle decompression and IV uids for tension pneumothorax Three-sided dressing for sucking chest wound Rapid transfer to surgical service SPECIAL CONSIDERATIONS IN CHILDREN THE FOLLOWING ARE DANGER SIGNS IN CHILDREN WITH BREATHING COMPLAINTS: • Fast breathing • Increased breathing e ort (chest indrawing/retractions) • Cyanosis • Altered mental status (including lethargy) • Poor feeding or drinking, or vomits everything • Seizures/convulsions, current or recent • Drooling or stridor when calm • Hypothermia Wheezing in children is often caused by an object inhaled into the airway, viral infection or asthma. Stridor in children is often caused by an object stuck in the airway or airway swelling from infection. Fast or deep breathing can indicate diabetic crisis (DKA), which may be the rst sign of diabetes in a child. FAST BREATHING MAY BE THE ONLY SIGN OF A SERIOUS BREATHING PROBLEM IN A CHILD. DISPOSITION Salbutamol and IM adrenaline e ects last for about 3 hours, and life-threatening symptoms may recur. Monitor closely, always have repeat dose available during transport and caution new providers at handover. Naloxone lasts approximately 1 hour, and most opioids last longer. Monitor closely, always have repeat dose available during transport and caution new providers. Following immersion in water (drowning), a person may develop delayed breathing problems after several hours. Monitor closely and caution new providers. Never leave patients with di culty in breathing unmonitored during handover/transfer. Make transfer arrangements as early as possible for any patient who may require intubation or assisted ventilation. 223 CRITICAL ACTIONS FOR HIGH-RISK CONDITIONS CHOKING unable to cough, not making sounds STRIDOR high pitched sounds on breathing IN WHEEZING high pitched sounds on breathing OUT SEVERE INFECTION TRAUMA Remove any visible foreign body Perform age- appropriate chest/ abdominal thrusts or back blows CPR if becomes unconscious Keep patient calm and allow position of comfort IM adrenaline for suspected allergic reaction Oxygen if concern for hypoxia Early handover/ transfer for advanced airway management Give salbutamol IM adrenaline for suspected allergic reaction Oxygen if concern for hypoxia Oxygen Antibiotics Oral/IV uids as appropriate Oxygen Needle decompression and IV uids for tension pneumothorax Three-sided dressing for sucking chest wound Rapid transfer to surgical service SPECIAL CONSIDERATIONS IN CHILDREN THE FOLLOWING ARE DANGER SIGNS IN CHILDREN WITH BREATHING COMPLAINTS: • Fast breathing • Increased breathing e ort (chest indrawing/retractions) • Cyanosis • Altered mental status (including lethargy) • Poor feeding or drinking, or vomits everything • Seizures/convulsions, current or recent • Drooling or stridor when calm • Hypothermia Wheezing in children is often caused by an object inhaled into the airway, viral infection or asthma. Stridor in children is often caused by an object stuck in the airway or airway swelling from infection. Fast or deep breathing can indicate diabetic crisis (DKA), which may be the rst sign of diabetes in a child. FAST BREATHING MAY BE THE ONLY SIGN OF A SERIOUS BREATHING PROBLEM IN A CHILD. DISPOSITION Salbutamol and IM adrenaline e ects last for about 3 hours, and life-threatening symptoms may recur. Monitor closely, always have repeat dose available during transport and caution new providers at handover. Naloxone lasts approximately 1 hour, and most opioids last longer. Monitor closely, always have repeat dose available during transport and caution new providers. Following immersion in water (drowning), a person may develop delayed breathing problems after several hours. Monitor closely and caution new providers. Never leave patients with di culty in breathing unmonitored during handover/transfer. Make transfer arrangements as early as possible for any patient who may require intubation or assisted ventilation. APPROACH TO THE PATIENT WITH SHOCK Key ABCDE Findings (Always perform a complete ABCDE approach fi rst!) IF YOU FIND... REMEMBER... Di culty breathing, stridor/wheezing, skin rash, swelling of mouth Severe allergic reaction Hypotension with absent breath sounds and hyperresonance on one side, distended neck veins Tension pneumothorax Distended neck veins, mu ed heart sounds, tachycardia, hypotension Pericardial tamponade Sweet smelling breath, deep or rapid breathing DKA History of trauma or no known cause Hidden sources of signi cant blood loss (stomach, intestines, intra-abdominal, chest, long-bone trauma) or spinal injury Key Findings from the SAMPLE History and Secondary Exam IF YOU FIND... REMEMBER... Vomiting and diarrhoea Ask about contacts and report cases per protocol. Black or bloody vomit or stool Stomach or intestinal bleeding Rapid or deep breathing, dehydration, high glucose, sweet- smelling breath, history of frequent urination or known diabetes Diabetic ketoacidosis Burns Severe uid loss (calculate uid needs based on burn size) Fever or HIV Infection Recent fall or other trauma Internal AND external bleeding Pale conjunctiva or malnutrition Severe anemia (adjust uids) Chest pain Heart attack (give aspirin if indicated) Vaginal bleeding Pregnancy and non-pregnancy related bleeding Numbness, weakness or shock that does not improve with uids Spinal shock (immobilize spine if indicated) CRITICAL ACTIONS FOR HIGH-RISK CONDITIONS For all shock: • Give oxygen • Give IV uids – ADULTS: 1 liter RL or NS bolus – CHILDREN with NO severe anaemia, NO malnutrition, NO uid overload: 10–20 ml/kg bolus – CHILDREN with malnutrition or severe anaemia: give 10–15 ml/kg dextrose-containing uid over 1 hour and assess for uid overload every 5 minutes. – For suspected heart attack with shock, give smaller boluses, and monitor closely for uid overload. • Monitor vital signs, mental status, breathing and urine output AND for speci c conditions: SEVERE ALLER- GIC REACTION TENSION PNEUMO- THORAX TAMPONADE FEVER WATERY DIARRHOEA POSTPARTUM BLEEDING DKA TRAUMA IM adrenaline Monitor for recurrence, may need repeat doses Rapid needle decompression Transfer for chest tube Rapid transfer to advanced provider for drainage Antibiotics (and anti- malarials if indicated) Assess for source of infection Full contact precautions Monitor output and continue uids Assess for cholera and notify public health authorities Oxytocin and uterine massage Direct pressure for perineal and vaginal tears Rapid transfer to advanced obstetric care Close monitor- ing for uid over- load in children Handover/ transfer for insulin Control external haemorrhage with direct pressure, wound packing, tour- niquet if indicated Calculate uid needs based on burn size Rapid transfer for sur- gery/transfusion as needed 224 SPECIAL CONSIDERATIONS IN CHILDREN IV FLUID IMMEDIATELY AVAILABLE? IV FLUID AVAILABLE NEARBY? START ORS via NG NASOGASTRIC TUBE REASSESS IMMEDIATELY AFTER BOLUS DID PERFUSION IMPROVE? TRANSFER IMMEDIATELY CONTINUE ORS VIA NG YES YES YES YES No No No No DID PERFUSION IMPROVE? IV FLUIDS REASSESS IMMEDIATELY AFTER BOLUS CONTINUE E <30 MINUTES <30 MINUTES START IV FLUIDS RE-BOLUS GIVING FLUID IN SHOCK NO malnutrition, overload or severe anaemia DISPOSITION Patients with shock should be at a unit capable of providing IV uid resuscitation, blood transfusion, and/or surgery, depending on the type of shock. Maintain uids during transport. Repeat ABCDE approach and monitor perfusion and breathing closely at all times. ASSESSING SHOCK IN CHILDREN The 2016 WHO guidelines for the care of critically ill children use the presence of three clinical features to de ne shock: • Cold extremities • Weak and fast pulse • Capillary re ll greater than 3 seconds Additional important considerations include: • Young children may not be able to drink enough uid on their own. • Children have larger surface area to volume ratio and can lose uids more quickly than adults. • For a child in shock WITH severe malnutrition or uid overload, add dextrose and reduce uids to 10–15 ml/kg over 1 hour. Other important signs of poor perfusion include: • Sunken eyes; sunken fontanelles in infants • Abnormal skin pinch test • Pallor (dehydration with anaemia is more di cult to treat) • Decreased and dark urine (number of nappies for infants) • Low blood pressure • Fast breathing • Altered mental status • Very dry mouth and lips • Lethargy (excessive drowsiness, slow to respond, not interactive) In children without severe malnutrition, severe anaemia or uid overload, give uid resuscitation over 30 minutes. WEIGHT (kg) FLUID VOLUME (15ml/kg) 4 60 6 90 10 150 14 210 20 300 30 450 APPROACH TO THE PATIENT WITH ALTERED MENTAL STATUS (AMS) Key ABCDE Findings (Always perform a complete ABCDE approach fi rst!) IF YOU FIND... REMEMBER... Tachypnoea Hypoxia, DKA, toxic ingestion Poor perfusion/shock Infection, internal bleeding Tachycardia with normal perfusion Alcohol withdrawal Coma Hypoxia, high or low blood glucose, DKA and toxic ingestion Hypoglycaemia Infection, medication side e ect (eg, diabetes medications, quinine) Very small pupils with slow breathing Opioid overdose Seizure/convulsion Abnormal glucose, infection, toxic ingestion (eg, TB meds) or withdrawal (eg, alcohol). Consider eclampsia if current pregnancy or recent delivery. Weakness on one side or unequal pupil size Brain mass or bleed Signs of trauma or unknown cause of AMS Consider brain injury (with possible spine injury) Key Findings from SAMPLE History and Secondary Exam IF YOU FIND... REMEMBER... History of wheezing Severe COPD crisis can cause AMS History of diabetes High or low blood sugar, DKA History of epilepsy Post-seizure confusion and sleepiness should improve over minutes to hours. Prolonged AMS or multiple convulsions without waking up in between require further workup. History of agricultural work or known pesticide exposure Organophosphate poisoning History of regular alcohol use Alcohol withdrawal History of substance use or depression Acute intoxication, accidental or intentional overdose History of HIV Infection, medication side e ect Rash on the lower abdomen or legs or bulging fontanelle in infants Brain infection (meningitis) Fever/Hyperthermia Infectious, toxic, and environmental causes 225 APPROACH TO THE PATIENT WITH ALTERED MENTAL STATUS (AMS) Key ABCDE Findings (Always perform a complete ABCDE approach fi rst!) IF YOU FIND... REMEMBER... Tachypnoea Hypoxia, DKA, toxic ingestion Poor perfusion/shock Infection, internal bleeding Tachycardia with normal perfusion Alcohol withdrawal Coma Hypoxia, high or low blood glucose, DKA and toxic ingestion Hypoglycaemia Infection, medication side e ect (eg, diabetes medications, quinine) Very small pupils with slow breathing Opioid overdose Seizure/convulsion Abnormal glucose, infection, toxic ingestion (eg, TB meds) or withdrawal (eg, alcohol). Consider eclampsia if current pregnancy or recent delivery. Weakness on one side or unequal pupil size Brain mass or bleed Signs of trauma or unknown cause of AMS Consider brain injury (with possible spine injury) Key Findings from SAMPLE History and Secondary Exam IF YOU FIND... REMEMBER... History of wheezing Severe COPD crisis can cause AMS History of diabetes High or low blood sugar, DKA History of epilepsy Post-seizure confusion and sleepiness should improve over minutes to hours. Prolonged AMS or multiple convulsions without waking up in between require further workup. History of agricultural work or known pesticide exposure Organophosphate poisoning History of regular alcohol use Alcohol withdrawal History of substance use or depression Acute intoxication, accidental or intentional overdose History of HIV Infection, medication side e ect Rash on the lower abdomen or legs or bulging fontanelle in infants Brain infection (meningitis) Fever/Hyperthermia Infectious, toxic, and environmental causes 226 CRITICAL ACTIONS FOR HIGH-RISK CONDITIONS (Always check blood glucose in AMS, or give glucose if unable to check.) HYPOGLYCAEMIA OPIOID OVERDOSE LIFE-THREATENING INFECTIONS SEVERE DEHYDRATION TOXIC EXPOSURE OR WITHDRAWAL Give glucose Evaluate for infection Monitor for return of hypoglycaemia Naloxone Monitor need for repeat doses (many opioids last longer than naloxone) IV uids Antibiotics For AMS with fever or rash, consider brain infection (meningitis) – isolate patient and wear mask. Cool if indicated for very high fever (avoid shivering). IV uids Assess for infection Consider DKA Gather history and consult advanced provider for locally- appropriate antidotes. Treat alcohol withdrawal with benzodiazepine. Decontaminate for chemical exposures (eg, pesticides). PAEDIATRIC CONSIDERATIONS ALWAYS consider unwitnessed toxic ingestion Ask about any medications in the household, and any chemicals (eg cleaning products, antifreeze) in or near the house. Check and regularly re-check blood glucose Low blood glucose is common in ill young children. High blood glucose can present with AMS and dehydration. AVOID hypothermia Keep skin-to-skin with mother, cover child’s head. Uncover only the parts you need to see, one at a time, during exam. Danger signs with ingestions • Stridor • Oral chemical burns Monitor closely and arrange handover/transfer for advanced airway management. Monitor uid status closely Paediatric patients are more susceptible to both uid losses and uid overload. DISPOSITION CONSIDERATIONS Patients with AMS who may not be able to protect the airway should never be left alone. Monitor closely and give direct handover to new provider. Naloxone lasts approximately 1 hour. Most opioids last longer-- always alert new providers that patients may need repeat doses. Hypoglycaemia often recurs. Alert new providers to monitor blood glucose frequently in any patient who has been treated for hypoglycaemia. 227 MEDICATIONS MEDICATION DOSAGE INDICATION Adrenaline (Epinephrine) Solution: 1mg in 1ml ampoule (1:1000) Adults: 50 kg or above: 0.5 mg IM (0.5 ml of 1:1000) 40 kg: 0.4 mg (0.4 ml IM of 1:1000) 30 kg: 0.3 mg (0.3 ml IM of 1:1000) Repeat every 5 minutes as needed Children: Anaphylaxis: 0.15 mg IM (0.15ml of 1:1000). Repeat every 5–15 minutes as needed Severe Asthma: 0.01 mg/kg IM up to 0.3mg. Repeat every 15 minutes as needed Anaphylaxis/severe allergic reaction and severe wheezing Acetylsalicylic acid (Aspirin) Oral Tablet: 100 mg, 300 mg 300 mg (preferably chewed or in water) immediately as single dose. Suspected heart attack Diazepam Oral Tablet: 2 mg, 5 mg Solution: 5 mg /1 ml ampoule Adults: First dose: 10 mg slow IV push or 20 mg rectally Second dose after 10 minutes: 5 mg slow IV push or 10 mg rectally Maximum IV Dose: 30 mg Children: First dose: 0.2 mg/kg slow IV push or 0.5 mg/kg rectally. Can repeat half of rst dose after 10 minutes if seizures/convulsions continue. Max IV Dose: 20 mg MONITOR BREATHING CLOSELY in all patients given diazepam. Seizures/ convulsions Glucose (Dextrose) Solution: 50% dextrose (D50), 25% dextrose (D25), or 10% Dextrose (D10) Adults and children greater than 40kg: 25–50 ml IV of D50, or 125–250 ml IV of D10 Children up to 40kg: 5 ml/kg IV of D10 (PREFERRED) 2 ml/kg IV of D25 1 ml/kg IV of D50 If no IV access: 2–5 ml of 50% Dextrose OR sugar solution in buccal space Hypoglycaemia (low blood sugar) Magnesium Sulphate Solution: 1 g in 2 ml ampoule (50% or 500 mg/ml), 5 g in 10 ml ampoule (50% or 500 mg/ml) Give 4 g IV (dilute to a 20% solution and give 20ml) slowly over 20 minutes AND give 10 g IM: 5 g (10 ml of 50% solution) with 1 ml of 2% lidocaine in each buttock. If unable to give IV, give 10 g IM injection only (as above, 5 g in each buttock). If seizures/convulsions recur: after 15 minutes give additional 2 g (10 ml of 20%) IV over 20 minutes. If transport delayed continue: Give 5 g of 50% solution IM with 1 ml of 2% lidocaine every 4h in alternate buttocks. Eclampsia or Pregnant with seizure/convulsion Naloxone Solution: 400 mcg/ml (hydrochloride) in 1 ml ampoule IV: 100 mcg single dose OR IM: 400 mcg single dose May repeat every 5 minutes as needed. May require 0.4 mg/hr infusion for several hours for long-acting opioids. Opioid overdose 228 MEDICATION DOSAGE INDICATION Oxytocin Solution: 10 IU in 1ml ampule Initial Dose: Give 10 IU IM AND start IV uids with 20 IU/L at 60 drops/minute. Once placenta is delivered, continue IV uids with 20 IU/L at 30 drops/minute if still bleeding. If placenta has to be manually removed or uterus does not contract: Repeat 10 IU IM. Continue IV uids with 20 IU/L at 20 drops/minute for one hour after bleeding stops. Max Dose: 3 L of IV uids containing oxytocin. Treatment of postpartum haemorrhage Paracetamol (acetaminophen) Oral Tablet: 250 mg, 500 mg. Rectal Suppositories: 250 mg, 500 mg Adults: 500 mg–1 g oral/rectal every 6hrs Max 4 g daily or max 2 g daily if liver impairment, cirrhosis Children: 10–15 mg/kg oral/rectal up to six times per day Mild to moderate pain, fever, headache Salbutamol (Albuterol) Inhaler: 100 mcg per pu • Adult: Prime with 5 pu s and give 2 pu s via spacer every 2 minutes until improved. • Child: Prime with 5 pu s and give 2 pu s into spacer. Keep spacer in mouth for 3–5 breaths. Repeat until 6 pu s given for < 5 years, or 12 pu s for > 5 years. Nebulizer: (ADULT) 5 mg in 5 ml sterile saline. (CHILD) 2.5 mg in 3 ml sterile saline. For severe wheezing, above doses can be given several times in an hour. Severe wheezing Tetanus Vaccine IM Injection: 0.5 ml (Give for children not up to date; adults with none in 5 years; or status unknown) Wounds (including burns and open fractures) 229 MEDICATION DOSAGE INDICATION Oxytocin Solution: 10 IU in 1ml ampule Initial Dose: Give 10 IU IM AND start IV uids with 20 IU/L at 60 drops/minute. Once placenta is delivered, continue IV uids with 20 IU/L at 30 drops/minute if still bleeding. If placenta has to be manually removed or uterus does not contract: Repeat 10 IU IM. Continue IV uids with 20 IU/L at 20 drops/minute for one hour after bleeding stops. Max Dose: 3 L of IV uids containing oxytocin. Treatment of postpartum haemorrhage Paracetamol (acetaminophen) Oral Tablet: 250 mg, 500 mg. Rectal Suppositories: 250 mg, 500 mg Adults: 500 mg–1 g oral/rectal every 6hrs Max 4 g daily or max 2 g daily if liver impairment, cirrhosis Children: 10–15 mg/kg oral/rectal up to six times per day Mild to moderate pain, fever, headache Salbutamol (Albuterol) Inhaler: 100 mcg per pu • Adult: Prime with 5 pu s and give 2 pu s via spacer every 2 minutes until improved. • Child: Prime with 5 pu s and give 2 pu s into spacer. Keep spacer in mouth for 3–5 breaths. Repeat until 6 pu s given for < 5 years, or 12 pu s for > 5 years. Nebulizer: (ADULT) 5 mg in 5 ml sterile saline. (CHILD) 2.5 mg in 3 ml sterile saline. For severe wheezing, above doses can be given several times in an hour. Severe wheezing Tetanus Vaccine IM Injection: 0.5 ml (Give for children not up to date; adults with none in 5 years; or status unknown) Wounds (including burns and open fractures) TRANSFER AND HANDOVER Arrange transfer • Check that patient needs match the available services at the destination facility (eg, operating theatre open, blood available) • Communicate directly with an accepting provider at the receiving facility prior to departure • Ensure that destination facility can be reached in time given patient condition • Ensure that patient and family are aware of reasons, plan, and destination for transport • Record family contact name and number in sending facility chart and in paperwork sent with patient • Secure patient valuables for transport (whenever possible, leave with family) • A brief written record (including name, date of birth, clinical presentation and all interventions) should ALWAYS accompany the patient. Prepare for needs during transport • PPE for sta • Airway equipment and suction (check if working before departure) • Adequate oxygen (with replacement tank if needed) and bag valve mask (BVM) • IV access: Check that IV is secured prior to transport; consider second IV or backup supply • Medications: Bring additional doses of medications and uids, and consider other medications that may be needed • Prepare for new or recurrent symptoms. • Seizure/convulsion patients: place pads/pillows around patient to limit injury from a seizure during transport. • Watch for vomiting and ensure that airway remains clear, particularly for those with cervical spine immobilization. • Check that there is adequate fuel for transport. • Ensure that telephone or radio is present in vehicle and working Patient positioning • Position patient for best airway opening and breathing. • Use recovery position if no trauma. • If >20 weeks pregnant and NO spine injury: Place pillows along the length of her right back to tilt patient onto her left side. This avoids compression of the large blood vessels by the pregnant uterus. • Check that cervical spine has been immobilized if indicated. • Possible spine injury: use backboard and log-roll manoeuvre to move patients. Check for pressure spots every 2 hours; pad areas with soft material as needed. If >20-weeks pregnant: Tip backboard slightly to the left using a wedge or other materials. • Splint or immobilize fractures to protect soft tissues and decrease pain and bleeding. On-going care during transport • Re-assess the ABCDE approach at least every 15 minutes, including repeat vital signs and glucose checks if patient has been hypoglycaemic • Control bleeding prior to transport and monitor site for new bleeding • Perform regular re-assessment of any splinted extremity • Continue necessary treatments (e.g. oxygen, IV uids, oxytocin, glucose) • Keep the patient from getting too hot or too cold during transport. 230 Paediatric Considerations • Prepare appropriate size equipment and weight-adjusted dosages of critical medications. • Bring a family member or friend, and tell the receiving facility who is accompanying the child. • Remember that critically ill or injured children can look well initially and then worsen quickly. Monitor closely. • Hypothermia and hypoglycaemia are common in children. Monitor closely. SBAR handover • Situation: Basic patient information (e.g. age, sex); chief complaint (the patient’s initial description of the problem, such as di culty in breathing for 3 days, or arm pain after a fall) • Background: 2–4 most important and relevant aspects of patient’s case and/or condition; important ABCDE ndings/ interventions. • Assessment: What you think is wrong with the patient; reason for the handover/transfer. • Recommendations: next steps in treatment plan; potential worsening of the patient’s condition (e.g. need for close airway observation if inhalation burn is suspected); cautions regarding prior therapies or interventions (e.g. time of last adrenaline dose to anticipate return symptoms, need to monitor mental status if sedating medications have been given, need to monitor 3-way dressing for clotting, etc.).
ISBN 978-92-4-151308-1 World Health Organization Avenue Appia 20 1211 Geneva 27 Switzerland Email: emergencycare@who.int B A SIC EM ER G EN C Y C A R E: A pproach to the acutely ill and injured
PA R TI C IP A N T W O R K B O O K B A SIC EM ER G EN C Y C A R E: A pproach to the acutely ill and injured APPROACH TO THE ACUTELY ILL AND INJURED BASIC EMERGENCY CARE APPROACH TO THE ACUTELY ILL AND INJURED Basic emergency care: approach to the acutely ill and injured ISBN (WHO) 978–92–4-151308–1 ISBN (ICRC) 978–2-940396–58–0 © World Health Organization (WHO) and the International Committee of the Red Cross (ICRC), 2018. Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. 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The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization, the International Committee of the Red Cross or the International Federation for Emergency Medicine concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization, the International Committee of the Red Cross or the International Federation for Emergency Medicine in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization and the International Committee of the Red Cross and the International Federation for Emergency Medicine to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization or the International Committee of the Red Cross or the International Federation for Emergency Medicine be liable for damages arising from its use. Design by Inís Communication – www.iniscommunication.com BEC | Contributors Editors Teri Reynolds, Nikki Roddie, Andi Tenner, Heike Geduld. Other contributors of written material Kalie Dove-Maguire, Vijay Kannan, Sean Kivlehan, Nelson Olim, Max Ritzenberg, Stas Salerno Amato, Morgan Broccoli, Farrah Kashfipour, Harald Veen, Lee Wallis Peer reviewers Annet Alenyo, John Brown, Emilie Calvello, Brendan Carr, Keegan Checkett, Matthew Cooke, Megan Cox, Anne Creaton, Rochelle Dicker, Shaheem De Vries, Stephen Dunlop, Rajith Ellawala, George Etoundi, Sabariah Faizah, Scott Fruhan, Nicolaus Glomb, Renee Hsia, Christina Huwer, Muhumpu Kafwamfwa, Joseph Kalanzi, Gamal Khalifa, Olive Kobusingye, Clifford Mann, Edgardo Menendez, Juma Mfinanga, Nee-Kofi Mould-Millman, Hani Mowafi, Andrew Muck, Brittany Murray, Marcos Musafir, Theresa Olasveengen, Gerard O’Reilly, Tom Potokar, Junaid Razzak, Anthony Redmond, Andres Rubiano, Kelly Schmiedeknecht, Chris Stein, Janis Tupesis, Vikas Kapil, and Benjamin Wachira. The following members of the International Liaison Committee on Resuscitation (ILCOR) Pediatric Task Force provided essential peer review on relevant sections: Ng Kee Chong, Allan de Caen, Ian Maconochie, and Remigio Véiz. The following members of the International Federation for Emergency Medicine executive committee provided essential peer review: Peter Cameron, James Ducharme, Jim Holliman, Bob Schafermeyer, and Andrew Singer. Focus groups and pilots We thank the nurses and doctors of Muhimbili National Hospital in Dar es Salaam, United Republic of Tanzania, for their invaluable input during early focus groups: Ally M. Akrabi, Prosper J. Bashaka, Avelina N. Ijumba, Jennifer Jamieson, Khadija H. Juma, Bernard Kepha, Said Kilindimo, Josephine Lazaro, Wendy Lukwambe, Peter S. Mabula, Deogratius Mally, Nyakanda Marwa, Juma Mbugi, Felix D. Mlay, Victoria Mlele, Brittany Murray, Kissa Mwampagama, Meera Nariadhara, Catherine R. Shari, Patrick J. Shao, Shahzmah Suleman, Renatus Tarimo, Tito William. We are grateful to the African Federation for Emergency Medicine for overall coordination of pilots conducted in 2015–2017. Uganda course pilots were led by Joseph Kalanzi, and course facilitators included Aliga Cliff Asher, Charmaine Cunningham, Heike Geduld, Nemganga Kizega, Namaganda Lukia, Grace Magambo, Alex Makupe, Juma Mbugi, Josephine Nabulime, Annet Alenyo Ngabirano, Muzaza Nthele. Participants: Halima Adam, Douglas Akibua, Muhwezi Amos, Beatrice Babirye, Andrew Balinda, Evans Bonabana, Kamara Francis, Alele Franco, Muduwa Grace, Jagwe Hakim, Henry Kagaba, Shadia Kaggwa, Andrew Kagwa, Peter Kavuma, Winnie Kibirige, Bazibu Musa Kireka, Brian Kisembo, Nakiyemba Margaret, Edward Mugisha, Linda Nalugya, Gertrude Namidembe, Joanita Namuddu, Denis Onyang, and Emma Tukehayo. United Republic of Tanzania course pilots were led by Hendry Sawe, and course facilitators included Charmaine Cunningham, Jimmy Ernest, Upendo George, Nemganga Kizega, Deogratius Mally, Juma Mbugi, Juma Mfinanga, Felix Mlay, Brittany L Murray, Suzanna Ngalla, and Nikki Roddie. Participants: Ntuli Abraham, Thomas Bwire, Hamza Haji, Agripina Hugho, Stella Ibrahim, Philomena Jumanne, Teonila Kamba, Neema Kayembe, Sikudhani Khamsini, Clemence Luambono, Raymond Makona, Rosemary Marishay, Rashidi Matitu, Vicent Mboya, Erick Mhaiki, Rashid Mhina, Asha Mkwachu, Frank Mlaguzi, Leonidas Mutakosa, Piensia Nanyimbula, Kiohombo Phim, Mary Shauritanga, and Ndamba Sigonda. Zambia course pilots were led by Muhumpu Kafwamfwa, and course facilitators included: Namasiku Chime, Chipoya Chipoya, Ngandu Hassan, Mwandameda Kabuku, Irene Lufunda, Alex Makupe, and Mzaza Nthele. Participants: Gloria Chambeshi, Maureen Chikwa, Azelina Chulu, Mwanza Jackson, Usaliwa Jere, Tina Malunga, Pidini Mary, Mable Nakazwe Mulenga, Joy Judy Mweshi, Chicco Siame, Ivan Sinaulieni, and Franko Zulu. We wish to thank Morgan Broccoli, Simon Charwey, Catherine Haeffele, Farrah Kashfipour for input on visual design and illustration, and Tein Jung for the original illustrations throughout. INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 The ABCDE and SAMPLE history approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Module 1: The ABCDE and SAMPLE history approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Module 2: Approach to trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 Module 3: Approach to difficulty in breathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75 Module 4: Approach to shock. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95 Module 5: Approach to altered mental status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 WHO BASIC EMERGENCY CARE [SKILLS]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 GLOSSARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 WHO sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214 Basic Emergency Care Quick Cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 Contents vi INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 1 INTRODUCTION Overview Health emergencies happen every day, everywhere. They affect adults and children and include injuries and infections, heart attacks and strokes, acute complications of pregnancy and of chronic disease. While specialised care may never be available at all times in all places, a systematic approach to emergency conditions saves lives. The Disease Control Priorities Project estimates that nearly half of deaths and a third of disabilities in low- and middle-income countries result from conditions that could be addressed by emergency care. The World Health Organization (WHO), in collaboration with the International Committee of the Red Cross (ICRC) and the International Federation for Emergency Medicine (IFEM), has developed the Basic Emergency Care (BEC) course for frontline providers who manage acute life-threatening conditions with limited resources. These may include students, nurses, pre- hospital technicians, clinical officers and doctors who are working in field (pre-hospital) or hospital settings. Emergency care providers must respond to ‘undifferentiated’ patients, those with acute symptoms for which the cause may not be known. This course introduces a systematic approach to managing acute, potentially life-threatening conditions even before a diagnosis is known. BEC is based on the clinical recommendations of the WHO IMAI District Clinician Manual, WHO Pocket Book of Hospital Care for Children, WHO Emergency Triage Assessment and Treatment (ETAT) and WHO Integrated Management of Pregnancy and Childbirth. It includes modules on: the ABCDE and SAMPLE history approach, trauma, difficulty in breathing, shock, and altered mental status. The practical skills section covers the essential time-sensitive interventions for these key acute presentations. The WHO BEC package consists of: Participant workbook: the main reference source for participants, this interactive workbook provides all the necessary course content, and includes an in-depth guide to essential skills, a glossary of terms, review questions and case scenarios. Quick cards: these simple reference cards organize key assessment and management points for use in clinical settings beyond the course. These are found at the end of each module and together at the end of the workbook. Facilitator guide: this is an annotated version of the BEC workbook intended for facilitators. Challenging concepts are highlighted, and notes on teaching strategy and lecture preparation provided on each page. This volume also includes a Coordinator section with information on course planning and logistics, and offers guidance for selecting and training facilitators. Presentation slide sets: these cover all course modules and are provided to support course delivery. INTRODUCTION 2 The BEC course may be implemented in many different ways to meet local needs, but a recommended 5-day schedule is described in detail in the Coordinator section of the Facilitator guide. The BEC content might also be spread across a few weeks as a module in undergraduate nursing or medical curricula. The BEC package is designed to support the efforts of governments, educational institutions, professional societies and others to train emergency care providers acting within their designated scope of practice. WHO does not certify or accredit courses, instructors or providers. Scope of the course Key acute presentations These modules teach a practical and systematic approach to four acute and potentially life- threatening presentations: Trauma Difficulty in breathing Shock Altered mental status Most life-threatening conditions, whether the original cause was medical or surgical, infection or injury, will present with one of these. In some cases the diagnosis may be known, while in others, intervention may be required before a diagnosis can be made, perhaps because of limited diagnostic resources, but often because of the acuity of the condition. These modules introduce a systematic approach to assessment and management that can be used whether or not a diagnosis has been made. Frontline health-care providers will face many more presentations than are covered in this course. This material is not meant to cover every acute condition, but to help providers address time-sensitive conditions where early intervention has the potential to save lives. The course is designed to lay a foundation for broader emergency assessment and management. Many participants may already, or will later, be trained to provide care beyond what is described here. Recommendations for handover to an “advanced provider” are meant to signal the need for care beyond the scope of this course. In some cases, participants themselves may already be trained to provide this additional care. Other emergency presentations There are other complaints that may represent a life-threatening condition requiring emergency care even before it progresses to any of the key acute presentations listed above. These include: chest discomfort; poisoning/ingestion/exposure; envenomation (bites/stings); any severe pain from an unclear source; INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 3 contractions, pain or bleeding in late pregnancy. These complaints may represent the early stage of a critical illness requiring rapid intervention even when the person appears relatively well. The complete assessment and management of these conditions is beyond the scope of this course, but they should always trigger transport to, or consultation with, an advanced provider. In addition, there are certain infectious exposures that require time-sensitive prophylaxis (preventive treatment) whose effectiveness may be reduced by delays. These include: needle stick injury in a health care worker; unprotected sexual encounter, including in the context of assault; exposure to the saliva of an animal with suspected rabies. These exposures should be evaluated as soon as possible at a center capable of providing timely prophylaxis. Special considerations for fever Fever is a very common complaint and may be a sign of a life-threatening condition, or simply a sign of a mild condition that will resolve itself. Because fever does not reliably indicate an emergency condition, it is not addressed in a separate module here, but is covered in each of the core modules. When associated with abnormal ABCDE findings (see “Approach to the emergency patient” section), or any of the acute presentations above (trauma, difficulty in breathing, shock, altered mental status), fever can be an important clue to severe illness and should be taken very seriously. There are many more causes of fever than can be covered in this basic course, but most causes of fever requiring emergency treatment are associated with one of the four key acute presentations. There is no single approach to fever that is right for all emergencies, but there are some general principles that can help in the assessment and management of emergency patients. • Always consider infection in a person with fever (e.g. malaria, meningitis, pneumonia). • Never use the absence of fever to rule out infection. People with overwhelming infection or immune system problems may not be able to produce a fever and may have a normal or low body temperature. • Fever with abnormal vital signs and/or any of the four key acute conditions listed above will likely require early antibiotic (and/or anti-malarial) treatment. • Always consider whether local screening protocols for infectious disease outbreaks (e.g. for haemorrhagic fevers) require further action (e.g. special reporting or management) in a person with fever. Obstetric delivery and neonatal resuscitation Management of obstetric delivery and neonatal resuscitation are critical topics covered else- where in existing WHO materials and are not covered in this course. See the WHO Maternal, Newborn, Child and Adolescent Health department website (http://www.who.int/maternal_ child_adolescent/documents/en/) for training materials on these topics. INTRODUCTION 4 Expected participant background knowledge This course assumes a basic knowledge in the following areas: Use of personal protective equipment Basic human anatomy Basic history taking Basic physical examination skills, including taking vital signs, chest auscultation and abdominal assessment Use of a glucometer Set up of an intravenous (IV) infusion Safe intramuscular injection Cardiopulmonary resuscitation (CPR) Cardiopulmonary resuscitation (CPR) The decision about whether or not CPR is appropriate for a specific patient depends on many factors, including understanding of the cause of the condition, knowledge of available resources, and awareness of relevant institutional protocols and practices. There are many situations where it may be appropriate to initiate and then terminate CPR after a certain interval, and others where it may not be appropriate to initiate CPR. While this course addresses several aspects of resuscitation, it does not cover general CPR protocols, as they may vary greatly by setting. Course facilitators should direct participants to the appropriate source for relevant CPR protocols. Medication The medications discussed in this course are widely available and appropriate for use by the frontline providers for whom the course is designed. They can be used in pre-hospital or facility- based settings and are important early treatments for emergency conditions. The included medications provide a foundation for initial emergency care, but almost every condition discussed in this workbook will require treatments beyond those listed. Many important emergency treatments used by advanced providers are not included in this course. Handover/transfer This course is designed to help providers identify and provide initial management for acute, life-threatening conditions. Most acutely ill patients will require care beyond this initial stage. This may be ongoing care delivered by the same provider, but more often will require handover to a more advanced provider or facility. This process of deciding the appropriate disposition – or next step of care – for the acutely ill patient is a vital part of emergency care. Choosing an appropriate disposition involves assessing severity; estimating how rapidly the condition may progress; considering whether transfer for a specific intervention (e.g. surgery, blood transfusion) is needed; and identifying any specific risks based on a suspected or known diagnosis (e.g. risk of recurrent seizure/convulsion, or worsening airway blockage). The special disposition considerations for each key acute presentation and its associated diagnoses are covered in the modules. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 5 Planning for handover/transfer requires communicating essential information with the receiving facility, creating a transport plan, and ensuring availability of the necessary supplies to protect providers and care for patients. These components will be covered in detail in “Transfer and handover” in the Skills section. Triage Triage is the systematic process of classifying patients by acuity to ensure the best match between available resources and user needs. Triage is an essential component of emergency care during routine and surge conditions, and is a higher-level process applied to all patients, allowing assessment of the individual patient in context. As such, it is not addressed in this course, but is often taught at the same time. WHO and ICRC, in collaboration with Médecins Sans Frontières (MSF) and the South African Triage Score (SATS) team, have developed a set of integrated triage tools and an associated open-access training module. Contact emergencycare@who.int to request these materials. Approach to the emergency patient The BEC course is intended for a wide range of frontline providers and offers a basic approach for life-threatening presentations. Emergency conditions often require urgent intervention long before a diagnosis is established, and a presentation-based approach is essential to managing patients effectively. The modules in this course teach the elements of a general approach that can be used for any emergency patient. Aaron The ABCDE approach allows rapid assessment and intervention for life threats using the following categories: A: AIRWAY B: BREATHING C: CIRCULATION D: DISABILITY E: EXPOSURE Essential ABCDE considerations are listed in the modules for each of the four key presentations. The SAMPLE history is a method of rapidly gathering the history critical to the management of the acutely ill patient. The SAMPLE history categories are: S: SIGNS AND SYMPTOMS A: ALLERGIES M: MEDICATIONS P: PAST MEDICAL HISTORY L: LAST ORAL INTAKE E: EVENTS SURROUNDING ILLNESS Essential SAMPLE questions are listed in the modules for each of the four key presentations. INTRODUCTION 6 The secondary survey is a complete physical examination based on the specific condition. The essential relevant components of the secondary survey are listed in the modules for each of the four key presentations. Further details are covered in the Skills section. How to use this Participant Workbook This Participant Workbook is linked with the WHO BEC course presentations and is designed to help participants prepare for each lesson to maximize learning. Each module provides reading material and exercises to complete before the lesson. Participants should not worry if there are elements they do not fully understand while reading alone, as all workbook content will be reviewed during the lessons. Before each lesson, participants should: write out the definitions for the Key terms of the relevant module by copying from the Glossary in the back of the workbook; complete all workbook review questions in the relevant modules. The multiple choice questions and case scenarios at the end of each module will be covered in the small group sessions during the course, but participants should read through them before the session. On completion of the course, participants can use this book for reference. Accompanying the book are reference quick cards. These cards provide a summary of the essential points from the course and are designed to be carried in the clinical setting to guide day-to-day practice. Module format This course includes one module on the general approach to all emergency patients (ABCDE and SAMPLE); one module on the approach to injured patients (trauma); three modules on other specific clinical presentations (difficulty in breathing, shock, and altered mental status); a skills section; and a Glossary. The modules include the following sections: Objectives: A list of things participants should be able to do by the end of the course. Essential skills: A list of skills relevant to the module (and later taught in the Skills section). Key terms: Important words and phrases needed to understand the module. All definitions can be found in the Glossary and should be written in the space provided prior to the lecture. Overview: A brief introduction to the clinical presentation being discussed in the module. Goals of initial assessment: The main purpose of the assessment of the clinical presentation. Goals of acute management: The desired result of the management of the clinical condition. ABCDE key elements: ABCDE findings and interventions related to the specific clinical condition addressed in the module. Key history findings (ASK): Specific SAMPLE history elements related to the clinical presentation that are critical for management. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 7 Secondary survey findings (CHECK, including Look, Listen and Feel): Relevant secondary examination findings to check for in the clinical presentation the module addresses. Possible causes: Specific diseases, injuries, or illnesses that can cause the condition presented in the module (along with their specific signs and symptoms). Management (DO): These sections describe management of specific conditions. Note that the ABCDE and Trauma modules have much longer lists of possible emergency conditions, and the Possible causes and Management sections are presented in tables. The Trauma module has a separate table for Primary Survey conditions. Special considerations in children: Important differences in the signs and symptoms and management needs of children. Disposition considerations: Specific things to consider when transferring or handing over patients. Facilitator-led case scenarios: These scenarios test participants’ ability to use what they have learned to manage a patient. These scenarios will be led by the instructor. Multiple choice questions (MCQ): There are five multiple choice questions to test your knowledge at the end of each module in preparation for the final written exam. Participant requirements Participants should confirm course requirements with their facilitator. When implemented in full, the Basic Emergency Care course requires completion of ALL components listed below. Pre-test. Before receiving the Basic Emergency Care course workbook, participants should have completed this brief confidential test, which helps facilitators understand their current knowledge level. Attendance report. Participants must sign in for both the morning and afternoon sessions each day. Participants must attend all sessions to pass the course. Workbook completion. As described above, participants should complete all key terms and workbook questions in the relevant module prior to each lesson. All key terms must be defined, and all workbook questions answered for the workbook to be considered completed. The workbooks will be reviewed each day by facilitators. Participants must complete the workbook to pass the course. Skill stations. During the skills day, facilitators will demonstrate skills at a practical station. Participants will have an opportunity to practise the skill at each station several times. Participants may practise a skill as many times as needed within the allotted station time. During practice, participants may use the workbook and skill checklist for reference, and may ask questions as needed of facilitators. During assessment, no reference materials will be allowed, so participants should also practise without references, and have another participant observe for any missed steps. Participants will have plenty of time to practise and feel confident with the skills prior to assessment, and when ready, should request that an instructor assess them performing the skill. All steps in the skill checklist must be performed to pass the assessment. Participants must pass the skill station assessments to pass the course. INTRODUCTION 8 Case scenarios. All participants must successfully lead and manage a case scenario to pass the course. These scenarios give participants an opportunity to practise an integrated approach to management in small groups of 3–4 participants. Facilitators will discuss with the group how to approach the case scenarios using the ABCDE approach. In the later modules, each participant will be assessed on the ability to lead and manage a case scenario. Leading a case scenario includes identifying critical aspects of assessment and management, as well as presenting a handover summary (see the Handover section in Skills). Facilitators will complete the checklist below to assess the participant leading the case. Participants who are unsuccessful in identifying and managing the critical conditions in the scenario will be given a second case in the same or a subsequent session. Assessments are based on a standardized guide and reported on the form below. Case scenario assessment Not identified Identified some Identified all Critical airway interventions Critical breathing interventions Critical circulation interventions Critical disability interventions Critical exposure interventions Critical medications (if needed) Gave appropriate brief handover summary Yes No Participant performed all essential components Yes No Comments (including notation of any missed elements): Written final exam To qualify to sit the final examination participants must: complete the pre-test; complete the key terms and workbook questions; attend all course sessions; lead a case scenario; pass all skill stations as examined by an instructor. The final examination will include multiple choice questions. Participants must score at least 75% to pass. Your input will help improve future training courses. Please send any comments, corrections or questions to emergencycare@who.int. We encourage all participants and facilitators to fill out a short pre- and post-course survey at www.who.int/emergencycare. PARTICIPANT WORKBOOK 9 The ABCDE and SAMPLE history approach 10 Notes ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 11 Module 1: The ABCDE and SAMPLE history approach OBJECTIVES On completing this module you should be able to: 1. list the hazards that must be considered when approaching an ill or injured person; 2. list the elements to approaching an ill or injured person safely; 3. list the components of the systematic ABCDE approach to emergency patients; 4. assess an airway; 5. explain when to use airway devices; 6. explain when advanced airway management is needed; 7. assess breathing; 8. explain when to assist breathing; 9. assess fluid status (circulation); 10. provide appropriate fluid resuscitation; 11. describe the critical ABCDE actions; 12. list the elements of a SAMPLE history; 13. perform a relevant SAMPLE history. Essential skills • Assessing ABCDE • Cervical spine immobilization • Full spine immobilization • Head-tilt and chin-lift/jaw thrust • Airway suctioning • Management of choking • Recovery position • Nasopharyngeal and oropharyngeal airway placement • Bag-valve-mask ventilation • Oxygen administration • Skin pinch test • AVPU (alert, voice, pain, unresponsive) assessment • Glucose administration • Needle decompression for tension pneumothorax • Three-sided dressing for chest wound • Intravenous (IV) line placement • IV fluid resuscitation • Direct pressure for haemorrhage control, including deep wound packing • Tourniquet for haemorrhage control • Pelvic binding • Wound management • Fracture immobilization • Snake bite management Module 1: The ABCDE and SAMPLE history approach 12 KEY TERMS Write the definition using the Glossary at the back of the workbook. ABCDE: Accessory muscle use: Altered mental status (AMS): Anaphylaxis: AVPU: Bag-valve-mask (BVM): Capillary refill: Cardiopulmonary resuscitation (CPR): Cervical spine (c-spine): Convulsion: Crackles (crepitations): Crepitus: Deep wound packing: Defibrillator: Diaphoresis: Difficulty in breathing (DIB): Disposition: Foreign body: INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 13 GCS (Glasgow Coma Scale): Hives: Haematoma: Haemorrhage: Haemothorax: Hyperresonance: Hyperthermia: Hypoglycaemia: Hypothermia: Hypotension: Hypoxia: Inhalation injury: Intubation: Large bore IV: Nasal flaring: Nasopharyngeal airway (NPA): Needle decompression: Oedema: Oropharyngeal airway (OPA): Oxygen saturation (O2 sat): Module 1: The ABCDE and SAMPLE history approach 14 Percussion: Perfusion: Pericardial tamponade: Personal protective equipment (PPE): Pleural effusion: Pneumothorax: Pulse oximeter: Retractions: SAMPLE history: Seizure: Shock: Stridor: Sucking chest wound: Tachypnoea: Tension pneumothorax: Wheezing: INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 15 OVERVIEW Approaching every patient in a systematic way ensures that life-threatening conditions are recognized promptly and that the most critical interventions are done first. In a stable patient, the initial ABCDE approach may only take seconds to a few minutes. The ABCDE should be followed by a rapid history using the SAMPLE approach (Signs and Symptoms, Allergies, Medications, Past medical history, Last oral intake and Events). The SAMPLE history categories are described in general below, and essential questions for a specific presentation are listed in the relevant module. Using the standard SAMPLE and ABCDE approach together ensures that different providers can easily communicate about acutely ill patients. The goal of the ABCDE approach is to rapidly identify life-threatening conditions; ensure the airway stays open; and ensure that breathing and circulation are adequate to deliver oxygen to the body. The goal of the SAMPLE approach is to rapidly gather history critical to the management of the acutely ill patient. This module will address: Safety considerations Elements of the ABCDE approach In-depth: acute life-threatening conditions (signs, symptoms and management) Paediatric considerations in the ABCDE approach Elements of the SAMPLE history Disposition considerations SAFETY CONSIDERATIONS A critical part of the approach to any ill or injured patient is keeping providers and others safe. An ill or injured provider will be unable to help anyone, and instead becomes an extra patient for other responders to treat. Safety consideration involves checking for: scene hazards. Is there a fire, electrical wire or chemical spill that could injure providers or bystanders? At a road traffic crash, is the scene closed to oncoming traffic? If a building has collapsed, is it safe to enter? At the scene of an explosion, always consider the possibility of further explosions. Remember that delayed building collapse may follow explosions, fires and earthquakes. violence. Is there a chance that providers may be harmed by the patient or by others? For patients who are aggressive or agitated, request help as needed from security personnel or police before beginning your assessment. infectious disease risk. Is there a possibility for disease exposure (such as flu or haemorrhagic fever)? Module 1: The ABCDE and SAMPLE history approach 16 USE PERSONAL PROTECTIVE EQUIPMENT You may not know the cause of illness or injury when you first approach a patient, and without appropriate personal protective equipment (PPE), may expose yourself to diseases, chemicals or poisons. You must use appropriate PPE every time you approach a patient. Always protect yourself from any exposure to bodily fluids. This will almost always require gloves and eye protection, and may require a gown and mask. Some circumstances, such as suspected or confirmed haemorrhagic fever outbreaks, require specific protective practices. Always be sure that you are up-to-date on current local recommendations. CLEANING AND DECONTAMINATION Infectious disease exposure is a significant risk. Use PPE and wash your hands before and after every patient contact. At the scene, hand washing may not be immediately possible; carry an alcohol gel cleanser if possible. Between patients, clean and disinfect all facility and vehicle surfaces and all reusable equipment. Decontamination may be required after exposure to pesticides or other chemicals (dry or wet) and, depending on the chemical, may include washing or brushing to remove the substance. Not all chemicals can be safely washed away, and some must be removed in specific ways to avoid further injury. You must wear appropriate PPE for this. Refer to local decontamination protocols for people and equipment. ASK FOR MORE HELP IF NEEDED If multiple people are injured or ill, call for help or send someone to call. If advanced care is needed, begin making arrangements as early as possible for consultations or transfers. Know the relevant local agencies to contact for suspected outbreaks or hazardous exposures, such as chemical spills or radiation. There is often support and guidance available for containment and decontamination. Workbook question 1: Safety A person walks into your health post vomiting, bleeding from the mouth, and complaining of abdominal pain. Using the workbook section above, describe what is needed to safely approach this person: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 17 ELEMENTS OF THE ABCDE APPROACH The ABCDE approach The ABCDE approach provides a framework for the systematic and organized evaluation of acutely ill patients in order to rapidly identify and intervene for life-threatening conditions: A – Airway: check for and correct any obstruction to movement of air into the lungs B – Breathing: ensure adequate movement of air into the lungs C – Circulation: evaluate whether there is adequate perfusion to deliver oxygen to the tissues; check for signs of life-threatening bleeding D – Disability: assess and protect brain and spine functions E – Exposure: identify all injuries and any environmental threats and avoid hypothermia This stepwise approach is designed to ensure that life-threatening conditions can be identified and treated early, in order of priority. If a problem is discovered in any of these steps, it must be addressed immediately before moving on to the next step. The ABCDE approach should be performed in the first 5 minutes and repeated whenever a patient’s condition changes or worsens. Module 1: The ABCDE and SAMPLE history approach 18 THE ABCDE ASSESSMENT AND MANAGEMENT REMEMBER... Always check for signs of trauma in each of the ABCDE sections, and reference the trauma module as needed. [see TRAUMA] ASSESSMENT IMMEDIATE MANAGEMENT Airway A Can the patient talk normally? If YES, the airway is open. If the patient cannot talk normally: • look to see if the chest wall is moving and listen to see if there is air movement from the mouth or nose. • listen for abnormal sounds (such as stridor, grunting, or snoring) or a hoarse or raspy voice that indicates a partially obstructed airway. – Stridor plus swelling and/or hives suggest a severe allergic reaction (anaphylaxis). • Look and listen for fluid (such as blood, vomit) in the airway. • Look for foreign body or abnormal swelling around the airway, and altered mental status. • Check if the patient is able to swallow saliva or is drooling. • If the patient is unconscious and not breathing normally and: – NO TRAUMA: open the airway using the head-tilt and chin-lift manoeuvre. [See SKILLS] – CONCERN FOR TRAUMA: maintain cervical spine immobilization and open the airway using the jaw thrust manoeuvre. [See SKILLS] – Place an oropharyngeal or nasopharyngeal airway to maintain the airway. [See SKILLS] • If a foreign body is suspected: – If the object is visible, remove it – be careful not to push the object any deeper. – If the patient is able to cough or make noises, keep the patient calm and encourage coughing. – If the patient is choking (unable to cough, not making sounds) use age-appropriate chest thrusts/ abdominal thrusts/back blows. [See SKILLS] – If the patient becomes unconscious while choking, follow relevant CPR protocols. • If secretions or vomit are present, suction when available, or wipe clean. Consider placing patient in the recovery position if the rest of the ABCDE is normal and no trauma is suspected. [See SKILLS] • If the patient has swelling, hives or stridor, consider severe allergic reaction (anaphylaxis), and give intramuscular adrenaline. [See SKILLS] • Allow the patient to stay in a position of comfort and prepare for rapid handover/transfer to a centre capable of advanced airway management, if needed. If the airway is open, move onto “Breathing”. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 19 ASSESSMENT IMMEDIATE MANAGEMENT Breathing B • Look, listen, and feel to see if the patient is breathing. • Assess if breathing is very fast, very slow, or very shallow. • Look for signs of increased work of breathing (such as accessory muscle use, chest indrawing/ retractions, nasal flaring) or abnormal chest wall movement. • Listen for abnormal breath sounds such as wheezing or crackles. [See DIFFICULTY IN BREATHING] • With severe wheezing, there may be limited/no breath sounds on examination because narrowing of the airways may be so severe that breathing cannot be heard. • Listen to see if breath sounds are equal on both sides. • Check for the absence of breath sounds and dull sounds with percussion on one side (large pleural effusion or haemothorax). [See SKILLS] • If there are no breath sounds on one side, and hypotension, check for distended neck veins or a shifted trachea (tension pneumothorax). • Check oxygen saturation with a pulse oximeter when available. • If unconscious with abnormal breathing, start bag-valve-mask ventilation and follow relevant CPR protocols. • If not breathing adequately (too slow for age or too shallow), begin bag-valve-mask ventilation with oxygen [See SKILLS]. If oxygen not immediately available, DO NOT DELAY ventilation. Start ventilation while oxygen is being prepared. Plan for rapid handover/transfer. • If breathing fast or hypoxic, give oxygen [See SKILLS] • If wheezing, give salbutamol. [See SKILLS] Repeat salbutamol as needed. • If concern for severe allergic reaction (anaphylaxis), give intramuscular adrenaline. [See SKILLS] • If concern for tension pneumothorax, perform needle decompression immediately and give IV fluids and oxygen. [See SKILLS] Plan for rapid handover/ transfer. • If concern for large pleural effusion or haemothorax, give oxygen and plan for rapid handover/transfer. • If cause unknown, remember the possibility of trauma [See TRAUMA] If breathing is adequate, move onto “Circulation”. Circulation C • Look and feel for signs of poor perfusion (cool, moist extremities, delayed capillary refill greater than 3 seconds, low blood pressure, tachypnoea, tachycardia, absent pulses). • Look for both external AND internal bleeding, including bleeding: – into chest; – into abdomen; – from stomach or intestine; – from pelvic or femur fracture; – from wounds. • Look for hypotension, distended neck veins and muffled heart sounds that might indicate pericardial tamponade. • For cardiopulmonary arrest, follow relevant CPR protocols. • If signs of poor perfusion, give IV fluids and oxygen [See SKILLS] and: – For external bleeding, apply direct pressure or use other technique to control. [See SKILLS] – If internal bleeding or pericardial tamponade are suspected, refer rapidly to a centre with surgical capabilities. If cause unknown, remember the possibility of trauma: Bind pelvic fractures and splint femur fractures, or any fracture with compromised blood flow. [See TRAUMA and SKILLS] If circulation is adequate, move onto “Disability”. Module 1: The ABCDE and SAMPLE history approach 20 ASSESSMENT IMMEDIATE MANAGEMENT Disability D • Assess level of consciousness with the AVPU scale (Alert, Voice, Pain, Unresponsive) or in trauma cases, the Glasgow Coma Scale (GCS). [See SKILLS] • Always check glucose level in the confused or unconscious patient. • Check for pupil size, whether the pupils are equal, and if pupils are reactive to light. • Check movement and sensation in all four limbs. • Look for abnormal repetitive movements or shaking on one or both sides of the body (seizure/convulsion). • If altered mental status and no evidence of trauma, place in recovery position. [See SKILLS] • If glucose low (<3.5 mmol/L) or glucose test not available and patient has altered mental status, give glucose. [See SKILLS] • For active seizures, give a benzodiazepine. [See SKILLS] • If pregnant and having seizures, give magnesium sulphate. [See SKILLS] • If pupils are small and breathing slow, consider opioid overdose and give naloxone. [See SKILLS] • If pupils are not equal, consider increased pressure on the brain and raise head of bed 30 degrees if no concern for spinal injury. Plan for rapid transfer to an advanced provider or facility with neurosurgical care. If cause unknown, remember possibility of trauma: Immobilize the cervical spine if concern for trauma. [See TRAUMA and SKILLS] Exposure E • Examine the entire body for hidden injuries, rashes, bites or other lesions. • Rashes, such as hives, can indicate allergic reaction, and other rashes can indicate serious infection. • If snake bite is suspected, immobilize the limb. [See SKILLS] Take a picture of the snake if possible from a distance and send with patient. Do not risk additional bites to catch/kill snake. • Remove constricting clothing and all jewelry. • Cover the patient as soon as possible to prevent hypothermia. Acutely ill patients have difficulty regulating body temperature. • Remove any wet clothes and dry patient thoroughly. • Respect the patient and protect modesty during exposure. If cause unknown, remember the possibility of trauma: Log roll if suspected spinal injury [See TRAUMA and SKILLS] INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 21 ABCDE IN DEPTH: ACUTE, LIFE-THREATENING CONDITIONS This section takes a deeper look at conditions that must be managed during the ABCDE approach. AIRWAY conditions A CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT Obstruction due to foreign body • Visible secretions, vomit or foreign bodies in the airway • Abnormal sounds from the airway (such as stridor, snoring, gurgling) • Mental status changes leading to airway obstruction from the tongue • Poor chest rise The airway can become obstructed by secretions, vomit or foreign bodies. • Remove the foreign body if possible and suction fluid. Be careful not to push a foreign body further into the airway. Do not try to remove a foreign body unless clearly visible. • Use age-appropriate chest thrusts/abdominal thrusts/back blows if the airway is completely obstructed. [See SKILLS] • The tongue may obstruct the airway in patients with a decreased level of consciousness. – Open the airway using a head-tilt and chin- lift manoeuvre, or use jaw thrust (if there is concern for trauma); and place an oral or nasopharyngeal airway as needed. [See SKILLS] – These patients may also not be able to protect their airway and need to be watched for vomiting and aspiration. • Plan for rapid handover/transfer to advanced provider capable of advanced airway management if the obstruction cannot be removed. Obstruction due to burns • Burns to head and neck • Burned nasal hairs or soot around the nose or mouth • Abnormal sounds from the airway (such as stridor) • Change in voice • Poor chest rise Burns can cause airway swelling due to inhalational injuries. • Give oxygen to ALL patients with suspected airway burn even if they do not show signs of hypoxia. [See SKILLS] • Open the airway using appropriate manoeuvre and place an oral or nasopharyngeal airway as needed. [See SKILLS] • Maintain cervical spine immobilization if there is evidence of trauma. [See SKILLS] • The airway can swell and close off very quickly in burn patients. Plan for rapid handover/transfer to a provider capable of advanced airway management. Module 1: The ABCDE and SAMPLE history approach 22 CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT Obstruction due to severe allergic reaction (anaphylaxis) • Mouth, lip, and tongue swelling • Difficulty breathing with stridor and/or wheezing • Rash or hives (patches of pale or red, itchy, warm, swollen skin) • Tachycardia and hypotension • Abnormal sounds from the airway (such as stridor, snoring, gurgling) • Poor chest rise Severe allergic reactions can cause swelling of the airway that can lead to obstruction. • Give intramuscular adrenaline for airway obstruction, severe wheezing or shock. [See SKILLS] – Adrenaline can wear off in minutes so be prepared to give additional doses. • Place an IV and give IV fluids. [See SKILLS] • Reposition airway as needed (sit patient upright if no trauma) and give oxygen. [See SKILLS] • If severe or not improving, prepare for rapid handover/transfer for advanced airway management. Obstruction due to trauma • Neck haematoma or injuries to head and neck • Abnormal sounds from the airway (such as stridor, snoring, gurgling) • Change in voice • Poor chest rise Airway obstruction may result from injuries to the head or neck. Blood, bone or damaged tissue may block the airway. Penetrating wounds to the neck may also cause obstruction due to swelling or expanding haematoma. • Suction to remove any blood that might block the airway. • Open the airway using jaw thrust only (do not use head-tilt/chin-lift); and place an oral airway as needed (do not use nasopharyngeal airways if there is facial trauma). [See SKILLS} • Maintain cervical spine immobilization if there is evidence of trauma. [See SKILLS] • Plan for rapid handover/transfer to advanced provider capable of advanced airway management or surgical intervention. For any abnormal airway sounds, re-assess airway frequently as partial obstruction may worsen rapidly and block airway. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 23 BREATHING conditions B CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT Tension pneumothorax Hypotension WITH difficulty in breathing AND any of the following: • distended neck veins • absent breath sounds on affected side • hyperresonance with percussion on affected side [See SKILLS] • tracheal shift away from affected side Any pneumothorax can become a tension pneumothorax. Air in the cavity between the lungs and the chest wall can collapse the lung (simple pneumothorax). Building pressure (tension) from a large pneumothorax can displace and block flow from the main vessels back to the heart, causing shock (tension pneumothorax). • If tension pneumothorax is suspected, perform emergency needle decompression. [See SKILLS] • Give oxygen. [See SKILLS] • Give IV fluids. [See SKILLS] • Arrange for rapid handover/transfer to an advanced provider capable of placing a chest tube. Suspected opioid overdose • Slow respiratory rate • Hypoxia • Very small pupils Opioid medications (such as morphine, pethidine, and heroin) can decrease the body’s drive to breathe. • Give naloxone to reverse the effects of opioids. [See SKILLS] – Monitor closely as naloxone will wear off and additional doses may be needed. • Give oxygen. [See SKILLS] Asthma/ COPD (chronic obstructive pulmonary disease) • Wheezing • Cough • Accessory muscle use • May have history of asthma/COPD diagnosis, allergies or smoking Asthma and COPD are conditions causing spasm in the lower airways, resulting in narrowing that causes difficulty in breathing and wheezing. • Administer salbutamol as soon as possible. (Salbutamol helps to relieve the spasm in the air passages) [See SKILLS] • Give oxygen if indicated. [See SKILLS] Large pleural effusion/ haemothorax • Decreased breath sounds on affected side • Dull sounds with percussion on affected side [See SKILLS] • If there is a large amount of fluid, may have shock Pleural effusion occurs when fluid builds up in the space between the lung and the chest wall or diaphragm. As the fluid builds up, it limits expansion of the lungs. • Give oxygen. [See SKILLS] • Arrange for handover/transfer immediately (many of these patients will need a procedure to drain fluid). If cause unknown, remember the possibility of trauma [See TRAUMA] Module 1: The ABCDE and SAMPLE history approach 24 CIRCULATION conditions C CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT Pulselessness • No pulse • Unconscious • Not breathing Follow relevant cardiopulmonary resuscitation (CPR) protocols. Shock • Rapid heart rate (tachycardia) • Rapid breathing (tachypnoea) • Pale and cool skin • Capillary refill>3 seconds • Sweating (diaphoresis) • May have dizziness, confusion, altered mental status • May have hypotension Poor perfusion is the failure to deliver enough oxygen-carrying blood to the vital organs. When poor perfusion continues until organ function is affected, this is called shock and can lead rapidly to death. • Initial treatment for shock includes laying the patient flat (if tolerated). • Give oxygen. [See SKILLS] • Control bleeding. [See SKILLS] • Start an IV and give IV fluids. [See SKILLS] • If there are signs of infection, give antibiotics if available. • Prepare for rapid handover/transfer. Severe bleeding (haemorrhage) • Bleeding wounds • Bruising around the umbilicus (belly button) or over the flanks can be a sign of internal bleeding • Bleeding from the rectum or vagina or in vomit • Pelvic fracture • Femur fracture • Decreased breath sounds on one side of the chest (haemothorax) • Signs of poor perfusion (such as hypotension, tachycardia, pale skin, diaphoresis) External bleeding that is not controlled can lead quickly to shock. A large quantity of blood can also be lost into the chest, pelvis, thigh and abdomen before the bleeding is recognized. • Stop the bleeding. Depending on the source, use: – direct pressure [See SKILLS] – deep wound packing [See SKILLS] – a tourniquet [See SKILLS] – pelvic binder or femur splint. [See SKILLS] • Give IV fluids. [See SKILLS] • Refer for blood transfusion and ongoing surgical management if needed. A tourniquet should be used only for life- threatening bleeding. Pericardial tamponade • Signs of poor perfusion (tachycardia, tachypnoea, hypotension, pale and cool skin, cold extremities, capillary refill >3 seconds) • Distended neck veins • Muffled heart sounds • May have dizziness, confusion, altered mental status Pericardial tamponade occurs when fluid builds up in the sac around the heart. The pressure from this fluid can collapse the chambers of the heart and keep them from filling properly, limiting blood flow to the tissues and causing shock. Treatment is drainage by pericardiocentesis. • In order to keep the patient alive until the fluid around the heart can be drained, give IV fluids to ensure that as much volume as possible enters the heart. [See SKILLS] • Refer rapidly for surgical management. If cause unknown, remember the possibility of trauma [See TRAUMA] INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 25 DISABILITY conditions D CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT Hypoglycaemia • Sweating (diaphoresis) • Altered mental status (ranging from confusion to unconsciousness) • Seizures/convulsions • Blood glucose <3.5 mmol/L • History of diabetes, malaria or severe infection • Responds quickly to glucose Patients with hypoglycaemia (low blood sugar) need glucose immediately. [See SKILLS] • If the person can speak and swallow, give oral glucose. • If the person cannot speak or is unconscious, give IV glucose if possible. • If IV glucose is not possible or available, give buccal (inside of the cheek) glucose. [See SKILLS] Increased pressure on the brain • Headache • Seizures/convulsions • Nausea, vomiting • Altered mental status • Unequal pupils • Weakness on one side of the body Increased pressure on the brain can occur from trauma, tumours, increased fluid, bleeding or infections. Because the skull is rigid, any swelling, fluid, or mass increases the pressure around the brain, limiting blood flow and possibly displacing brain tissue, causing death. • Raise the head of the bed to 30 degrees if there is no concern for trauma and there is no hypotension. • Check glucose. [See SKILLS] • If there are seizures/convulsions, give a benzodiazepine. [See SKILLS] • The pressure must be reduced as quickly as possible. Arrange for rapid handover/transfer to a surgical centre. Seizure/ convulsion Signs and symptoms of active seizure: • Repetitive movements, gaze fixed to one side or alternating rhythmically and not responsive. Sign and symptoms of recent seizure: • Bitten tongue • Urinated on self • Known history of seizures/convulsions • Confusion that gradually improves over minutes to hours The goal in managing seizures/convulsions is to prevent hypoxia and injury. • Protect the seizing person from falls and from any hard or sharp objects nearby. • Do not place anything in the mouth of a person with active seizure except to suction airway. [See SKILLS] • Give oxygen. [See SKILLS] • Check blood glucose. Give glucose if <3.5 mmol/L. [See SKILLS] • Treat with a benzodiazepine [See SKILLS] and monitor closely for slowing or difficult breathing. • Place patient in recovery position if there is no trauma suspected. [See SKILLS] • If the patient is pregnant, or recently gave birth, give magnesium sulphate. [See SKILLS] If cause unknown, remember the possibility of trauma [See TRAUMA] Module 1: The ABCDE and SAMPLE history approach 26 EXPOSURE conditions E CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT Snake bite • History of snake bite • Bite marks may be seen • Oedema • Blistering of the skin • Bruising • Hypotension • Paralysis • Seizures • Bleeding from wounds The goal of managing snake bites is to limit the spread of the venom and the effects of venom on the body. • Immobilize the extremity. [See SKILLS] • Take a picture of the snake when possible and send with the patient (for example, with the patient’s mobile phone). • Give IV fluids if evidence of shock. [See SKILLS] • These patients may have delayed shock or airway problems. Monitor closely and plan early for rapid handover/transfer. Vital signs should be checked at the end of the ABCDE A full set of vital signs (blood pressure, heart rate, respiratory rate, and oxygen saturation if available) should be performed after the ABCDE approach. Do not delay ABCDE interventions for vital signs. ABCDE SHOULD BE REPEATED FREQUENTLY The ABCDE approach is designed to quickly identify reversible life-threatening conditions. Ideally, the ABCDE approach should be repeated at least every 15 minutes or with any change in condition. Workbook question 2: ABCDE approach Using the workbook section above, list the management for airway blocked by a foreign body. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 27 PAEDIATRIC ABCDE CONSIDERATIONS While the ABCDE approach is used in both adults and children, there are some aspects of assessing and managing children that are different from adults. The “Paediatric considerations” sections throughout the workbook highlight these differences. Paediatric considerations Pediatric airway conditions A Excessive drooling, stridor, airway swelling and unwillingness to move the neck are all high-risk signs in children. Look carefully in the airway for foreign bodies, burns or obstruction. Allow the child to remain in a position of comfort. Position airway as needed below. Compared to adults, children have: So you must do this: Bigger tongues. • Place the child in the “sniffing” position (modified head-tilt, chin-lift – like the slight upward and forward tilt of the head when sniffing a flower). Shorter necks with airways that are softer and more easily blocked. • Avoid over-extending or flexing the neck. A larger head compared to the rest of the body. • Watch closely for airway obstruction. • Use the jaw thrust if airway is not open. [See SKILLS] • Position head (using padding under shoulders for very small children) to open airway if no trauma. [See SKILLS] Neutral position in infants page 2 For choking, use age-appropriate chest thrusts/abdominal thrusts/back blows. [See SKILLS] Module 1: The ABCDE and SAMPLE history approach 28 Pediatric breathing conditions B • Nasal flaring, head bobbing, grunting and chest indrawing OR retractions, are signs of respiratory distress in children. • CYANOSIS – a blue/grey discoloration around the lips, mouth or fingertips – is the result of a lack of oxygen and is a danger sign. • CHEST INDRAWING is a common presentation of paediatric accessory muscle use. – Look at the lower chest wall (lower ribs). The child has chest indrawing if the lower chest wall goes IN when the child breathes IN. – In normal breathing, the whole chest wall (upper and lower) and the abdomen move OUT when the child breathes IN. • A SILENT CHEST (no breath sounds when you listen to the chest) is a sign of severe respiratory distress in a child. With severe spasm and narrowing of the airways, there may be limited air movement and few breath sounds on exam. Give salbutamol and oxygen and re-assess frequently. [See SKILLS] • STRIDOR signals severe airway compromise, and there are many possible causes. Children with stridor should be allowed to stay in a position of comfort and transferred immediately to an advanced provider. Further treatment will often include nebulized adrenaline. If immediate transfer is not possible, consider intramuscular adrenaline as per severe allergic reaction treatment. [See SKILLS] Pediatric circulation conditions C • MANAGEMENT OF POOR PERFUSION IN CHILDREN MAY CHANGE based on the cause and on the condition of the child. [See SHOCK and SKILLS modules] • LOW BLOOD PRESSURE IN A CHILD IS A SIGN OF SEVERE SHOCK. Children are able to maintain normal blood pressure for longer than adults when in shock. Closely monitor other signs of poor perfusion, such as decreased urine output and altered mental status. • THE AMOUNT OF INTRAVENOUS FLUID GIVEN TO CHILDREN IS DIFFERENT FROM ADULTS. [See SKILLS] • IN MALNOURISHED CHILDREN, both the rate of fluid administration and the type of fluid are different. [See SKILLS] • SEVERE SIGNS: Sunken fontanelle, poor skin pinch [See SKILLS], lethargy, altered mental status. Chest indrawing page 33 Chest indrawing INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 29 Pediatric disability conditions D • LOW BLOOD GLUCOSE is a very common cause of altered mental status in sick children. – If possible, check blood glucose in children with altered mental status. – When it is not possible to check the blood glucose level, administer glucose. • Always check for seizure/convulsions. • It is sometimes difficult to determine if infants are acting normally. Always ask the person caring for the child. Pediatric exposure conditions E • INFANTS AND CHILDREN HAVE DIFFICULTY MAINTAINING TEMPERATURE and can very quickly become hypothermic (low body temperature) or hyperthermic (high body temperature). – Remove wet clothing and dry skin thoroughly. Place infants skin-to-skin when possible. – For hypothermia, be sure to cover infants’ heads (but do not obstruct face). – For hyperthermia, unbundle tightly wrapped infants. PAEDIATRIC DANGER SIGNS IN ABCDE In addition to performing a thorough ABCDE approach, all paediatric patients should be evaluated for the presence of danger signs. Children with danger signs need URGENT attention and referral/ handover to a provider able to provide advanced paediatric care. Paediatric danger signs include: • Signs of airway obstruction (stridor or drooling/unable to swallow saliva) • Increased breathing effort (fast breathing, nasal flaring, grunting, chest indrawing or retractions) • Cyanosis (blue colour of the skin, especially at the lips and fingertips) • Altered mental status (including lethargy or unusual sleepiness, confusion, disorientation) • Moves only when stimulated or no movement at all (AVPU other than “A”) • Not feeding well or cannot drink or breastfeed • Vomiting everything • Seizures/convulsions • Low body temperature (hypothermia) Module 1: The ABCDE and SAMPLE history approach 30 Workbook question 3: ABCDE approach Using the workbook section above, list one of each of the following: a paediatric airway consideration ______________________________________________________________________ a paediatric breathing consideration ______________________________________________________________________ a paediatric circulation consideration ______________________________________________________________________ a paediatric disability consideration ______________________________________________________________________ a paediatric exposure consideration ______________________________________________________________________ Elements of the SAMPLE history The SAMPLE approach is a standard way of gathering the key history related to an illness or injury. Sources of information include: the ill/injured person, family members, friends, bystanders, or prior providers. SAMPLE stands for: S: Signs and symptoms The patient/family’s report of signs and symptoms is essential to assessment and management. A: Allergies It is important to be aware of medication allergies so that treatments do not cause harm. Allergies may also suggest anaphylaxis as the cause of acute symptoms. M: Medications Obtain a full list of medications that the person currently takes and ask about recent medication or dose changes. These may affect treatment decisions and are important to understanding the person’s chronic conditions. P: Past medical history Knowing prior medical conditions may help in understanding the current illness and may change management choices. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 31 L: Last oral intake Record the time of last oral intake and whether solid or liquid. A full stomach increases the risk of vomiting and subsequent choking, especially with sedation or intubation that might be required for surgical procedures. E: Events surrounding the injury or illness Knowing the circumstances around the injury or illness may be helpful in understanding the cause, progression and severity. Workbook question 4: SAMPLE history Using the workbook section above, list what the letters in SAMPLE stand for: S: ______________________________________________________________________ A: _____________________________________________________________________ M: _____________________________________________________________________ P: ______________________________________________________________________ L: ______________________________________________________________________ E: ______________________________________________________________________ DISPOSITION CONSIDERATIONS If you have to intervene in any of the ABCDE categories, immediately plan for handover/ transfer to a higher level of care. Once you have completed the ABCDE approach, take a SAMPLE history and complete a physical examination based on the specific condition (secondary examination). A good handover summary [See SKILLS] to the next provider requires: – brief identification of the patient; – relevant elements of the SAMPLE history; – physical examination findings; – record of interventions given; – plans for care needed next and other concerns you may have. Module 1: The ABCDE and SAMPLE history approach 32 FOR REFERENCE: NORMAL VITAL SIGNS NORMAL ADULT VITAL SIGNS Pulse rate: 60–100 beats per minute Respiratory rate: 10–20 breaths per minute – A respiratory rate of less than eight breaths per minute is a danger sign and may require intervention. Systolic blood pressure >90 mmHg If you cannot take a blood pressure reading, you can use the pulse to estimate systolic blood pressure. Feeling for a pulse at the locations below can provide an estimate of systolic blood pressure in an adult (although this method may not work well in the elderly): • Carotid (neck) pulse ≥ 60 mmHg • Femoral (groin) pulse ≥ 70 mmHg • Radial (wrist) pulse ≥ 80 mmHg NORMAL PAEDIATRIC VITAL SIGNS Vital signs are age-dependent in children. Normal heart rate and respiratory rate are higher in younger children, and normal blood pressures are lower. The brachial (middle of the upper arm) artery should be used to check the pulse in infants and small children. Normal paediatric vital signs AGE (in years) NORMAL HEART RATE (beats per minute) ≤1 100–160 1–3 90–150 4–5 80–140 AGE RESPIRATORY RATE (breaths per minute) ≤2 months 40–60 2–12 months 25–50 1–5 years 20–40 * To estimate a child’s (1–10 years old) weight in kilograms use the formula: [age in years + 4] x 2 or use weight-estimation tools such as PAWPER, Mercy TAPE, or Broselow tape. Children are able to maintain normal blood pressure for longer than adults when they are in shock. You must check closely for signs of poor perfusion. The amount of IV fluid appropriate for children is different from that for adults. [See SKILLS] Location of brachial pulse in a child page 35 Location of brachial pulse in a child INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 33 FACILITATOR-LED CASE SCENARIOS These case scenarios will be discussed in small groups. These cases in this module will NOT be assessed and are for practice only. It is important that you practise with these scenarios since you will be assessed on how you lead a case in later modules. To complete a case scenario, the group must identify the critical findings and management needed and formulate a 1–2 line handover summary that includes assessment findings and interventions. You should use the Quick Cards to manage these scenarios. CASE #1: ADULT ABCDE A 70-year-old man is brought in by taxi. The driver states the patient lost consciousness while talking with his daughter. There was no trauma, but the daughter poured water on him to try to wake him up. Initially he was confused and vomiting. Now he is unconscious with a respiratory rate of 3 breaths per minute. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate 1–2 sentences to summarize this patient for handover. Module 1: The ABCDE and SAMPLE history approach 34 CASE #2: PAEDIATRIC ABCDE A mother brings in her 2-year-old son for difficulty in breathing. She reports that he has had a fever for 3 days and has had worsening difficulty in breathing. He has been coughing a lot and today will not eat or drink. 1. What is your initial approach to this patient? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator for specific findings when you look, listen and feel; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate a 1–2 sentence summary of this patient for handover. MULTIPLE CHOICE QUESTIONS Answer the questions below. Questions and answers will be discussed within the session. 1. A mother brings in her 3-year-old child because of difficulty in breathing. On assessment, you hear loud, high-pitched sounds when the child breathes in. What is the most immediate concern? A. Severe infection B. Shock C. Asthma attack D. Upper airway obstruction 2. An elderly woman fell at home. She had normal vital signs, but complained of neck and knee pain prior to transport. During transport, she starts snoring and gurgling when taking a breath. What is the most appropriate method to immediately manage this problem? A. Placing her in the recovery position B. Administering salbutamol C. Jaw thrust D. Head-tilt/chin-lift INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 35 3. A 50-year-old man has collapsed in a store and you are called to assist him. He is unconscious, has a respiratory rate of four breaths per minute and a pulse of 100 beats per minute. The collapse was witnessed and there is no trauma. What is the best next step? A. Begin chest compressions B. Open the airway C. Begin bag-valve-mask ventilations D. Check pupils 4. A 2-year-old boy is brought to you for being more sleepy than normal. He is unconscious. You open his airway, and insert an oropharyngeal airway. What is your next step? A. Check blood pressure B. Check AVPU scale C. Check glucose D. Check breathing 5. You are listening to the lungs of a 26-year-old man who has sudden onset chest pain and he is taking 30 breaths a minute. Which lung-sound finding is most suggestive of pneumothorax? A. Crackles on both sides B. Absent lung sounds on one side C. Stridor D. Wheezing on both sides 36 Notes ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS 37 PARTICIPANT WORKBOOK Module 2: Approach to trauma Objectives On completing this module you should be able to: 1. recognize key history findings suggestive of high-risk injuries; 2. recognize physical examination findings suggestive of high-risk injuries; 3. perform Trauma Primary Survey (the ABCDE approach to trauma patients); 4. perform Trauma Secondary Survey (the head-to-toe trauma exam); 5. recognize life-threatening injuries; 6. perform critical interventions for high-risk conditions. Essential skills • Cervical spine immobilization • Spine immobilization and log-roll manoeuvre • Jaw-thrust manoeuvre • Airway suctioning • Insertion of oropharyngeal and nasopharyngeal airway • Recovery Position • Oxygen delivery • Bag-valve-mask ventilation • Needle decompression for tension pneumothorax • Three-sided dressing for a sucking chest wound • Direct pressure for haemorrhage control, including deep wound packing • Tourniquet for haemorrhage control • IV line insertion • IV flluid resuscitation • AVPU and GCS assessment • Pelvic binding • Basic fracture immobilization • Trauma secondary survey • Basic wound management, including irrigation (washing) • Burn management KEY TERMS Write the definition using the Glossary at the back of the workbook. AVPU: Bradycardia: Circumferential burn: Crepitus: Compartment syndrome: Module 2: Approach to trauma 38 Cyanosis: Decontamination: Deep wound packing: Diaphoresis: Direct pressure: Disposition: Escharotomy: Flail chest: Fracture: Glasgow Coma Scale: Guarding: Haemorrhage: Haemorrhagic shock: Haematoma: Haemothorax: Hyperresonance: Hypothermia: Hypovolaemic shock: Hypoxia: Laceration: Large bore IV: INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 39 Log-roll manoeuvre: Needle decompression: Parkland Formula: Percussion: Pericardial tamponade: Pneumothorax: Priapism: Rebound tenderness: SAMPLE history: Shock: Sprain: Sucking chest wound: Tension pneumothorax: Trauma primary survey: Trauma secondary survey: Module 2: Approach to trauma 40 Overview GENERAL PRINCIPLES OF TRAUMA CARE Early priorities for an injured person include managing airway and breathing emergencies, controlling bleeding, treating shock and immobilizing the spine if needed. The goal of INITIAL ASSESSMENT is to identify life-threatening injuries. The goal of ACUTE MANAGEMENT is to ensure oxygenation and perfusion, to control pain and to plan ongoing care. This module will guide you through the: Approach to trauma ABCDE: Trauma primary survey DO: Important conditions to recognize and manage in the primary survey (signs, symptoms and management) ASK: Key history findings (SAMPLE history) CHECK: Trauma secondary survey DO: Important conditions to recognize and manage based on the history and secondary survey (Signs, symptoms and management) Special populations – Trauma in pregnancy – Special considerations in children Disposition considerations APPROACH TO TRAUMA Approach to the trauma patient consists of three phases: Trauma primary survey: The ABCDE approach for injured patients SAMPLE history: Signs and Symptoms, Allergies, Medications, Past medical history, Last oral intake, and Events surrounding the injury Trauma secondary survey: A complete head-to-toe examination to look for injuries not identified by the primary survey During primary and secondary surveys, if life-threatening problems are identified, STOP AND MANAGE them. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 41 ABCDE: TRAUMA PRIMARY SURVEY The ABCDE approach in injured patients is often also called the trauma primary survey. As for all patients this should be conducted within the first 5 minutes and repeated whenever the patient’s condition worsens. This trauma-specific ABCDE approach includes the initial assessment and management for all immediately life-threatening injuries. Always suspect head and spine injury in a trauma patient with altered mental status. ASSESSMENT IMMEDIATE MANAGEMENT Airway with cervical spine immobilization A Look for: • blood, vomit, tongue or objects obstructing the airway • burned nasal hairs or soot around the nose or mouth • head or neck trauma • neck haematoma (bleeding under the skin) • altered mental status, as this can affect the ability to protect the airway Listen for abnormal airway sounds (such as gurgling, snoring, stridor, noisy breathing). • Stabilize the cervical spine. [See SKILLS] • Open airway using jaw thrust, NOT head-tilt chin-lift if suspected spine injury. [See SKILLS] • Suction airway secretions, blood and/ or vomit. Remove any visible foreign objects from the airway. [See SKILLS] • Place oral airway (avoid nasal airway if facial trauma). [See SKILLS] • If the patient has an expanding neck haematoma or evidence of airway burns or trauma, plan for rapid handover/transfer to a provider capable of advanced airway management. If the airway is open, move onto “Breathing”. Breathing B Look for: • increased work of breathing • abnormal chest wall movement which may indicate flail chest • tracheal shift • sucking chest wound • cyanosis (blue-grey color of the skin) around the lips and fingertips • abrasion, bruising or other signs of injury to chest • circumferential burns (burns that go all the way around a body part) to chest or abdomen • absent or decreased breath sounds Listen for dull sounds or hyperresonance with percussion. Feel for crepitus (cracking and popping when pressing on the skin). • Give oxygen. [See SKILLS] • Perform needle decompression immediately and give oxygen and IV fluids for tension pneumothorax. [See SKILLS] • Place three-sided dressing for sucking chest wound. [See SKILLS] • If breathing not adequate or patient remains hypoxic on oxygen, assist breathing with bag-valve-mask ventilation. [See SKILLS] • For chest or abdominal burns that restrict breathing, handover for escharotomy (a surgical procedure to cut and release burned tissue that may restrict breathing or blood supply to a limb). If breathing is adequate, move onto “Circulation”. Module 2: Approach to trauma 42 ASSESSMENT IMMEDIATE MANAGEMENT Circulation C Look for: • capillary refill longer than 3 seconds • pale extremities • distended neck veins • external AND internal bleeding Common sources of serious bleeding are: • chest injuries • abdominal injuries • pelvic fractures • femur fractures • amputations or large external wounds • burns, noting size and depth Feel for: • cold extremities • weak pulse or tachycardia • Apply direct pressure to control active bleeding, or deep wound packing if large or gaping. [See SKILLS] • If amputated limbs or any other source of uncontrolled bleeding are present, apply tourniquet (document time of application), start IV fluids and plan for urgent transfer to a surgical unit. [See SKILLS] • If ongoing blood loss or evidence of poor perfusion, place two large bore IVs, give IV fluids and re-assess. [See SKILLS] • If burn injury, start IV fluids according to burn size. • Splint suspected femur fracture. [See SKILLS] • Bind pelvic fracture. [See SKILLS] • Leave any penetrating objects in place and stabilize object for transfer to a surgical team. • Position pregnant patients on their left side while maintaining spinal immobilization. If circulation is adequate, move onto “Disability”. Disability D Look for: • confusion, lethargy or agitation • seizures/convulsions • unequal or poorly reactive pupils • deformities of skull • blood or fluid from ear or nose Check: • AVPU or GCS • movement and sensation in all extremities • blood glucose level if confused or unconscious • If GCS <9 (or for children, AVPU score of P or U), plan for rapid handover/ transfer to a provider capable of advanced airway management. • If patient is lethargic or unconscious, re-assess the airway frequently as above. • Suspect spine injury or closed head injury with any trauma and altered mental status. • Give oxygen if concern for hypoxia as a cause of altered mental status. [See SKILLS] • Give glucose if altered mental status and: measured low blood glucose, unable to check blood glucose, or history of diabetes. [See SKILLS] • If seizing, give a benzodiazepine. [See SKILLS] INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 43 ASSESSMENT IMMEDIATE MANAGEMENT Exposure E Remove all clothing. Examine entire body for evidence of injury (including the back, spine, groin and underarms) using the log-roll manoeuvre. • If spinal injury is suspected, perform log-roll manoeuvre to examine the back. [See SKILLS] • Remove restrictive clothing and all jewellery. • Remove any wet clothes and dry patient thoroughly. • Cover the patient as soon as possible to prevent hypothermia. Acutely injured patients have difficulty regulating body temperature. • Respect the patient and protect modesty during exposure. Workbook question 1: Approach to trauma A middle-aged man is brought in after being hit by a car. Using the workbook section above, list the immediate management for the assessment findings below. PRIMARY SURVEY FINDINGS IMMEDIATE MANAGEMENT On airway assessment: • Gurgling airway sounds • Obvious head trauma 1. ������������������������������������������������ 2. ������������������������������������������������ 3. ������������������������������������������������ 4. ������������������������������������������������ On circulation assessment: • Weak pulses • Capillary refill of <3 seconds • Unstable pelvis on exam 1. ������������������������������������������������ 2. ������������������������������������������������ 3. ������������������������������������������������ Module 2: Approach to trauma 44 DO: IMPORTANT CONDITIONS TO RECOGNIZE AND MANAGE IN THE PRIMARY SURVEY A Airway conditions CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Airway obstruction • Visible blood, secretions, vomit, tongue or foreign bodies in the airway • Changes in voice • Abnormal sounds from the airway (such as stridor, snoring, gurgling) • Neck haematoma or burns to head and neck • Mental status changes leading to airway obstruction • Poor chest rise • Injury causing swelling of the airway (such as anaphylaxis or airway burn) Head and neck injuries may result in obstruction of the airway by blood, secretions, vomit, foreign bodies, or swelling. Penetrating wounds to the neck can cause expanding haematomas. Inhalational injuries due to burns can cause swelling. • Patients with a decreased level of consciousness may not be able to protect their airways and need to be watched for vomiting and aspiration. – Suction the airway and remove foreign bodies. – Open the airway using a jaw thrust manoeuvre (NOT head-tilt/chin-lift) and place an oral airway as needed. [See: SKILLS] • Maintain cervical spine immobilization throughout, if needed. • Plan for rapid handover/transfer to a provider capable of advanced airway management. B Breathing conditions CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Tension pneumothorax • Hypotension WITH: – difficulty breathing – distended neck veins – absent breath sounds on affected side – hyperresonance with percussion on affected side – may have tracheal shift away from affected side Any pneumothorax can become a tension pneumothorax. Air in the cavity between the lungs and the chest wall can collapse the lung (simple pneumothorax). Building pressure (tension) from a large pneumothorax can displace and block flow from the great vessels to the heart, causing shock as the heart cannot receive and pump enough blood to the rest of the body (tension pneumothorax). In tension pneumothorax, perfusion is compromised. • Treat tension pneumothorax immediately with needle depression. [See: SKILLS] • Give oxygen and IV fluids. [See: SKILLS] • Plan for rapid handover/transfer to an advanced provider capable of placing a chest tube. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 45 CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Sucking chest wound (open pneumothorax) • Open wound in the chest wall with air passing through causing bubbling or “sucking” noises • Difficulty in breathing • Chest pain Sucking chest wounds are important to recognize because they can rapidly cause a tension pneumothorax. Air enters the chest cavity (into the space between the chest wall and the lungs) through the wound in the chest wall when the patient takes a breath. Pressure on the lung builds if the air cannot escape. • Give oxygen. [See SKILLS] • Place a three-sided dressing that allows air to leave with exhalation but prevents air from entering when the person inhales. [See SKILLS] – There is a danger of the dressing becoming stuck to the chest wall with clotted blood and causing a tension pneumothorax. – After applying a three-sided dressing the patient should be observed continuously. – Remove the dressing if worsening respiratory status or evidence of worsening perfusion. Plan for rapid handover/transfer to an advanced provider capable of placing a chest tube. Flail chest • Difficulty in breathing • Chest pain • Part of chest wall moving in the opposite direction of the rest of the chest when breathing Flail chest segments occur when ribs are broken in multiple places, freeing an entire section of ribs from the chest wall. Without the connection to the chest wall, this section will move abnormally with breathing and prevent part of the lung from expanding. Flail chest is also usually associated with damage to underlying lung tissue. • Give oxygen and pain control. [See SKILLS] • There is a very high risk of developing difficulty in breathing and hypoxia. • Plan for rapid handover/transfer to a provider capable of chest tube placement, advanced airway placement and ventilation. Haemothorax • Difficulty in breathing • Decreased breath sounds on affected side • Dull sounds with percussion on affected side • Large haemothorax may cause shock Haemothorax (blood in the space between the lungs and the chest wall) can present with decreased or absent breath sounds and dull sounds with percussion on the affected side. • Give oxygen and IV fluids. • Plan for rapid handover/transfer to a centre with surgical capacity. Module 2: Approach to trauma 46 C Circulation conditions CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Hypovolaemic shock • Tachycardia, tachypnoea, pale skin, cold extremities, slow capillary refill • May have dizziness, confusion or altered mental status • May have hypotension • External bleeding or internal bleeding (chest, abdomen, pelvis, femur, blood vessels) Hypovolaemic shock can result from rapid loss of blood (haemorrhagic shock) or from the fluid loss associated with burns. An adult patient in shock may have only tachycardia (elevated heart rate) and/or tachypnoea (high respiratory rate) and may not have low blood pressure until the condition is immediately life-threatening. Even with a systolic blood pressure greater than 90 mmHg, suspect hypovolaemic shock if there is severe bleeding or any sign of poor perfusion (such as cool, moist, or pale skin, slow capillary refill, fast breathing, confusion, restlessness, anxiety). • Stop bleeding with direct pressure, deep wound packing if wound is gaping, a tourniquet, splinting of fractures and binding the pelvis as needed. [See SKILLS] • Start two large-bore IV lines and give IV fluids. [See SKILLS] • Patients with suspected large haemothorax or other internal haemorrhage will need rapid handover/transfer to a unit with surgical care and blood transfusion capabilities. REMEMBER... Children and young people are able to maintain a normal blood pressure until they have lost up to a quarter of their blood. Always check for other signs of shock. [See “Special considerations in children” section] Pericardial tamponade • Signs of poor perfusion (such as tachycardia, tachypnoea, hypotension, pale skin, cold extremities, capillary refill greater than 3 seconds) • Distended neck veins • Muffled heart sounds • May have dizziness, confusion, altered mental status Pericardial tamponade occurs when fluid builds up in the sac around the heart. The pressure from this fluid can collapse the chambers of the heart and prevent them from filling, limiting the amount of blood the heart can pump. • Give IV fluid to improve heart filling. [See SKILLS] • Patients need immediate handover/transfer to an advanced provider for drainage of the fluid. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 47 D Disability conditions CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Severe head injury • Visual changes, loss of memory, seizures/ convulsions, vomiting, headache • Altered mental status or other neurologic deficit • Scalp wound and/or skull deformity • Bruising to head (particularly around eyes or behind ears) • Blood or fluid from the ears or nose • Unequal pupils • Weakness on one side of the body Brain injuries can range from mild bruising to severe bleeding in or around the brain. Because the skull is rigid, the bleeding cannot expand and causes increased pressure on the brain. If the pressure becomes too high, it will prevent blood from entering into the skull and perfusing the brain, and can squeeze part of the brain through the base of the skull, causing death. Any trauma to the brain can cause significant impact on function. • Always remember that head injuries can be associated with spinal injuries. Immobilize the spine and use the log-roll technique to examine the back of the body. • Use the Glasgow Coma Scale (or AVPU in children) to assess and monitor patients with head injury. • Be sure to frequently re-assess ABCDE. • If concern for open skull fracture, give IV antibiotics as per local protocol. • Always check glucose and administer as needed. • Do not give food or drink by mouth. • Plan for early handover/transfer to a facility with specialist care. REMEMBER… People who initially appear well may have hidden life-threatening injuries, such as internal bleeding. It is very important to re-assess trauma patients frequently using the primary survey. Once you find a primary survey problem and manage it, go back and repeat the primary survey to identify any new problems and make sure that the management worked. Ideally, the ABCDE approach should be rechecked every 15 minutes and with any change in condition. Vital signs should be checked at the end of the primary survey A full set of vital signs (blood pressure, heart rate, respiratory rate and oxygen saturation if available) should be performed after the primary survey. Do not delay primary survey interventions for vital signs. Module 2: Approach to trauma 48 Workbook question 2: Approach to trauma Using the workbook section above, list five important conditions to recognize in the primary survey 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ ASK: KEY HISTORY FINDINGS FOR TRAUMA PATIENTS Information about an injured person and the injury event can be critical to planning management. Children, older adults and people with chronic disease have an increased risk of complications from trauma. They may need to be watched for several hours even when they appear well. Certain mechanisms are often associated with multiple injuries, some of which may not be obvious right away. High-risk mechanisms include: pedestrian being hit by a vehicle; motorcycle crashes or any vehicle crash with unrestrained occupants; falls from heights greater than 3 metres (or in children, twice the child’s height); gunshot or stab wounds; and explosion or fire in an enclosed space. Use the SAMPLE approach to obtain a history. Remember that you may be able to obtain information from bystanders, family, police, fire service or other health-care workers. If the history identifies a primary survey condition, STOP AND RETURN IMMEDIATELY TO PRIMARY SURVEY to manage it. S: SIGNS AND SYMPTOMS Is there a history of hoarse or raspy voice, or other voice changes? Changes in voice in the setting of injury to the head, neck or with burns may suggest that the airway is swelling and that it may obstruct. Is there any difficulty in breathing? Problems with breathing may develop over time and might not be present in the initial primary survey. Difficulty in breathing may suggest that the person has an injury to the lungs, ribs, muscles, chest wall or spine. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 49 Is there reported bleeding? It is usually quite difficult for patients to estimate the volume of blood loss, but it may be helpful to know how long there has been bleeding, how many bandages have been soaked and if the bleeding is getting lighter or heavier. Is there confusion or unusual sleepiness? Confusion after injury may be a sign of head injury, lack of oxygen or shock (with decreased blood flow to the brain). A head injury can cause bleeding or increased pressure on the brain leading to confusion, lethargy (increased sleepiness) and coma. Is there pain? Where is the pain, what does it feel like and how severe is it? Pain is a sign of underlying injury. Headache may suggest that the person has an injury to the skull or the brain. Pain along the spine can suggest an injury that may progress to cause damage to the spinal cord. Pain in the chest or abdomen may suggest damage to the heart, lungs or other organs. Pain in the pelvis or hips may suggest a fracture in the pelvis which can cause serious bleeding and shock. Pain may be the first sign of an internal injury in the chest, abdomen or pelvis. Is there nausea or vomiting? This may indicate an abdominal or head injury. Is there reported numbness or weakness? This may indicate a spinal injury. Are there reported vision changes? Direct trauma to the eye, fractures of bones around the eye, and head injuries can all cause vision changes. A: ALLERGIES Any allergies to medications? M: MEDICATIONS Currently taking any medications? Medications that affect blood clotting (e.g. aspirin, warfarin, clopidogrel) can make bleeding more difficult to control and increase the risk of delayed bleeding. Blood pressure medications can make it hard to manage shock. Obtain a full list of medications if possible or ask family members to bring in medications. Module 2: Approach to trauma 50 P: PAST MEDICAL HISTORY Is the person pregnant? Pregnancy causes some of the organs to be moved out of their usual position and causes changes in the body that need to be considered when managing trauma. Always ask women of childbearing age about the date of last menstrual period. Tetanus status? A person who has not had a tetanus vaccination within the past 5 years and who has an injury that damages the skin needs a tetanus vaccination. Are other conditions present that put the person at higher risk for serious injury? RISK FACTORS FOR POOR OUTCOMES FROM INJURY: – Age less than 5 years or greater than 55 years – Heart or lung disease – Diabetes – Liver failure (cirrhosis) – Severely overweight – Pregnancy – Immunosuppression (including HIV) – Bleeding disorder or taking blood-thinning medications (medications that prevent clotting) L: LAST ORAL INTAKE When did the person last eat or drink? E: EVENTS SURROUNDING INJURY Certain mechanisms of injury are so high risk that patients should be observed closely, even if they do not appear to be significantly injured. Was there a fall from 3 metres or more (or twice the height in children)? Falls are a common cause of injury for both adults and children. A greater distance fallen increases the chance of serious injury. Falls in adults are often associated with older age, alcohol intoxication, or the failure of workplace equipment, including scaffolding and ladders. Children often fall from trees, windows or balconies. Was a pedestrian or a cyclist hit by a vehicle? Adults and children who are hit by a vehicle while walking or using non-motorized forms of transport (such as bicycles) are always at high risk of serious injury. Young children may be less able than adults to report events, even major events like being hit by a vehicle. Always consider the possibility of unwitnessed trauma in young children. Children and adults can sustain multiple injuries when hit by a vehicle – both from direct impact to the body, especially the lower extremities, and from secondary impact if they are thrown against the windscreen or road, which may cause injuries anywhere in the body, including to head, neck, chest or limbs. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 51 In a motorcycle (or powered 3-wheeler) crash, was the rider thrown? Motorcycles collisions often result in a rider being thrown. Ask if the motorcyclist was wearing a helmet and how far away from the vehicle the rider was found. Common injury sites include head (especially when no helmet was worn), spine, chest, abdomen and pelvis (as the rider hits the handlebars), as well as limbs and skin (as the rider hits the road). Was there a road traffic crash at high speed? Was the person thrown from or trapped inside a vehicle? Did any vehicle occupants die in this crash? With higher-speed crashes, greater force is transmitted to vehicle occupants increasing the risk of serious injury. Vehicle occupants may be injured by impact with the windscreen or steering wheel, or by the forces that result from the sudden stopping of the vehicle. A person thrown from a vehicle is at very high risk of serious injury. If a person was trapped within a vehicle it is important to find out what part of the body was trapped (arm/leg, etc.) and for how long. Consider crush injury in a person who has been trapped. A death at the scene of a road traffic crash suggests that there was significant force exerted on the vehicle and its passengers. All passengers involved in the crash, even if they appear unhurt, are at high risk for serious injury. In a motor vehicle crash, was the patient wearing a seatbelt? Some types of injuries are more common in patients who were not wearing a seat-belt (being thrown from the vehicle, head strike on the windscreen, chest strike on the steering column). However, in very high-speed crashes, seat belts can also cause certain types of injuries (cervical spine injury, abdominal injury). Was a weapon used? Any time there is a history of a stab or gunshot wound, there may be multiple wounds. Always check the full body for wounds. After a bullet enters the body it may not follow a direct path and can twist throughout the body. Many internal organs can be injured by a single bullet. A stab wound creates a direct path (it is important to know the length of the blade that was used). Remember that blunt injuries from objects such as sticks and bats can cause damage to internal organs in addition to obvious injuries such as fractures, bruises and lacerations. Was there a burn? If so, what type of burn was it? Burns from fires (flame burns) are the most common. A history of flame burn in an enclosed space can also suggest an inhalation or airway injury. Scald burns (due to hot liquids) are common in children. Electrical injuries often come from high-voltage sources such as overhead electrical wires coming in contact with the body. On the surface, these electrical injuries may look small but they can cause extensive tissue and muscle damage. The electrical current often crosses the body, taking the shortest path from the point of contact with the skin to the ground, often leaving entry and exit burn marks. In the case of chemical burns, information about the specific chemical may be needed to remove it properly. For burns, was first aid provided at the scene? It is important to know if the burning process was stopped, and in the event of a chemical exposure, if decontamination was performed. If the burn is less than 3 hours old and no first aid was provided, the wound will need to be washed with clean water to stop the burning process. If there is a history of chemical exposure, protect yourself from the chemical and ensure that it is properly removed from the skin. Module 2: Approach to trauma 52 Did the person sustain a crush injury? Is there severe pain or numbness? Is there dark urine? Crush injuries may damage skin, muscle, blood vessels and bone. Damaged muscle can release a muscle by-product (called myoglobin) that can build up and damage the kidneys. It is important to know how long a body part was crushed. Even a small crushed area can cause the release of a dangerous amount of myoglobin (for example when a limb is caught under falling debris for an extended time). If a person with a crush injury has dark urine, this may be a sign of build-up of myoglobin in the kidneys. Tissue damage and swelling from crush injury can also cause a build-up of pressure (particularly in limb-crush injuries) that can limit blood flow to the muscles and nerves (compartment syndrome). Did the person sustain a blast injury? Blast injuries (from explosions) can involve all systems of the body, especially the hollow organs. Common blast injuries include damage to the lungs, intestines and ears. Patients involved in explosions need to be checked carefully and repeatedly because these injuries are easily missed. Blasts may also be associated with foreign bodies in the skin and eyes, burns or chemical injury, and toxin or radiation exposure. Workbook question 3: Approach to trauma Using the workbook section above, list five questions you would ask when taking a SAMPLE history from a person injured in a road traffic crash: 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ CHECK: TRAUMA SECONDARY SURVEY Following the primary survey and SAMPLE history, the secondary survey is a detailed head-to- toe examination designed to identify any additional injuries or issues requiring intervention. The secondary survey gives the provider an organized way to assess the entire body for signs of trauma that may not have been obvious on the primary survey. Remember that very painful or frightening injuries may distract both patients and providers from recognising other injuries. Always examine the entire body. If the secondary survey identifies a primary survey condition, STOP AND RETURN IMMEDIATELY TO THE PRIMARY SURVEY to manage it. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 53 Head, ears, eyes, nose, and throat (HEENT) Look for: • Scalp wounds or bruising • Skull deformities • Blood in mouth or throat • Unequal or unresponsive pupils indicating head injury • Vision loss or changes and eye injuries • Any problems with eye movements • Blood or fluid from ear or nose, which can indicate tissue injury or skull fracture • Tooth injury or poor alignment of teeth • Signs of airway burns: ash, singed nasal hairs, new or worsening lip/ mouth swelling Listen for: • Stridor which could indicate that the airway will obstruct soon • Gurgling indicating fluid in the airway • Changes in voice, which can indicate airway or vocal cord injury Feel for: • Tenderness or abnormal movement of facial bones, suggesting fracture • Loose teeth that may accidentally be inhaled • Defects or crepitus in the skull or facial bones concerning for fracture Neck Look for: • Reduced ability to move neck or pain on movement • Bruising, bleeding or swelling • Haematoma (bruising/bleeding under the skin) – this may eventually cause airway obstruction • Penetrating neck wounds • Distended neck veins (which may indicate tension pneumothorax or tamponade) Feel for: • Air in the skin or soft tissue – concerning for airway injury or pneumothorax • Tenderness or deformity along the spine – concerning for fracture Chest Look for: • Bruising, deformity, wounds • Uneven chest wall movement–concerning for pneumothorax or flail chest • Burns around the entire chest (circumferential) which can cause difficulty in breathing Listen for: • Breath sounds (decreased, unequal or absent, wheeze, crepitations) • Muffled heart sounds – concerning for pericardial tamponade Feel for: • Tenderness • Crepitus – concerning for fracture or pneumothorax Module 2: Approach to trauma 54 Abdomen Look for: • Abdominal distension • Visible abdominal wounds, bruising or abrasions • Bruising on back or abdomen, which may indicate internal bleeding • Circumferential burns to the abdomen (may cause severe problems with breathing) Feel for: • Abdominal rebound tenderness (pain when releasing pressure on the abdomen) or guarding (sudden contraction of the abdominal wall muscles when the abdomen is pressed), suggesting serious injury • Abdominal tenderness, which can indicate organ or blood vessel injury Pelvis and genitals (always protect patient privacy during exam) Look for: • Bruising/lacerations to pelvis • Blood at the opening of the penis or rectum. May be a sign of sexual assault. • Vaginal lacerations or bleeding – these could indicate open pelvic fracture, injury to the uterus, or may be a source of significant blood loss. May be a sign of sexual assault. • Penile lacerations • Priapism (prolonged erection) can indicate spinal injury • Urine colour changes (dark urine or obvious blood) that might indicate muscle breakdown or kidney injury Feel for: • Tenderness or abnormal movement in pelvis Extremities Look for: • Swelling or bruising • Deformity, which could indicate fracture • Open fractures • Amputation • Circumferential burns • Pale skin that could indicate limited blood flow Feel for: • Absent or weak pulses • Cold skin that could indicate limited blood flow • Tenderness • Abnormally firm, painful muscular compartments in the extremities can indicate compartment syndrome INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 55 Spine/back Log roll the person with assistance, then: Look for: • Bruising • Deformity Feel for: • Tenderness, crepitus and misalignment along the entire spine (upper neck to lower back) • Tenderness, crepitus or misalignment over any other areas with visible evidence of trauma Skin Look for: • Bruising • Abrasions • Lacerations • Feel for peripheral pulses in all extremities • Burns – Look for circumferential burns: depending on the location, these can cause difficulty in breathing (if on the chest) or compartment syndrome (if on the extremities) Neurologic Check for: • Decreased level of consciousness (using AVPU or GCS) and seizures/ convulsions, which may be signs of serious head injury • Movement and strength in each limb • Sensation on face, chest, abdomen, limbs; if there is a sensory deficit, identify where it begins • Priapism (persistent penile erection) • Decreased sensation, decreased strength or priapism can indicate spinal cord injury Module 2: Approach to trauma 56 Workbook question 4: Approach to trauma Using the workbook section above, list one way that you would ASSESS the following systems. Head, ears, eyes, nose, throat: Listen for: _______________________________________________________________ Look for: ________________________________________________________________ Feel for: _________________________________________________________________ Chest: Look for: ________________________________________________________________ Listen for: _______________________________________________________________ Feel for: _________________________________________________________________ Pelvis and genitals: Look for: ________________________________________________________________ Feel for: _________________________________________________________________ INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 57 DO: IMPORTANT CONDITIONS TO RECOGNIZE AND MANAGE BASED ON HISTORY AND SECONDARY SURVEY Management of specific injuries found during secondary survey CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Head injury • Headache • Altered mental status • Abnormal pupils • Scalp lacerations and/or skull fractures • Bruising to head (particularly around eyes or behind ears) • Blood or clear fluid coming from nose or ears • Weakness on one side of the body • Seizures/convulsions • Visual change • Loss of memory • Vomiting Because the brain is encased in the rigid skull, any swelling or bleeding caused by brain injury can rapidly become life-threatening. • Monitor level of consciousness (a marker of brain function) using the Glasgow Coma Scale (GCS) or AVPU scale in children. [See SKILLS] • Any patient who has significant head injuries is at risk of having spine injuries as well. [See SKILLS] • Always monitor immobilized patients for vomiting to avoid choking. • If there is concern for an open skull fracture, give IV antibiotics. • Check blood glucose and give glucose if less than 3.5 mmol/L or unable to measure. • Any patient with GCS less than 9 should be transferred for a CT scan within 2 hours of injury, if possible. Facial fractures • Deformities or unusual movement in the facial bones • Patient reports jaw not closing normally or teeth not aligned • Problems with eye movements • Give antibiotics for open facial fractures (laceration over a broken bone). • Update tetanus vaccination. • Suspect cervical spine injury and immobilize the cervical spine if needed. [See SKILLS] • Remember to position patient to keep blood from flowing into airway. • Avoid nasopharyngeal airways and nasogastric tubes when facial fracture is suspected. Penetrating eye injury • Any visible object in the eye • Painful red eye or a reported feeling of something in the eye; it may be difficult to see small objects that have penetrated the eye • Problems with vision • An abnormally shaped pupil or clear liquid draining from the eye may indicate a puncture wound • Evidence of facial trauma • Avoid any pressure on the injured eye – this could worsen the injury • Do not remove objects penetrating the eye. • Give antibiotics. • Update tetanus vaccination if needed. • Keep the head elevated and place a loose patch over both eyes (do NOT put pressure on the eye). • Plan for handover/transfer to an advanced provider. Module 2: Approach to trauma 58 Management of specific injuries found during secondary survey CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Penetrating neck wound • Small lacerations or puncture wounds may be the only sign of serious injury • Swelling (suggesting haematoma) • Look carefully for penetrating objects Patients with penetrating neck wounds are at risk of airway obstruction, so monitor the airway closely. Neck wounds may also have significant haemorrhage. • Maintain cervical spine precautions. [See SKILLS] • Stabilize, but do not remove penetrating objects. • Apply firm pressure to bleeding site, being careful not to block the airway. • Do not insert anything into wound to check the depth – this can cause further damage. • Initiate rapid handover/transfer to a unit with surgical care and advanced airway management capabilities. Chest injury • Difficulty in breathing • Crepitus or tenderness to palpation over the ribs • Uneven chest wall movement or unequal breath sounds Monitor closely for difficulty in breathing due to lung injury which can develop over time. Tension pneumothorax is treated in the primary survey; however, chest injury may also be associated with simple pneumothorax which can progress to a tension pneumothorax. • Any patient with a pneumothorax should be placed on oxygen and monitored closely for development of a tension pneumothorax. • Crepitus or tenderness may be signs of rib fractures which are often associated with underlying chest or abdominal injury. • Plan for handover/transfer for chest tube (pneumothorax) or advanced airway and breathing management. Abdominal injury • Abdominal pain or vomiting • Tender, firm or distended abdomen on examination • Sudden abdominal wall muscle contractions when the abdomen is touched (guarding) • Very few or no bowel sounds on examination • Rectal bleeding • Visible wound in the abdominal wall • Bruising around the umbilicus or over the flanks can be a sign of internal bleeding Severe pain or bruising to the abdomen is concerning for organ injury or internal bleeding. • If you suspect abdominal injuries, give IV fluids. • Do not give the patient anything to eat or drink. • If bowel is visible: – leave it outside the body; – cover it with sterile gauze soaked in sterile saline; – give antibiotics. • If there is any concern for abdominal injury, plan for rapid handover/transfer to a unit with surgical capabilities. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 59 Management of specific injuries found during secondary survey CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Spinal cord injury • Midline spinal pain/tenderness • Movement problems: paralysis, weakness, abnormal reflexes • Sensation problems: tingling (“pins and needles” sensation), loss of sensation • Loss of control of urine or stool • Priapism • May have hypotension, bradycardia • Crepitus when you touch the spinal bones • Spinal bones that are not properly aligned • Difficulty in breathing (upper cervical spine injury) • Provide spinal immobilization to any person with a history of trauma who is unconscious; or who is conscious and has neck pain, cervical spine tenderness, numbness or weakness. – Use a rolled sheet or neck collar to immobilize the cervical spine. [See SKILLS] Keep the patient lying flat in bed to immobilize the rest of the spine. [See SKILLS] When examining or moving the trauma patient, the spine should be protected by using the log-roll manoeuvre. [See SKILLS] • Give IV fluids. [See SKILLS] • Any patient with possible spinal trauma needs handover/transfer to a specialist unit. NOTES: • Spinal trauma is not always obvious. Fractured spinal bones can injure the spinal cord, causing paralysis. If the spinal cord injury is in the cervical spine, paralysis could involve the muscles that control respiration and could lead to death. Examination findings should be carefully documented so that future providers can evaluate if the patient’s condition has changed. • Spinal injuries can also cause shock. This can occur when nerves that control the contraction of the blood vessels in the body are damaged. When the walls of a blood vessel relax, the vessel dilates and pressure drops, leading to poor perfusion and shock. Risk is higher if there is also blood loss, so patients must be monitored closely. Always consider spinal injury in a patient with shock that does not improve with treatment. • Spine boards should only be used to move patients. Leaving patients on spine boards for long periods of time can cause pressure sores. Remove patients from boards as soon as they arrive at the facility and can be laid flat. Internal bleeding (not seen on primary survey) • Bruising around the umbilicus or over the flanks can be a sign of internal bleeding • Pelvic fracture • Femur fracture • Decreased breath sounds on one side in the chest (haemothorax) • Signs of poor perfusion (hypotension, tachycardia, pale skin, diaphoresis) A large quantity of blood can be lost into the chest, pelvis, thigh, and into the abdomen before bleeding is recognized. • Stop the bleeding if possible – bind pelvis or splint femur. [See SKILLS] • Give IV fluid. [See SKILLS] • Refer for blood transfusion and ongoing surgical management if needed. Module 2: Approach to trauma 60 Management of specific injuries found during secondary survey CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Pelvic fracture • Pain with palpation of the pelvis • Instability or abnormal movement of the pelvic bones • Blood at opening of the penis or rectum • Give IV fluids and pain control. [See SKILLS] • Compress pelvis gently to check for stability. • Do not open and rock pelvis or perform repeat exams as this can worsen internal bleeding. • Stabilize the pelvis with a sheet or pelvic binder. [See SKILLS] • Plan for early handover/transfer to a unit with blood transfusion capabilities. Extremity fracture with poor perfusion • Deformity or crepitus of the bone • Absent pulses beyond the fracture • Capillary refill time of greater than 3 seconds beyond the fracture • Cold extremities beyond the fracture with blue or grey skin colour Fractures can displace blood vessels and limit blood supply to the limb beyond the fracture. • Look for signs of poor perfusion beyond the fracture. Feel the pulse. Check capillary refill. Look for pale skin. [See SKILLS] If a fracture is found with weak pulses or poor perfusion, re-establish perfusion by reducing (manually re-aligning bone ends to put limb back to its normal position) and splinting the fracture. [See SKILLS] Always check and document pulses, capillary refill and sensation before and after any reduction. • Plan for urgent handover/transfer to a specialist unit. Open fracture • Deformity or crepitus of the bone with overlying laceration Consider any patient to have an open fracture if there is a wound (more than just a skin abrasion) near a fracture site. Open fractures are emergencies because they can lead to severe bone infections. • Control haemorrhage with direct pressure. [See SKILLS] • Reduce the fracture immediately if there is poor perfusion. [See SKILLS] • Irrigate the wound well. [See SKILLS] • Dress wound. • Give antibiotics and tetanus vaccination. • Splint the wound. • Plan for handover/transfer to a specialist unit. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 61 Management of specific injuries found during secondary survey CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Open wound • Laceration • Abrasion • Wounds in the underarm area, genital area, buttocks or back are easily missed • Pumping or squirting blood can indicate arterial bleeding The goal of wound care is to stop bleeding, prevent infection, assess damage to underlying structures and promote healing. • Stop bleeding. [See SKILLS] • Clean wounds thoroughly with soap and clean water or antiseptic to remove any dirt, foreign bodies or dead/dying tissue. (Give local anaesthetic before cleaning the wound if available.) • Dress wounds with sterile gauze, if available. • Check perfusion beyond the wound (capillary refill and/or distal pulses) before and after dressing wounds. • Splint extremities with large lacerations to help with wound healing and pain control. [See SKILLS] • Stabilize but do not remove penetrating objects. • For snake bite, immobilize the extremity. [See WOUND MANAGEMENT in SKILLS] • For animal bites, consult advanced provider to assess for risk of infection and rabies exposure. Depending on vaccination status, management can be extremely time-sensitive. • Give tetanus vaccination if needed. REMEMBER… Always assess, treat and monitor pain. Applying direct pressure to a wound Applying direct pressure to a wound page 15 Module 2: Approach to trauma 62 SPECIAL CONSIDERATIONS Management by injury mechanism CONDITION CONCERNING SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Crush injury • Fractures, bruising, soft tissue damage • Evidence of compartment syndrome (pain, firm muscle compartments, numbness, decreased pulses or pale skin) • Small amounts of red-brown urine Crush injuries can have serious complications. Look for compartment syndrome (a build-up of pressure within the muscle compartments that can limit blood supply to muscles and nerves) and kidney damage due to by-products of muscle injury. • It is important to monitor urine output and look for red- brown urine (a concern for possible kidney damage). • Give IV fluids to help the kidneys maintain urine output. • Splint fractures to keep bone ends from causing further damage. • Plan for early surgical referral to release the pressure if compartment syndrome develops. • Patients may have many systemic problems related to muscle damage and should always be handed over to an advanced provider. Blast injury • Injury to air-filled organs (such as lung, stomach and bowel) • Delayed symptoms of tachypnoea, hypoxia, chest pain, cough with or without blood • Abdominal pain, nausea, vomiting with or without blood • Tympanic membrane (ear drum) rupture: hearing loss, ringing in the ears, pain, ear bleeding • Other injuries, burns, exposure to chemicals or toxins An explosive blast can cause injuries in three ways: 1. Visible injuries from shrapnel (fragments of metal released by an explosive device) or burns from heat or chemicals released; 2. Internal (often hidden) injuries from the change in pressure caused by the blast. The stomach and bowel, lungs, and ears are commonly injured; and 3. Additional blunt injuries that result when the body is thrown by the blast. • Examine carefully for pneumothorax. • Give oxygen if there is difficulty in breathing. [See SKILLS] • Update tetanus. • Burns should be dressed and fluid needs calculated based on burn area. [See SKILLS] • If the patient has abdominal pain, consider bowel perforation, give IV fluids [See SKILLS] • Prepare for rapid surgical referral. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 63 Management by injury mechanism CONDITION CONCERNING SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT Burn injury • Skin colour can range from pink, red, pale, or black, depending on the burn depth. The burn may or may not have blisters. • The following may suggest inhalation or airway injury. – Soot (ash) around nose or mouth, or singed (burned) nasal hairs – Swelling to lips or mouth – Voice changes Burns can affect the whole body and cause soft tissue injury, swelling and shock resulting from fluid loss due to the burn. The goal of burn management is to stop the burning process, watch for swelling and compensate for fluid loss. In significant burn injury, fluid leaks into the skin and surrounding tissue causing swelling and shock. • Burns involving the airway can rapidly cause airway obstruction. • It is crucial to replace fluid loss and anticipate ongoing losses. – In order to calculate the IV fluid requirements, it is important to determine the depth of the burn and the percentage of body surface area (BSA) that is burned. [See SKILLS] • Do not forget to give tetanus vaccination and pain relief for burn injuries. • Remove all jewelry and elevate the burned limb if possible. • Burns are at high risk for infection, even with good care. Clean and dress the wound carefully. [See SKILLS] BURNS REQUIRING RAPID HANDOVER/TRANSFER: • Serious burns to >15% of body [See SKILLS] • Burns involving the hands, face, groin area, joints, or circumferential burns • Inhalation injury • Burns with other associated trauma • Any burn in very young or elderly people • Significant pre-burn illness (such as diabetes) Module 2: Approach to trauma 64 Workbook question 5: Approach to Trauma Using the workbook section above, list what you would DO to manage the following injuries. INJURY MANAGEMENT Pelvic fracture 1. ______________________________________________________ 2. ______________________________________________________ 3. ______________________________________________________ 4. ______________________________________________________ Burn injury in an adult 1. ______________________________________________________ 2. ______________________________________________________ 3. ______________________________________________________ 4. ______________________________________________________ Abdominal injury 1. ______________________________________________________ 2. ______________________________________________________ 3. ______________________________________________________ 4. ______________________________________________________ INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 65 SPECIAL POPULATIONS TRAUMA IN PREGNANCY Any female patient aged 10–50 years should have a pregnancy test. Pregnancy causes many changes in physiology and there are added considerations for fetal well-being. Even minor trauma may cause harm to the mother and fetus. Women suffering trauma in the third trimester are at risk for placental abruption (where the placenta can separate from the uterus wall, resulting in bleeding), uterine rupture, and premature labour. Remember resuscitation of the mother resuscitates the fetus. KEY ELEMENTS OF PATIENT HISTORY Gestational age (age of the fetus or number of weeks since last menstrual period). Any pregnancy complications. PRIMARY SURVEY Airway: swelling in pregnancy can make airway obstruction more likely, so monitor closely. Breathing: the diaphragm is pushed up by the pregnant uterus, leaving less lung space for breathing. Circulation: check for vaginal bleeding; a pregnant uterus can also compress large blood vessels, causing hypotension. Place on left side with cervical spine precautions. [See SKILLS] Disability: always consider eclampsia if seizures/convulsions occur. Exposure: keep patient warm. COMMON CONDITIONS CAUSED BY TRAUMA Preterm (early) labour with or without premature rupture of membranes (loss of the fluid surrounding the baby). Placental abruption or uterine rupture: causing blood loss and shock. Seizures/convulsions. SPECIAL MANAGEMENT CONSIDERATIONS Plan early for handover/transfer to a specialist unit with obstetric care. If the uterus can be felt at the level of the umbilicus (belly button), this generally indicates that the patient is at least 20 weeks pregnant. If the woman is more than 20 weeks (5 months) pregnant, the pregnant uterus can compress the inferior vena cava, the large vessel that brings blood back to her heart, and can cause shock. When lying the pregnant patient flat, always place on the left side (on a spine board if immobilization necessary). [See SKILLS] Trauma in late pregnancy may trigger early labour. Prepare for neonatal resuscitation as well when trauma occurs in late pregnancy. Module 2: Approach to trauma 66 Workbook question 6: Approach to Trauma Using the workbook section above, list the common conditions in a pregnant woman that can be caused by trauma. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 67 SPECIAL CONSIDERATIONS IN CHILDREN Children can appear well after an injury, and yet deteriorate quickly. They have different injury patterns, and serious internal organ injuries may occur without overlying skull or rib fractures (paediatric bones are more flexible). Common management problems include over- or under-resuscitation, medication errors and failure to recognize hypothermia and hypoglycaemia. Below are special considerations for injured children. Refer also to the ABCDE module for normal paediatric vital signs and additional details. AIRWAY • When neck trauma or cervical spine injury is suspected, use jaw thrust to manually open airway while maintaining cervical spine immobilization. Children have big heads and large tongues that may easily obstruct their airways. Young children and infants may require a pad under the shoulders to align the airway. [See SKILLS] BREATHING • If the child is not breathing adequately after opening the airway, assist breathing with a bag-valve-mask, ideally with oxygen. • Give a breath every 4 seconds (15 breaths per minute) for older children and a breath every 3 seconds (20 breaths per minute) for infants. [See SKILLS] Neutral position in infants page 2 Module 2: Approach to trauma 68 CIRCULATION • For ongoing blood loss or evidence of poor perfusion in children with normal nutritional status (see also SKILLS): – place IV; – give IV fluids and re-assess. [See SKILLS] • For malnourished children, fluids MUST be adjusted. [See SKILLS] • For severe burn injury, initial bolus is with dextrose- containing fluids. [See SKILLS] • If significant haemorrhage, arrange for blood transfusion or rapid handover/transfer to a centre capable of blood transfusion. DISABILITY • Monitor child’s level of consciousness with the AVPU scale (Alert, responsive to Verbal stimuli, responsive to Painful stimuli, Unresponsive). AVPU is preferred to GCS in young children. • Assess for and manage seizures/convulsions. • Assess for and manage hypoglycaemia. EXPOSURE • Expose the entire body but watch for hypothermia. • Protect the child’s modesty at all times. • Use log-roll to assess remainder of child’s back and head. Estimate weight in children based on age Weight in kilograms = [age in years + 4] × 2 or use weight-estimation tools such as PAWPER tape, Mercy TAPE, or Broselow tape, etc. GENERAL Young children may be less able than adults to report events, even major events like being hit by a vehicle. Always consider the possibility of unwitnessed trauma in young children. Location of brachial pulse in a child page 35 Location of brachial pulse in a child INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 69 HEAD INJURIES Head injuries are a common cause of death in children, and children frequently suffer from acute brain swelling after a severe head injury. If a paediatric patient has signs of traumatic brain injury, transport urgently to a facility with critical care and/or surgical capacity. CHEST INJURIES Chest injuries can be life-threatening, and children require less force for more serious internal injuries. The ribs are more flexible than in adults, and there may be extensive chest injuries without rib fractures. ABDOMINAL INJURIES Children’s abdomens are relatively larger than adults, and the abdomen is a common site of injury in children. Injuries to the spleen and liver are especially common. Abdominal injuries should be considered in all paediatric trauma patients as they can be life- threatening and can cause severe internal bleeding. BURN INJURIES Burns in children can be difficult to manage. They require careful fluid resuscitation, close observation for airway swelling, and pain medications for dressing changes. In children who are burned, plan for rapid handover/transfer to a burn unit. Workbook question 7: Approach to Trauma Using the workbook section above, list the circulation considerations in children who suffer trauma. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ List the disability considerations in children who suffer trauma. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ Module 2: Approach to trauma 70 DISPOSITION CONSIDERATIONS Trauma patients can have complex injuries that may be hidden, and can worsen and die very quickly. Always refer seriously injured patients to a higher level of care for specialized treatment. The following high-risk conditions always require handover/transfer to a specialist unit for ongoing care: Airway problem requiring intervention. Signs of shock: – Tension pneumothorax: perform needle decompression prior to transfer (will need urgent chest tube placement). – Pericardial tamponade: ensure IV fluids started and continued on transfer. Altered mental status (drowsy, lethargic, confused or unconscious). Trauma in pregnancy: place on left side for transport (needs specialist obstetric care). Child with ABCDE problem, burn, or any head, chest or abdominal injury. Any serious burn injury: assess the burn depth and total burn surface area, commence fluid resuscitation (transfer preferably to a specialist burns unit). [See SKILLS] Other considerations for transfer: If a patient has required oxygen, arrange to continue it during transport and after handover. If an injured person is displaying signs of shock, ensure IV fluid started and continued during transfer. Ensure any external bleeding is controlled and monitored during transport. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 71 FACILITATOR-LED CASE SCENARIOS These case scenarios will be presented in small groups. The following cases WILL NOT be assessed and are for practice only. It is important that you practise these scenarios as you will be assessed on how you lead a case in the following modules. For each case scenario the group must identify the critical findings and management needed and formulate a one- line summary for handover, including assessment findings and interventions. You should use the Quick Cards for these scenarios. CASE #1: ADULT TRAUMA A taxi driver brings in a man that was severely injured. You come outside to find a 30-year-old male lying in the back seat of the taxi in severe pain. He was in a car crash a few kilometers away. His jeans are soaked with blood, with bone sticking out of the right thigh. 1. What do you need to do in your initial approach? 2. Use the primary survey to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate a short summary of this patient for handover. CASE #2: PAEDIATRIC TRAUMA A 5-year-old boy pulled a pan of boiling water off the stove at 8pm tonight. The boiling water spilled on him, burning his right side. His mother used a container of cool water to wash him down and then brought him in for evaluation. The child is crying and tells you he is in pain. He has burns to his right palm, and right inner arm up to the elbow, and the front of his chest and abdomen and the front of his right thigh. The mother does not know how much the child weighs. Module 2: Approach to trauma 72 1. What do you need to do in your initial approach? 2. Use the primary survey to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. Use the table below for your notes. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO A. Calculate the total burn surface area in this child. Try to shade in the children’s burn diagram for burn area estimation. B. Explain how you will decide if this child needs IV fluids? C. Calculate how much fluid is needed, explaining your method. D. What fluid would you use? 3. Formulate a short summary of this patient for handover. INTRO ABCDE TRAUM A BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 73 MULTIPLE CHOICE QUESTIONS Answer the questions below. Questions and answers will be discussed in the session. 1. Which of the following is a component of the trauma primary survey? A. Examine the arms for any fractures B. Check the skin color and temperature C. Examine the ears for any drainage of blood or clear liquid D. Check skin pinch 2. You are assessing a man who was in a car crash. He is very confused, but the remainder of his primary survey is normal. How do you perform a SAMPLE history if the patient is too confused to answer your questions? A. You do not need to do a SAMPLE history in a trauma patient B. Ask the patient repeatedly until he is able to answer C. Ask bystanders or family member for the information D. Assume that there is no important information 3. A 23-year-old man is carried in after diving head first into a river. He is speaking and his airway is open but he cannot walk or move his arms or legs. What is the first thing you must do? A. Place an IV line B. Examine him for other injuries C. Immobilize the cervical spine D. Give him a tetanus vaccination 4. You are evaluating a 21-year-old male who was in a motorcycle crash. He was thrown from the motorcycle and suffered injuries to his face, chest and legs. When you compress his pelvis, he screams in pain. His vital signs are: blood pressure 90/40 mmHg, heart rate 120 bpm, respiratory rate 25/min. What should be your next step? A. Place in a pelvic binder B. Administer tetanus vaccine C. Provide antibiotics D. Clean the abrasions with soap and water 5. A young woman has been brought in after an explosion. She has an open airway, a respiratory rate of 30/min, heart rate 125 bpm, blood pressure of 85/50 mmHg, has moist pale skin and she complains of abdominal pain. She has small wounds to her skin but there is no obvious bleeding. What would you do to manage this patient? A. Place two large-bore cannulae and give 1 litre of fluid B. Offer her a drink of water C. Check her temperature D. Provide antibiotics 74 Notes ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS 75 PARTICIPANT WORKBOOK Module 3: Approach to difficulty in breathing Objectives On completing this module you should be able to: 1. recognize signs of difficulty in breathing (DIB); 2. list the high-risk causes of difficulty in breathing; 3. perform critical actions for high-risk causes of difficulty in breathing. Essential skills Basic airway manoeuvres Basic airway device insertion Management of choking Oxygen administration Bag-valve-mask ventilation Needle decompression for tension pneumothorax Three-sided dressing for sucking chest wound KEY TERMS Write the definition using the Glossary at the back of the workbook. Accessory muscle use: Anaemia: Asthma: Chronic obstructive pulmonary disease (COPD): Circumferential burns: Crepitus: Module 3: Approach to difficulty in breathing 76 Cyanosis: Diabetic ketoacidosis (DKA): Diaphoresis: Difficulty in breathing (DIB): Disposition: Drowning: Haemothorax: Heart attack: Heart failure: Hives: Hyperventilation: Inflammation: Ischaemia: Large-bore IV: Needle decompression: Pericardial effusion: Pleural effusion: Pleuritic: Pneumonia: Pulmonary embolism: TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 77 Stridor: Tachycardia: Tachypnoea: Tracheal shift: Tripod position: Wheezing: Overview Difficulty in breathing (DIB) is a term used to describe a range of conditions from a feeling of shortness of breath to abnormal breathing movements, or any increased effort required to breathe. DIB can result from problems in the upper or lower airways, the lungs, the heart or the muscles used for breathing; or from conditions that may cause faster breathing (such as anaemia or chemical imbalance). DIB can be caused by: upper or lower airway obstruction (blockage by an object; by spasm of the airways, such as with asthma; by swelling due to allergy; infection or injury); fluid in the airspaces of the lung (such as from pneumonia or pulmonary oedema); air or fluid outside the lung causing lung collapse or compression (such as pneumothorax or effusion); blood clots in the vessels supplying the lungs; any other cause of decreased oxygen carried in the blood (such as anaemia); conditions that increase respiratory rate such as toxic ingestion, chemical imbalance (for example in diabetic ketoacidosis) or anxiety. The goal of INITIAL ASSESSMENT is to identify reversible causes of difficulty in breathing, and to recognize conditions that require urgent intervention or rapid transfer. The goal of ACUTE MANAGEMENT is to ensure the airway stays open and breathing is adequate to deliver oxygen to the organs. Module 3: Approach to difficulty in breathing 78 This module will guide you through: ABCDE key elements ASK: key history findings (SAMPLE history) CHECK: secondary exam findings Possible causes DO: management Special considerations in children Disposition considerations REMEMBER... • ALWAYS START WITH THE ABCDE APPROACH, intervening as needed. • Then do a SAMPLE history. • Then do a secondary exam. ABCDE: KEY ELEMENTS FOR PATIENTS WITH DIFFICULTY IN BREATHING For the patient with difficulty in breathing, the following are key elements that should be considered in the ABCDE approach. AIRWAY A person with difficulty in breathing may have airway swelling caused by a severe allergic reaction (anaphylaxis) or choking (obstruction from a foreign body). Stridor suggests serious airway narrowing. BREATHING Hypotension with absent breath sounds on one side – especially with distended (swollen or enlarged) neck veins or tracheal shift – may indicate tension pneumothorax. Wheezing may indicate asthma or severe allergic reaction. CIRCULATION Shock, heart attack, heart failure and severe infection can all present with poor perfusion and difficulty in breathing. Poor perfusion sends signals to the brain to increase the rate of breathing, which can feel and look like difficulty in breathing. Check for signs of shock by checking capillary refill, heart rate and blood pressure. Swelling in the legs or crackles in the lungs can indicate heart failure and fluid overload as a cause of difficulty in breathing. A B C TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 79 DISABILITY Patients with decreased level of consciousness may not be able to protect their airways. Drugs, infection or injury can directly affect the part of the brain that controls breathing. Assess for paralyzing conditions affecting the breathing muscles. Check level of consciousness with the AVPU scale: A: Alert V: Responds to Voice P: Responds to Pain U: Unresponsive EXPOSURE Expose the patient fully to assess for abnormal chest wall movement and any signs of trauma. Penetrating trauma to the back, chest, underarms or abdomen may cause lung injury and is often missed. ASK: KEY HISTORY FINDINGS FOR PATIENTS WITH DIFFICULTY IN BREATHING Use the SAMPLE approach to obtain a history from the patient and/or family. If the history identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it. S: SIGNS AND SYMPTOMS When did the symptoms start and was onset sudden? Do they come and go and how long do they last? Have they changed over time and has there been a similar episode previously? Sudden difficulty in breathing can suggest airway obstruction such as by a foreign body; swelling of the airway from allergic reaction or infection; trauma to the airway, lungs, heart or chest wall; or inhalation of hot gases or smoke. Acute heart problems such as heart attack, abnormal heart rhythm or valve problems can cause rapid onset DIB. A history of rapid or deep breathing may suggest poisoning, high acid levels in the blood (infection or diabetic ketoacidosis) or anxiety. DIB that starts slowly is more common with infection and chronic conditions such as a gradual build-up of fluid around the lungs (as occurs in TB and heart failure), fluid around the heart (from TB or kidney disease), lung cancer or diseases affecting the function of the chest wall. Recurrent difficulty in breathing associated with wheeze may suggest asthma or COPD. Did anything trigger the difficulty in breathing and what makes it better or worse? A history of allergies may suggest that the airway is blocked by swelling due to a severe allergic reaction. Inhaling smoke or hot gas (such as in fires) or some chemicals may cause E D Module 3: Approach to difficulty in breathing 80 DIB through upper airway injury and swelling. Exposure to some chemicals (such as certain pesticides) can cause fluid to build up in the airways and can cause weakness in the muscles involved in breathing. Difficulty in breathing that gets worse when the person lies flat can be due to fluid in the lungs. Is there any tongue or lip swelling, or voice changes? Swelling to the mouth, lips, tongue or upper throat, or a change in voice can suggest a severe allergic reaction or other inflammation of the airway. Are there abnormal sounds with breathing? High-pitched or ‘squeaking’ sounds when breathing IN may be stridor, which is caused by narrowing of the upper airway and may suggest severe allergic reaction or other airway obstruction. Wheezing – a high-pitched sound with breathing OUT – is caused by narrowing or spasm of the lower airways in the lungs and can suggest asthma, COPD, heart failure or allergic reactions. Gurgling sounds with breathing suggest that there is mucus, blood or other fluid in the airway. Is there pain associated with the difficulty in breathing? Difficulty in breathing with chest pain can suggest heart attack, pneumothorax, pneumonia or trauma to the lungs, ribs or ribcage muscles. In particular, pain that is worse with deep breaths (pleuritic pain) may suggest infection or blood clot in the lung (pulmonary embolism). Is there fever or cough? Fever suggests infection. Lung infection and any severe infection may cause fluid in the lungs. A cough may indicate fluid in the lungs from pneumonia or oedema. Cough and wheezing may suggest asthma or COPD. Is there foot or leg swelling or recent pregnancy? Difficulty in breathing with oedema of both feet or legs can suggest heart failure with fluid back-up to the lungs and body. Difficulty in breathing with swelling and pain in one leg may suggest a clot in a leg vein that has travelled to the lung (pulmonary embolism). Pregnancy is a risk factor for both pulmonary embolism and heart failure. A: ALLERGIES Any allergies to medications or other substances? Any recent insect bites or stings? Severe allergic reactions may cause difficulty in breathing due to airway swelling. People can have severe allergic reactions to almost anything, but food, plants, medications and insect bites/stings are the most common. M: MEDICATIONS Currently taking any medications? Ask about new medications and changes in doses. New medications can cause allergies with associated difficulty in breathing. Accidental overdose of some medications can stop or slow breathing. TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 81 P: PAST MEDICAL HISTORY Is there a history of asthma or chronic obstructive pulmonary disease (COPD)? Asthma and COPD often cause episodes of difficulty in breathing. A history of prior hospitalization or intubation for these conditions suggests a high-risk patient. Is there a history of heart disease or kidney disease? People with a history of heart or kidney failure may have fluid in the lungs. Heart attack may present with difficulty in breathing. Is there a history of tuberculosis (TB) or cancer? Conditions such as tuberculosis and cancer can cause build up of fluid in the sac around the heart (pericardial effusion) or build-up of fluid outside the lung (pleural effusion), both of which can cause a feeling of difficulty in breathing. Is there a history of diabetes? Diabetes can cause diabetic crisis (diabetic ketoacidosis or DKA). DKA causes fast breathing that may be reported as difficulty in breathing. Is there a history of smoking? Smoking increases the risk of asthma, COPD, lung cancer and heart attack. Is there a history of HIV? HIV infection increases the risk of other infections. L: LAST ORAL INTAKE When did the person last eat or drink? A full stomach puts the patient at risk of vomiting and possible choking. E: EVENTS SURROUNDING ILLNESS What was the person doing when the difficulty in breathing started? Always consider choking if DIB started while eating or drinking. DIB with exercise might be due to heart attack, especially when there is also chest pain. Was the patient found in or near water? Always consider drowning (inhalation of water) in a person found in or near water. Even a small amount of inhaled water can cause serious lung damage, which can worsen over time. Has there been exposure to pesticides or other chemicals? Inhaled chemicals can cause DIB by irritating the airways and lungs. Some pesticides used in farming can be absorbed through the skin, causing fluid buildup in the airways and lungs. Exposure to gases from a fire is often associated with chemical inhalation. Has there been any recent trauma? DIB with trauma is concerning for rib fractures, pneumothorax, haemothorax, and heart or lung bruising. Module 3: Approach to difficulty in breathing 82 Workbook question 1: Difficulty in breathing Using the workbook section above, list five questions about past medical history you would ask when taking a SAMPLE history. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ CHECK: SECONDARY EXAMINATION FINDINGS FOR PATIENTS WITH DIFFICULTY IN BREATHING DIB may present with changes in respiratory rate, respiratory effort, or low oxygen saturation. Always assess ABCDE first. The initial ABCDE approach identifies and manages life-threatening conditions. The secondary exam looks for changes in the patient’s condition or less obvious causes which may have been missed during ABCDE. If the secondary examination identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it. LOOK Look for signs of respiratory failure: Accessory muscle use and increased work of breathing. Difficulty speaking in full sentences. Inability to lie down or lean back. Diaphoresis (excessive sweating) and mottled skin. Confusion, irritability, agitation. Poor chest wall movement. Cyanosis (blue skin colour, especially lips and fingertips). Look at the pupils for size and reactivity: Very small pupils suggest possible opioid overdose or exposure to chemicals (including pesticides). Unequal or abnormally shaped pupils suggest head injury which can cause abnormal breathing. TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 83 Look at the face, nose and mouth: Cyanosis around the lips or nose suggests low oxygen levels in the blood. Pale inner surface of lower eyelids suggests severe anaemia. Swelling of the lips, tongue and mouth suggests an allergic reaction. Soot around the mouth or nose, burned facial hair or facial burns suggest smoke inhalation and airway burns. Bleeding or swelling of the airway may be due to trauma. Look at the neck and chest: Distended neck veins can be due to a back-up of blood due to heart failure, tension pneumothorax or pericardial tamponade. Excessive muscle use in the neck and chest (between the ribs) suggests significant respiratory difficulty. If the trachea is shifted to one side, think about tension pneumothorax or tumour. Swelling or redness of the neck suggests infection or trauma. Examine the entire neck and chest carefully for bruising, wounds or other signs of trauma. Look at the rate and pattern of breathing: People with wheeze may take longer to breathe out because of narrowing of the lower airways in the lung. Fast breathing can be due to dehydration, severe infection, chemical imbalance in the blood, poisoning or anxiety. Slow and shallow breathing might be due to opioid overdose. Look for very small pupils and altered mental status. Chest wall injury is often associated with pain that limits the ability to take deep breaths. A flail chest occurs when multiple rib fractures cause a segment of the rib cage to be separated from the rest of the chest wall. The segment may appear to be moving in the opposite direction from the rest of chest wall during breathing. Look at the legs: Swelling to the both lower legs suggests heart failure as a cause of difficulty in breathing. Swelling to one leg may be due to a blood clot in the leg. If there is also difficulty in breathing, this may mean that part of the clot has traveled to the lung. Look at the skin: Bites can be a source of allergic reaction. Rashes, such as hives, can indicate allergic reaction. When associated with difficulty in breathing, rashes can indicate widespread (systemic) infection. Pallor (pale skin) can indicate anaemia as a cause of DIB. Circumferential burns (a burn that goes entirely around a body part) to the chest can restrict chest wall expansion and limit breathing. Module 3: Approach to difficulty in breathing 84 LISTEN Listen to the breath sounds: Stridor suggests partial upper airway obstruction, which may be due to a foreign object, mass, or swelling from trauma or infection. Decreased or absent breath sounds suggest abnormal air movement in the lungs. This can be due to air or fluid around the lung (pneumothorax, haemothorax, effusion), narrowing or foreign body blockage of the airways, and infection or tumour in or around the lung. Wheezing, in particular, suggests lower airway obstruction such as from asthma, COPD, allergic reaction, foreign body or tumour. Crackles or crepitations suggest fluid in the airspaces of the lung. Listen to the heart sounds: Abnormal heart rhythms can cause the heart to pump blood abnormally, leading to poor perfusion and a feeling of difficulty in breathing. Difficulty in breathing accompanied by heart murmurs can suggest damage to the heart valves. Muffled or distant heart sounds accompanying low blood pressure, fast heart rate and distended neck veins suggest pericardial tamponade. FEEL Feel the ribs and chest wall: Deformities and abnormal movement when pressing on the chest wall suggest rib fracture. Crepitus (crackling or popping when pressing on the skin of the chest wall) may suggest underlying fracture or air under the skin (associated with pneumothorax). Unequal expansion of the chest wall suggests pneumothorax, haemothorax, or flail chest. Percuss the chest wall [See SKILLS]: Hollow sounds (hyperresonance) on one side when tapping the chest wall suggest pneumothorax. Dull sounds when tapping the chest wall may indicate fluid or blood either inside the airspaces of the lungs or between the lungs and the chest wall. TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 85 Workbook question 2: Difficulty in breathing Using the workbook section above, list three signs you should LOOK for in a patient with difficulty in breathing. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ List four things you should LISTEN for in a patient with difficulty in breathing. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ List three things you should FEEL the chest wall for in a patient with difficulty in breathing. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ POSSIBLE CAUSES OF DIFFICULTY IN BREATHING The causes of difficulty in breathing can be organized by body area: airway, lung, heart, or whole body. Key airway causes CONDITION SIGNS AND SYMPTOMS Foreign body in the airway • Acute difficulty in breathing • Visible secretions, vomit or foreign body in the airway • Abnormal sounds from the airway (such as stridor, snoring, gurgling) • Coughing • Drooling Severe allergic reaction • Swelling of lips, tongue and mouth • Stridor and/or wheezing • Rash or hives • May have tachycardia and hypotension • Exposure to known allergen Module 3: Approach to difficulty in breathing 86 CONDITION SIGNS AND SYMPTOMS Airway swelling (due to inflammation/ infection) • Stridor • Hoarse voice • Drooling or difficulty swallowing (indicates severe swelling) • Unable to lie down • May have fever (with infection) Airway burns • History of exposure to chemical or fire • Burns to head and neck (or singed facial hair or soot around nose or mouth) • Stridor • Change in voice Key lung causes CONDITION SIGNS AND SYMPTOMS Pneumonia • Fever and cough • Gradually more laboured breathing • Pain worse with breathing (pleuritic) • Abnormal lung examination (crackles) Asthma/COPD • Wheezing • Cough • Accessory muscle use • Tripod position (see figure) • May have history of smoking or allergies Pneumothorax • Decreased breath sounds on one side • Sudden onset • Hollow sounds (hyperresonance) to percussion on affected side [See SKILLS] • May have pain that worsens with breathing • May have history of trauma or evidence of rib fracture • Hypotension with distended neck veins and decreased breath sounds on one side indicate tension pneumothorax. Haemothorax • Decreased breath sounds on affected side • Dull sounds with percussion [See SKILLS] • May have a history of trauma, cancer or tuberculosis Shock (if large haemothorax) Pleural effusion • Decreased breath sounds on one or both sides • Dull sounds with percussion [See SKILLS] • May have history of cancer, tuberculosis, heart disease or kidney disease • Acute or chronic difficulty in breathing Acute chest syndrome in a patient with sickle dell disease • History of sickle cell disease • Chest pain • Fever • Hypoxia TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 87 Tripod position page 32 Key heart causes CONDITION SIGNS AND SYMPTOMS Heart attack • Pressure, tightness or crushing feeling in the chest • Diaphoresis and mottled skin • Nausea or vomiting • Signs of heart failure • History of smoking, heart disease, hypertension, diabetes, high cholesterol, family history of heart problems Heart failure • Worse with exertion • Worse when lying flat • Swelling to both legs • Distended neck veins • Crackles may be heard in the lungs • May have chest pain Pericardial tamponade • Signs of poor perfusion (tachycardia, tachypnoea, hypotension, pale skin, cold extremities, capillary refill greater than 3 seconds) • Distended neck veins • Muffled heart sounds • May have dizziness, confusion, altered mental status • History of tuberculosis, trauma, malignancy, kidney failure Tripod position Module 3: Approach to difficulty in breathing 88 Key systemic causes CONDITION SIGNS AND SYMPTOMS Anaemia • Pale skin and inner lower eyelids • Tachycardia • Tachypnoea • History of haemorrhage, malnourishment, cancer, pregnancy, malaria, sickle cell disease, renal failure Opioid overdose • Clinical or recreational opioid use • Altered mental status • Very small pupils • Slow, shallow breathing Diabetic ketoacidosis • May have known history of diabetes • Deep or rapid breathing • Frequent urination • Sweet smelling breath • High glucose in blood or urine • Dehydrated Workbook question 3: Difficulty in breathing Using the workbook section above, list the possible cause of difficulty in breathing next to the history and physical findings below. HISTORY AND PHYSICAL FINDINGS LIKELY CAUSE A 20-year-old man presents with difficulty in breathing, wheezing and: • swelling of lips, tongue and mouth • rash or hives (patches of pale or red, itchy, warm, swollen skin) • tachycardia and hypotension • history of allergies • exposure to known allergen A 50-year-old woman presents with difficulty in breathing, signs of poor perfusion (tachycardia, tachypnoea, hypotension, pale skin, cold extremities, capillary refill >3 seconds) and: • distended neck veins • muffled heart sounds • history of tuberculosis TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 89 DO: MANAGEMENT FIRST PERFORM ABCDE ASSESSMENT AND INTERVENE FOR LIFE-THREATENING CONDITIONS. Assess and manage airway and provide bag-mask-ventilation (BVM) for any patient who is not breathing or not breathing adequately (too slow for age or too shallow); any unconscious patient with abnormal (slow, shallow, gasping or noisy) breathing; or any patient with a pulse who is not breathing. For patients without a pulse, follow relevant CPR protocols. CONDITION MANAGEMENT CONSIDERATIONS Airway inflammation or burns Keep patients calm. Give oxygen if you can do this without upsetting the patient. [See SKILLS] If the patient is fully alert and no spinal injury suspected, the seated position may be more comfortable. Patients with airway burns may require early intubation as the airway can swell and block quickly; delays may make intubation more difficult. A person with airway inflammation or burns requires urgent handover/ transfer. Choking Use age-appropriate chest thrusts/abdominal thrusts/back blows. [See SKILLS] Allergic reaction Remove the allergen, if possible. For severe allergic reaction with difficulty breathing give intramuscular adrenaline as soon as possible. Give oxygen for severe cases. [See SKILLS] Asthma/COPD Administer salbutamol as soon as possible. Give oxygen if indicated. [See SKILLS] Fever Give antibiotics as soon as possible if infection might be the cause of difficulty in breathing. If the patient has signs of poor perfusion, give IV fluids with caution to avoid fluid overload. [See SKILLS] Heart attack Give aspirin. While oxygen is no longer recommended in all patients with heart attack, it should initially be given to patients with shock or difficulty in breathing. [See SKILLS] For those patients who already have nitroglycerin, you can assist them in taking it if perfusion is adequate. Chronic, severe anaemia Give IV fluids more slowly and check the lungs for crackles (fluid overload) frequently. [See SKILLS] These patients may need handover/transfer for blood transfusion. Diabetic ketoacidosis Give IV fluids. [See SKILLS] A person with diabetic ketoacidosis is extremely ill and requires urgent transfer to an advanced provider. Opioid overdose Support breathing with a bag-valve-mask as needed. Give naloxone. [See SKILLS] Pleural effusion or haemothorax Give oxygen. [See SKILLS] Arrange for handover/transfer immediately. Many of these patients will need a chest tube or other drainage. Trauma All trauma patients with difficulty in breathing should be given oxygen. IV fluid should be given to help fill the heart if either pericardial tamponade or tension pneumothorax is suspected. Needle decompression should be performed if tension pneumothorax is suspected. Treat sucking chest wounds with a 3-sided dressing. [See SKILLS] The patient will need urgent handover/transfer for a chest tube if needle decompression is performed or a 3-sided dressing is applied. Acute chest syndrome Give oxygen, IV fluids, antibiotics. May need transfer for advanced management. Module 3: Approach to difficulty in breathing 90 Workbook question 4: Difficulty in breathing Using the workbook section above, list what you would DO to manage a person who presents with: DIB, coughing. You suspect choking. 1. ���������������������������������������� 2. ���������������������������������������� DIB, high fever, cough. You suspect serious infection. 1. ���������������������������������������� 2. ���������������������������������������� DIB, hoarse voice and stridor on breathing in. You to suspect airway inflammation. 1. ���������������������������������������� 2. ���������������������������������������� 3. ���������������������������������������� SPECIAL CONSIDERATIONS IN CHILDREN The following are danger signs in children: • Signs of airway obstruction (unable to swallow saliva/drooling or stridor). • Increased breathing effort (fast breathing, nasal flaring, grunting, chest indrawing or retractions). • Cyanosis (blue colour of the skin, especially at the lips and fingertips). • Altered mental status (lethargy or unusual sleepiness, agitation). • Poor feeding or drinking. • Vomiting everything. • Seizures/convulsions. • Low temperature (hypothermia). REMEMBER... • Wheezing in children can be caused by viral infection, asthma or an inhaled object blocking the airway. • Stridor in children can be caused by an object stuck in the upper airway OR airway swelling. • Children may present with rapid breathing as the only sign of pneumonia. • Rapid breathing can also indicate diabetic crisis (DKA), which may be the first sign of diabetes in a child. TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 91 Workbook question 5: difficulty in breathing Using the workbook section above, list the paediatric danger signs. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ 6. ______________________________________________________________________ 7. ______________________________________________________________________ 8. ______________________________________________________________________ DISPOSITION CONSIDERATIONS Keep in mind that the effects of inhaled medications such as salbutamol last for only approximately 3 hours. Patients need to be monitored closely. If a patient with a severe allergic reaction is given adrenaline, the reaction can return when the adrenaline wears off. Patients need to be monitored closely. Naloxone only lasts about 1 hour. Most opioid medications last longer than this, so patients may need repeat naloxone doses. Following immersion in water (drowning), a person may develop late signs of breathing problems after several hours and should be observed closely. Never leave patients who might need definitive airway placement unmonitored during handover/transfer. Ensure that a new provider is monitoring the patient before leaving. Make transfer arrangements as early as possible for any patient who may require assisted ventilation. Module 3: Approach to difficulty in breathing 92 FACILITATOR-LED CASE SCENARIOS These case scenarios will be presented in small groups. One participant will be identified as the lead and will be assessed while the rest of the group writes the responses in the workbook. To complete a case scenario, the group must identify the critical findings and management needed and formulate a one-line summary for handover, which includes assessment findings and interventions. You should use the Quick Cards for these scenarios while being assessed. CASE #1: ADULT WITH DIFFICULTY IN BREATHING A 22-year-old man arrives by taxi. He was robbed on the street, and was stabbed in the left chest with a knife. He is now having severe difficulty in breathing. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Cards for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate one sentence to summarize this patient for handover. TRAUM A INTRO ABCDE BREATHING SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 93 CASE #2: PAEDIATRIC PATIENT WITH DIFFICULTY IN BREATHING A mother brings in her 6-year-old son for difficulty in breathing. The mother states that her son has been having difficulty breathing for the past 3 days. She says he makes funny noises when he breathes. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate one sentence to summarize this patient for handover. Module 3: Approach to difficulty in breathing 94 MULTIPLE CHOICE QUESTIONS Answer the questions below. Questions and answers will be discussed in the session 1. You are evaluating a 34-year-old female complaining of difficulty in breathing, coughing, and fever for 3 days. Which of the following actions should you do first? A. Check blood pressure B. Administer antibiotics C. Start an IV D. Check the lung sounds 2. A 67-year-old man with a history of a heart attack is complaining of difficulty in breathing that is worse whenever he lies flat. His legs are both swollen, which has become worse in the past 2 weeks. What is the most likely cause of his difficulty in breathing? A. Heart failure B. Asthma C. Pneumothorax D. Pneumonia 3. There was a fire in a nearby house and a patient is brought to you with burned nasal hairs and shortness of breath. What should you do first? A. Give oxygen B. Give intramuscular adrenaline C. Start an IV line D. Perform needle decompression 4. A 30-year-old woman was stung by a bee and now has difficulty in breathing, facial swelling, and a rash. She has a history of severe allergic reactions to bee stings. What medication should you give her? A. Naloxone B. Benzodiazepine C. Adrenaline D. Aspirin 5. You are assessing a 10-year-old boy for difficulty in breathing. You notice that the skin on his fingertips and around his mouth has a blue color. What is this finding called? A. Retractions B. Nasal flaring C. Crepitus D. Cyanosis BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 95 Module 4: Approach to shock Objectives On completing this module you should be able to: 1. recognize signs of shock/poor perfusion; 2. perform critical actions for patients with shock; 3. assess fluid status; 4. select appropriate fluid administration based on patient age, weight and condition; 5. recognize malnourishment, anaemia and burns and adjust fluid resuscitation. Essential skills Oxygen administration IV line placement Fluid status assessment IV fluid resuscitation Burn management Needle decompression Three-sided dressing Direct pressure for bleeding control Uterine massage for bleeding control Trauma secondary survey KEY TERMS Write the definition using the Glossary at the back of the workbook. Bolus: Bradycardia: Capillary refill: Cholera: Module 4: Approach to shock 96 Diaphoresis: Dehydration: Diabetic ketoacidosis (DKA): Dilation (of blood vessels): Disposition: Ectopic pregnancy: Fluid status: Fontanelle: Gastroenteritis: Large-bore IV: Lethargy: Oral rehydration solution (ORS): Perfusion: Pericardial tamponade: Resuscitation: Shock: Skin pinch testing: BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 97 Overview Poor perfusion is when the body is not able to get enough oxygen-carrying blood to vital organs. When organ function is affected, this is called shock and can lead rapidly to death. Infants, children and older adults are more likely to be affected by shock. Causes of poor perfusion which may lead to shock include: loss of blood (haemorrhage); loss of fluid due to diarrhoea, vomiting, extensive burns or excess urination (such as caused by high blood sugar); poor fluid intake. Small children, the elderly and the very ill may be unable to drink enough fluids without assistance and are at risk of dehydration; abnormal relaxation and enlargement (dilation) of the blood vessels (with the same amount of blood inside the vessel) can lower blood pressure. This can occur in severe infection, spinal cord injury and severe allergic reaction; poor filling of the heart can result from blood or other fluid in the sac around the heart (pericardial tamponade), or increased pressure in the chest that can shift and block the vessels returning blood to the heart (tension pneumothorax); failure of the heart muscle to pump effectively can be due to a heart attack (vessel blockage that causes acute heart muscle damage); inflammation or other disease of the heart muscle itself; an abnormal rhythm or valve problems. (Shock due to failure of the heart to pump effectively is sometimes called cardiogenic shock.) The goal of INITIAL ASSESSMENT is to identify shock and any reversible causes of shock. The goal of ACUTE MANAGEMENT is to restore perfusion (oxygen delivery to the organs) and address ongoing fluid loss where possible. This module will guide you through: ABCDE key elements ASK: key history findings (SAMPLE history) CHECK: secondary examination findings Possible causes DO: management Special considerations in children Disposition considerations REMEMBER... ALWAYS START WITH THE ABCDE APPROACH, intervening as needed. Then do a SAMPLE history. Then do a secondary examination. Module 4: Approach to shock 98 ABCDE: KEY ELEMENTS IN SHOCK For the person in shock, the following are key elements that should be considered in the ABCDE approach. AIRWAY Face/mouth swelling or voice changes can indicate an allergic reaction. A severe allergic reaction can cause shock. BREATHING Wheezing can indicate a severe allergic reaction which can cause shock. Shock, difficulty in breathing and absent breath sounds on one side can indicate a tension pneumothorax. Poor perfusion itself can sometimes cause rapid breathing when vital organs do not receive enough oxygen. Severe heart failure can cause poor perfusion with difficulty in breathing when fluid backs up into the lungs. Any infection severe enough to cause shock may be associated with lung inflammation that causes difficulty in breathing. CIRCULATION Shock can be caused by many types of bleeding (from the stomach or intestines, pregnancy-related, and internal and external haemorrhage from trauma). Shock can also result from the fluid loss associated with diarrhoea, vomiting, extensive burns, or excess urination (such as caused by high blood sugar). DISABILITY Confusion in a person with poor perfusion suggests severe shock. Paralysis may indicate a spinal cord injury causing shock. EXPOSURE Look for signs of bleeding, trauma, and excessive sweating (diaphoresis). Hives can indicate allergic reaction, and other rashes can indicate systemic infection. ASK: KEY HISTORY FINDINGS IN SHOCK Use the SAMPLE approach to obtain a history from the patient and/or family. If the history identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it. A B C D E BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 99 S: SIGNS AND SYMPTOMS Has there been vomiting and/or diarrhoea? For how long? Fluid losses through vomiting and diarrhoea can be severe and can lead to shock. The amount of vomiting or diarrhoea can help give a rough estimate of the risk for shock, so always ask about frequency of episodes. Has the person had blood in stool or vomit? Bleeding in the stomach and/or intestines can be severe before it is recognized. A person can lose a significant portion of his or her blood volume in the intestines. Blood may appear black in both vomit and stools. Has there been any vaginal bleeding? Vaginal bleeding may be related to pregnancy in women of childbearing years. Always ask about pregnancy status, last menstrual period, any missed periods, or known recent pregnancy. Blood loss from normal delivery or miscarriage can cause shock. A pregnancy developing outside the uterus (ectopic pregnancy) can also be life-threatening if it ruptures. Ectopic pregnancy rupture can occur before a woman even knows she is pregnant. Other causes of vaginal bleeding are masses in the cervix or uterus. Has the person had any chest pain? Chest pain may suggest the person has had a heart attack. The muscle damage to the heart from a heart attack can reduce its ability to pump blood around the body, which can cause shock. Has there been fever? Fever may suggest infection as the cause of shock. Severe infection causes both dilation of the blood vessels (which lowers blood pressure) and fluid leakage from the blood vessels (with fluid loss into the tissues). Has there been any exposure to toxins, medications, insect stings or other substances? Severe allergic reactions can lead to shock. Additionally, many medications, including blood pressure and seizure/convulsion medications, can cause shock. Has there been altered mental status or unusual sleepiness? The brain is one of the last organs to be affected by poor perfusion, so altered mental status may be a sign of severe shock. A: ALLERGIES Does the person have any known allergies? Allergic reactions can lead to shock by causing abnormal relaxation of the blood vessels. Module 4: Approach to shock 100 M: MEDICATIONS Currently taking any medications? Obtain a full medication list from the person or the family. Knowing the patient’s medication list can help understand why the patient is in shock (such as heart medications). Overdose of blood pressure or seizure/convulsion medications can cause shock, and it may be more difficult to treat shock from any cause in patients taking these medications. Medications that thin the blood can worsen bleeding. Always ask about new medications in particular and recent dose changes to evaluate for allergic reaction or unexpected side effects. P: PAST MEDICAL HISTORY History of pregnancy or recent miscarriage or delivery? Blood loss following delivery can be severe if the uterus does not contract well. Hidden blood loss leading to shock can occur with ruptured ectopic pregnancy, even in women who do not know they are pregnant. Any woman of childbearing age with shock should be evaluated for pregnancy. History of recent surgery or induced abortion? Internal bleeding or infection after surgery can lead to shock. History of heart disease (heart attack or heart valve problems)? Patients with heart disease are at risk for worsening heart function that may lead to shock or worsen shock from other causes. Is there a history of HIV? HIV increases the risk of infection. L: LAST ORAL INTAKE When did the person last eat or drink? A person who is not eating or drinking well can develop severe dehydration, leading to shock. E: EVENTS SURROUNDING ILLNESS Has there been any recent trauma? Trauma can cause hidden internal bleeding, tension pneumothorax, and bruising or bleeding around the heart, all of which may reduce blood flow and cause shock. In addition, trauma to the neck or back causing spinal cord injury can interfere with the blood vessels’ ability to maintain blood pressure. Has there been any recent illness? Any infection can cause a blood infection that can spread throughout the body and lead to shock. BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 101 Workbook question 1: Shock Using the workbook section above, list six questions about signs and symptoms you would ask when taking a SAMPLE history. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ 6. ______________________________________________________________________ CHECK: SECONDARY EXAMINATION FINDINGS IN SHOCK A person with shock will have signs of poor perfusion, which may include a fast heart rate, a low systolic blood pressure, fast breathing, pale and cool skin, slow capillary refill, dizziness, confusion, altered mental status, decreased urine output or excessive sweating. REMEMBER: Perfusion can be limited even before blood pressure falls, especially in the young. Low blood pressure with poor perfusion is a very serious sign. Always assess ABCDE first. The initial ABCDE approach identifies and manages life-threatening conditions. The secondary exam looks for changes in the patient’s condition or less obvious causes that may have been missed during ABCDE. If the secondary examination identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it. REMEMBER: Children have different normal vital signs ranges, and children with shock may not have changes in vital signs until they are very ill. Always do a careful exam for any signs of shock. Check breath sounds and respiratory rate: – Abnormal or noisy breathing can indicate pneumonia as a source for system-wide infection causing shock. – High sugar levels can result in chemical imbalance (diabetic ketoacidosis) that the body tries to address by faster or deeper breathing. This condition may also result in sweet or ‘fruity’ smelling breath. Since elevated blood glucose levels cause increased urination, severe dehydration and shock can result. Check for bleeding: – All external bleeding should be controlled with direct pressure. [See SKILLS] Arterial bleeding may appear as pulsing or high pressure bleeding, and significant blood volume can be lost in minutes. Module 4: Approach to shock 102 – Vaginal bleeding may be an important source of blood loss from pregnancy-related bleeding (even in those who think they are not pregnant) or from masses in the cervix or uterus. Check fluid status: In dehydration states, the patient may feel thirsty or may have dry lips and mouth, abnormal skin pinch, lethargy, and delayed capillary refill. Patients with heart failure can be in shock with fluid overload, and may have lower body swelling (usually in both legs), crackles on lung examination, and distended neck veins. Check for pale conjunctiva (the inside of the lower eyelid): No matter the person’s skin color, the inside of the eyelid should appear pink and moist. If the inner portion of the eyelid (conjunctiva) is pale, it may indicate significant blood loss. You can compare the patient’s conjunctiva to another healthy person or look at your own in a mirror. Check mental status: Confusion in a patient with other signs of poor perfusion suggests severe shock. Check for fever: Fever in a patient with shock suggests severe infection. Check blood sugar: Low blood glucose can sometimes look like shock. If you cannot check blood glucose, but the person has altered mental status, a history of diabetes or another reason to have low sugar (for example, is taking quinine for malaria, is very ill, or is very malnourished), give glucose. [See SKILLS] Check for severe abdominal pain or a very firm abdomen: If the person has severe abdominal pain, this can be a sign of bleeding or infection in the abdomen. In a patient who might be pregnant, this can be a sign of an ectopic pregnancy. Check urine: Check the urine colour and volume. Small amounts of darker urine may indicate substantial dehydration. Check stool: Any significant diarrhoea can cause dehydration. A large amount of watery, “rice-water” stool suggests cholera, which can rapidly cause severe dehydration and shock. Black, dark, or reddish colored stool can suggest stomach or intestinal bleeding. BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 103 Check for malnourishment [see SKILLS]: If the person appears malnourished, fluid must be adjusted [see SKILLS]. Be sure to ask about recent changes in weight. Check for swelling, rash or excessive sweating: Swelling of mouth or body can indicate an allergic reaction. Rashes can indicate allergic reaction (hives) or systemic infection. Swelling of both legs can indicate heart failure. Sweating may occur with moderate to severe shock. Workbook question 2: Shock Using the workbook section above, list what you need to check for in a person with shock. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ 6. ______________________________________________________________________ 7. ______________________________________________________________________ 8. ______________________________________________________________________ 9. ______________________________________________________________________ 10. _____________________________________________________________________ Visible severe wasting in a child page 23 Visible severe wasting in a child Assessing for pitting edema in children with malnutrition page 22 Assessing for pitt ng edema in children with malnutri ion page 2 Asse ing for pitting ed ma in children with malnutrition page 22 Assessing for pitting edema in children with malnutrition Module 4: Approach to shock 104 POSSIBLE CAUSES OF SHOCK POOR PERFUSION DUE TO DILATED BLOOD VESSELS CONDITION SIGNS AND SYMPTOMS Severe infection • Fever • Tachycardia • Tachypnoea • May have hypotension • May or may not have obvious infectious source: visible skin infection, cough and crackles in one area of the lungs (often with tachypnoea), burning with urination, urine that is cloudy or foul smelling, or any focal pain in association with fever Spinal cord injury • History or signs of trauma • May have spinal pain/tenderness, vertebrae not in line, or crepitus (crunching) when you touch the spinal bones • Movement problems: paralysis, weakness, abnormal reflexes • Sensation problems: tingling (“pins and needles” sensation), loss of sensation • Unable to control urine and stools • Priapism • May have hypotension or bradycardia • Difficulty in breathing with an upper cervical spine injury Severe allergic reaction • Swelling of the mouth • Difficulty breathing with stridor and/or wheezing • Skin rash • Tachycardia • Hypotension POOR PERFUSION DUE TO FLUID LOSS CONDITION SIGNS AND SYMPTOMS Diabetic ketoacidosis (DKA) • May have known history of diabetes • Rapid or deep breathing • Frequent urination • Sweet-smelling breath • High glucose in blood or urine • Dehydration Severe dehydration • Abnormal skin pinch • Decreased fluid consumption or increased fluid loss (vomiting, diarrhoea, excessive urination) • Dry mucous membranes • Tachycardia Burn injury • Red, white or black areas of skin depending on depth of burn • May have blistering • May have signs of inhalational injury BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 105 POOR PERFUSION DUE TO BLOOD LOSS CONDITION SIGNS AND SYMPTOMS External bleeding • History of trauma • Visible bleeding • Use of blood-thinning medications Large bone fracture • History of trauma • Pain or abnormal movement of the pelvis, blood at opening of penis or rectum (pelvic fracture) • Deformity or crepitus of the femur, shortening of the leg with the injury (femur fracture) Abdominal bleeding • Bruising around the umbilicus or over the flanks can be a sign of internal bleeding • Abdominal pain • Very firm abdomen Bleeding in the stomach or intestines • Blood in vomit or stool • Black vomit or stool • History of alcohol use Haemothorax • Difficulty in breathing • Decreased breath sounds on affected side • Dull sounds with percussion on affected side • Shock (if large amount of blood) Ectopic pregnancy • History of pregnancy, missed menstrual cycle or any woman of childbearing age • Abdominal pain • Vaginal bleeding Postpartum haemorrhage • Recent delivery • Heavy vaginal bleeding: – Pad or cloth soaked in <5 minutes – Constant trickling blood – Bleeding >250 ml – Soft uterus/lower abdomen Module 4: Approach to shock 106 POOR PERFUSION DUE TO PROBLEMS WITH THE HEART CONDITION SIGNS AND SYMPTOMS Heart failure • Difficulty breathing with exertion or when lying flat • Swelling to both legs • Distended neck veins • Crackles may be heard in the lungs • May have chest pain Heart attack • Pressure, tightness, pain or crushing feeling in the chest • Diaphoresis and mottled skin • Difficulty in breathing • Nausea or vomiting • Pain moving to jaw or arms • Signs of heart failure • History of smoking, heart disease, hypertension, diabetes, high cholesterol, family history of heart problems Abnormal heart rhythm • Very fast or very slow pulse • Irregular pulse Heart valve problem • History of rheumatic fever or heart disease • Murmur Pericardial tamponade • Signs of poor perfusion (tachycardia, tachypnoea, hypotension, pale skin, cold extremities, capillary refill greater than 3 seconds) • Distended neck veins • Muffled heart sounds • May have dizziness, confusion, altered mental status • History of tuberculosis, trauma, cancer, kidney failure Tension pneumothorax • Hypotension WITH the following: – Difficulty breathing – Absent breath sounds on affected side – Hyperresonance with percussion on affected side – Distended neck veins – May have tracheal shift away from affected side REMEMBER... hypoglycaemia can look like shock. Signs and symptoms include: • Sweating (diaphoresis) • Seizure/convulsion • Blood glucose <3.5 mmol/L • Altered mental status (ranging from confusion to unconsciousness) • History of diabetes, malaria, or a severe illness, especially in children BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 107 Workbook Question 3: Shock Using the workbook section above, list the possible cause of shock next to the history and physical findings below. HISTORY AND PHYSICAL FINDINGS LIKELY CAUSE A 35-year-old woman presents with shock, fever and: • burning with urination • cloudy urine A 20-year-old woman presents with shock, abdominal pain and: • missed menstrual cycle • vaginal bleeding A 17-year-old man presents after a motor vehicle crash with shock, bruising to the pelvis and: • a femur fracture DO: MANAGEMENT FIRST PERFORM ABCDE ASSESSMENT AND INTERVENE FOR LIFE- THREATENING CONDITIONS. Start by giving IV fluid (normal saline or Ringer’s Lactate in adults and children with normal nutritional status). Then work to address underlying causes. Place IV access rapidly (two large-bore IVs) and start IV fluids. Place IV access rapidly (two large-bore IVs), start IV fluids and assess response. Repeat with additional boluses if needed. [See SKILLS] If you cannot place an IV, immediately call for a provider who can place a nasogastric tube (a tube that goes from the nose into the stomach) or intraosseous line (a needle that is placed directly into the bone). See if the patient can safely take oral fluids in the meantime. CAUTION! For severely malnourished or severely anaemic people, or anyone with signs of volume overload, do NOT follow the fluid protocol below. Use adjusted protocol. [See SKILLS] Module 4: Approach to shock 108 Uterine massage for postpartum hemorrhage page 17 If vaginal bleeding after delivery (postpartum haemorrhage) is suspected as a cause of shock: ALL patients need rapid handover/transfer to an advanced obstetric provider. While arranging for transport and during transport, it is important to try to stop the bleeding. Give BOTH intramuscular and IV oxytocin. This is a loading dose. After these doses, continue oxytocin IV until one hour after the bleeding stops. [See SKILLS] Bleeding frequently happens if the uterus is not fully contracted (does not feel hard on palpation). Perform uterine massage [See SKILLS] until the uterus is hard. You should use BOTH oxytocin and uterine massage to stop the bleeding. If the placenta delivers, collect it in a leak-proof container and keep with the patient to allow the advanced obstetric provider to examine it. Visually check externally for a perineal or vaginal tear. If found, apply direct pressure with sterile gauze and put legs together. Even if the bleeding stops, these patients still need rapid handover/transfer to an advanced obstetric provider (see figure). IV FLUID IMMEDIATELY AVAILABLE? IV FLUID AVAILABLE NEARBY? START ORS via NG NASOGASTRIC TUBE REASSESS IMMEDIATELY AFTER BOLUS DID PERFUSION IMPROVE? TRANSFER IMMEDIATELY CONTINUE ORS VIA NG YES YES YES YES No No No No DID PERFUSION IMPROVE? IV FLUIDS REASSESS IMMEDIATELY AFTER BOLUS CONTINUE E <30 MINUTES <30 MINUTES START IV FLUIDS RE-BOLUS GIVING FLUID IN SHOCK NO malnutrition, overload or severe anaemia Uterine massage for postpartum hemorrhage BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 109 REMEMBER... fluid only addresses the immediate problem of perfusion. Patients with shock need rapid handover/transfer to a unit capable of addressing the causes of shock and providing advanced management, including transfusion. REMEMBER... fluid status assessment is critical. Patients who have signs of poor perfusion but overall volume overload can be particularly difficult to manage. Patients with malnutrition, severe anaemia, and excess fluid in the lungs due to heart, liver, or kidney failure can present this way. These patients still need fluids, but the fluids must be given cautiously and, especially in malnourished children, according to a specific protocol. [See SKILLS] Postpartum Haemorrhage 1. Arrange immediate transfer to qualifi ed obstetric provider! 2. Attempt to control bleeding while arranging and during transfer. 3. Check: 4. Transfer immediately Heavy bleeding after delivery? Has the placenta delivered? Still bleeding? Is there a perineal or lower vaginal tear? Massage uterus until it is hard. Give oxytocin IM. Give IV uids and IV oxytocin. Empty bladder. Continue uterine massage. When uterus is hard, the placenta will likely deliver. Collect placenta and keep with patient. Continue oxytocin. Continue oxytocin for at least 1 hour after bleeding stops. Apply pressure with sterile gauze, put legs together. Continue to massage uterus until hard. Continue oxytocin. Continue IV uids with oxytocin. Insert second IV line. YES YES NO NO YES Module 4: Approach to shock 110 DO: MANAGEMENT OF SPECIFIC CONDITIONS • Always perform ABCDE first. Patients in shock need oxygen. • In all forms of shock, the primary management is administration of IV fluids appropriate for age and condition. • The specific conditions below require additional considerations. CONDITION MANAGEMENT CONSIDERATIONS Burns • Burns disrupt the skin barrier and can cause significant fluid losses that can lead to shock. These patients have different fluid replacement needs. [See SKILLS] Hyperglycaemia • If concern for diabetic ketoacidosis, treat with IV fluids. [See SKILLS] A person with diabetic ketoacidosis is extremely ill and requires rapid transfer to a unit where IV infusion and close monitoring are available. Fever • Give fluids and start antibiotics. [See SKILLS] If infectious diarrhoea (like cholera) is suspected, use gloves, aprons and relevant isolation precautions and report it to the local public health agency. If signs of poor perfusion do not improve with fluids, consider rapid handover/transfer. Spinal cause • Give IV fluids and refer for ongoing management at a unit that can provide spinal care. [See SKILLS] Stomach or intestinal bleeding • Start IV fluids and refer for blood transfusion. [See SKILLS] Ectopic pregnancy • Give IV fluids and refer for blood transfusion and obstetric care. [See SKILLS] Postpartum haemorrhage • Give oxytocin and IV fluids and plan for rapid transfer to facility with blood transfusion and obstetric care capabilities. • Give IV fluids and massage uterus until it is hard. [See SKILLS] • Give oxytocin. [See SKILLS] • If the placenta has delivered, collect it in a leak-proof container and keep with patient for inspection by advanced provider. • Check for perineal and vaginal tears and apply direct pressure. Tension pneumothorax • Perform needle decompression immediately to relieve the pressure, give oxygen and IV fluids. [See SKILLS] Any patient who has had a needle decompression will need rapid handover/ transfer to a unit that can place a chest tube. Pericardial tamponade • Give IV fluids to help fill the heart against the building pressure in the heart sac. [See SKILLS] Plan for rapid handover/transfer to a provider who can drain the pericardial fluid. BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 111 CONDITION MANAGEMENT CONSIDERATIONS Suspected heart attack • Give aspirin if indicated. Place an IV and give fluids, re-assessing the patient frequently. [See SKILLS] • While oxygen is no longer recommended in all patients with heart attack, it should initially be given in patients with shock or difficulty in breathing, even when heart attack is the suspected cause. • Plan for rapid handover/transfer to advanced provider. Heart failure • Give IV fluids more slowly, checking the lungs for crackles (fluid overload) frequently. Stop IV fluids if fluid overload develops (difficulty in breathing, crackles in the lungs, increased respiratory rate, increased heart rate). [See SKILLS] • Plan for rapid handover/transfer to an advanced provider. Severe allergic reaction • Give intramuscular adrenaline [See SKILLS]. These patients will also need IV access and fluids as their condition can rapidly worsen once the adrenaline wears off. You may give a second dose if the effects wear off. [See SKILLS] If the airway is swollen or there is difficulty in breathing, patients may need rapid transfer. Traumatic injury or rapid blood loss suspected • Stop the bleeding, give IV fluids, and conduct a thorough trauma assessment. [See SKILLS] Refer for blood transfusion and ongoing surgical management. Workbook question 4: Shock Using the workbook section above, list what you would do to manage this patient. A 6-year-old boy is brought in with fever. He is in shock and does not appear malnourished. Your facility has supplies to put in an IV. 1. ________________________________________ 2. ________________________________________ 3. ________________________________________ A young man is brought in after a motorcycle crash. He has a large cut to his arm that is bleeding and there is a large pool of blood under him. He is in shock when you examine him. 1. ________________________________________ 2. ________________________________________ 3. ________________________________________ A 30-year-old woman is brought in after accidentally eating prawns. She has a known shellfish allergy, her body is covered in a red, itchy rash and she is in shock. 1. ________________________________________ 2. ________________________________________ 3. ________________________________________ Module 4: Approach to shock 112 SPECIAL CONSIDERATIONS IN CHILDREN Shock can occur quite rapidly in children and is life-threatening. Children have a relatively larger surface area (compared to their body volume) and are thus likely to become dehydrated more rapidly. Infants and young children are particularly at risk as they are unable to say when they are thirsty and cannot drink more on their own. Assessing shock in children: The clinical definition of shock in children varies. The 2016 WHO guidelines for the care of critically ill children use the presence of three clinical features: cold extremities, capillary refill greater than 3 seconds, and weak and fast pulse. There are also other important signs of poor perfusion, including low blood pressure, fast breathing, altered mental status, and decreased urination (always ask parents how much urine the child is passing). [See SKILLS] Signs of dehydration in children • Very dry mouth and lips • Lethargy (excessive drowsiness and slowness to respond), child not interactive • Sunken eyes • Small amounts of dark urine (ask about number of nappies for infants) • Sunken fontanelles in infants under 1 year • Delayed capillary refill (normal capillary refill is less than 3 seconds) • Abnormal skin pinch [See SKILLS] • Pallor (anaemia makes dehydration even more difficult to treat [See SKILLS]) Abnormal skin pinch in a child page 34 Abnormal skin pinch in a child Common causes of shock and dehydration in children include: • Vomiting and diarrhoea: Gastroenteritis causes sudden onset of vomiting and diarrhoea with some abdominal pain and fever. Large amount of watery diarrhoea may suggest cholera, and needs to be reported to public health authorities. • Vomiting without diarrhoea: Vomiting without diarrhoea or fever may suggest raised pressure on the brain (trauma, tumour, brain swelling), or intestinal blockage. It is important to examine the child for signs of trauma. Vomiting associated with fever may suggest infection. • Overwhelming infection: Fever can cause children to become dehydrated quickly. In addition, overwhelming infection can cause blood vessels to dilate, worsening shock. BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 113 Special management considerations: • Malnourishment: Malnourished children are at high risk for hypoglycaemia and will need sugar in addition to fluids. Give specialized fluids if available. [See SKILLS] Give less IV fluid more slowly, and check the lungs for crackles (fluid overload) every 5 minutes. Stop IV fluids if fluid overload develops (crackles in the lungs, increased respiratory rate, increased heart rate). Switch to oral fluids as soon as signs of poor perfusion improve. These patients need rapid handover/transfer over to an advanced provider at a centre with blood transfusion capabilities. Workbook question 5: Shock Using the workbook section above, list signs of severe dehydration in children. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ 6. ______________________________________________________________________ 7. ______________________________________________________________________ 8. ______________________________________________________________________ DISPOSITION CONSIDERATIONS People with shock can worsen and die quickly. They must be monitored very closely. Additionally, the same illnesses that cause shock interfere with the body’s ability to manage fluids, so these patients must be monitored very closely for signs of difficulty in breathing. Patients with shock may be confused and anxious. Ensure they are safe and contained during transfer. Patients with shock are often transferred for transfusion or general or obstetric surgery. Always communicate directly with the receiving facility to make sure that these resources are actually available at the time of transfer. Module 4: Approach to shock 114 FACILITATOR-LED CASE SCENARIOS These case scenarios will be presented in small groups. One participant will be identified as the lead and will be assessed while the rest of the group writes the responses in the workbook. To complete a case scenario, participants must identify the critical findings and management needed, and formulate a one-line summary for handover, including assessment findings and interventions. You should use the Quick Card for these scenarios while being assessed. CASE #1: ADULT SHOCK A 48-year-old male with a history of alcohol abuse is brought in by his wife to be evaluated for weakness. His wife states that he has been having very dark stools for the past 2 days and now cannot stand up. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 115 3. Formulate one sentence to summarize this patient for handover. CASE #2: PAEDIATRIC SHOCK The patient is a 4-year-old girl brought in by her mother. She has been having almost constant diarrhoea for the past 3 days and vomiting every time she tries to drink anything. The mother thinks she may have had a fever as well. She has no signs of malnutrition. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTIONS TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate one sentence to summarize this patient for handover. Module 4: Approach to shock 116 MULTIPLE CHOICE QUESTIONS Answer the questions below. Questions and answers will be discussed in the session. 1. A 7-year-old boy has had lethargy, vomiting and diarrhoea for the past 4 days. His vital signs are: blood pressure 80/40 mmHg, heart rate 140 beats per minute, respiratory rate 18 breaths per minute. The patient vomits when you try to give anything by mouth. What is your most immediate management? A. Start an IV line and give fluids B. Continue to attempt oral rehydration C. Place a nasogastric (NG) tube and hydrate through it D. Rapidly transfer to a referral hospital 2. You are taking care of a 28-year-old man who was shot in the abdomen. He is lethargic and the vital signs are as follows: blood pressure 80/40 mmHg, heart rate 130 beats per minute, respiratory rate 20 breaths per minute. There is heavy bleeding from the gunshot wound and the abdomen is rigid and tender. What is the first intervention you should give this patient? A. IV fluids B. Intraosseous line C. Surgery D. Adrenaline 3. A child that presents with sunken eyes, small amounts of dark urine, dry mucous membranes and abnormal skin pinch testing is most likely suffering from: A. Pneumonia B. Head injury C. Dehydration D. Hypoglycaemia 4. A 60-year-old man states he has been weak and dizzy for the past week. His vital signs are: blood pressure 90/50 mmHg, heart rate 125 beats per minute, respiratory rate 16 breaths per minute. His skin is cool and pale. He states that his stools have been black for the past 2 days. What is the most likely cause of his shock? A. Stomach bleeding B. Abdominal trauma C. Dehydration D. Severe infection BREATHING TRAUM A INTRO ABCDE SHOCK AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 117 5. You are assessing a 23-year-old man who was stabbed in the chest. You expose the chest to find one stab wound in the right chest with minor bleeding. He is complaining of severe difficulty in breathing and there are no lung sounds on the right side. His neck veins are distended and his skin is cool and sweaty. His vital signs are: blood pressure 86/56 mmHg, heart rate 136 beats per minute, respiratory rate 28 breaths per minute. What is your next step? A. Chest tube placement B. Needle decompression C. Blood transfusion D. Start IV fluids 118 Notes ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS 119 PARTICIPANT WORKBOOK Module 5: Approach to altered mental status Objectives On completing this module you should be able to: 1. recognize key history findings suggestive of different causes of altered mental status; 2. recognize key physical findings suggestive of different causes of altered mental status; 3. list high-risk causes of altered mental status in adults and children; 4. perform critical actions for high-risk causes of altered mental status. Essential skills Glasgow Coma Scale AVPU assessment Recovery position Oxygen administration IV cannula insertion IV fluid resuscitation Snake-bite management Spinal immobilization KEY TERMS Write the definition using the Glossary at the back of the workbook. Altered mental status: Coma: Confusion: Convulsion: Cyanosis: Module 5: Approach to altered mental status 120 Delirium: Dementia: Diabetic ketoacidosis (DKA): Eclampsia: Envenomation: Human Immunodeficiency Virus (HIV): Hypoglycaemia: Hypoxia: Ingestion: Kangaroo care: Large-bore IV: Level of consciousness: Orientation: Psychosis: Rabies: Seizure: Stroke: SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 121 Overview Altered mental status (AMS) is a term used for a range of presentations, from sudden or gradual changes in behaviour to disorientation, confusion and coma. Changes in mental status and/or level of consciousness may be due to conditions that affect the brain (such as lack of oxygen or glucose; or shock causing lack of perfusion) or problems with the brain itself (such as infection, inflammation or injury). While chronic psychiatric problems and dementia can cause changes in mental status, altered mental status is often an indication of severe disease, and other life- threatening causes must always be considered. The presence of delirium – a rapidly changing state of confusion with agitation, loss of focus and inability to interact appropriately – always requires a full assessment. Always ask family/friends about baseline mental status when possible. The goal of INITIAL ASSESSMENT is to identify rapidly reversible causes of altered mental status, and to recognize dangerous conditions requiring transfer. The goal of ACUTE MANAGEMENT is to ensure that blood, oxygen and glucose reach the brain; and to protect the brain from additional injury. This module will guide you through: ABCDE key elements ASK: key history findings (SAMPLE history) CHECK: secondary exam findings Possible causes DO: Management Special considerations in children Disposition considerations REMEMBER... ALWAYS START WITH THE ABCDE APPROACH, intervening as needed. Then do a SAMPLE history. Then do a secondary exam. Module 5: Approach to altered mental status 122 ABCDE: KEY ELEMENTS FOR ALTERED MENTAL STATUS For the person with altered mental status, the following are key elements that should be considered in the ABCDE approach. AIRWAY People with altered mental status may not be able to protect their airways and may be at risk of choking on vomit. BREATHING Hypoxia (lack of oxygen) can be a cause of altered mental status. Search for any signs of difficulty breathing, or cyanosis (blue colouring of the skin). Abnormal breathing can reflect diabetic ketoacidosis or poisoning. CIRCULATION Lack of perfusion to the brain can cause altered mental status. Look for and manage signs of shock (low blood pressure, elevated heart rate, delayed capillary refill). DISABILITY Check AVPU or GCS (in trauma). Look for abnormal glucose (hypoglycaemia or hyperglycaemia can cause altered mental status). Very small pupils suggest opioid overdose or poisoning (consider pesticides). Very dilated pupils suggest stimulant drug use. Unequal pupils suggest an increased pressure on the brain. If the patient can follow commands, test for strength and sensation in face, arms and legs. Weakness or loss of sensation on one side suggests a mass, bleeding, or blocked blood vessels in the brain (stroke), though hypoglycemia can also present this way. Altered mental status with general muscle weakness may suggest salt (electrolyte) imbalance in the blood. Look for abnormal repetitive movements or shaking on one or both sides of the body (seizure/ convulsion) – this may be due to a tumour, bleeding, brain infection, hypoglycaemia, or salt (electrolyte) imbalance. EXPOSURE Remember that patients with altered mental status may not report their history accurately. Examine the entire body for infections, rashes, and any evidence of trauma, bites or stings. Needle marks on the arms may suggest drugs as a cause. ASK: KEY HISTORY FINDINGS FOR PATIENTS WITH ALTERED MENTAL STATUS Use the SAMPLE approach to obtain a history from the patient and/or family. It is important to obtain a history from bystanders, friends or family as it may be difficult to obtain accurate history from a confused patient. For example, a person with hypoglycaemia may be too confused to relate a history of diabetes. If the history identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it. A B C D E SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 123 S: SIGNS AND SYMPTOMS How does the current condition compare to baseline mental status? Always ask family/friends about baseline mental status when possible. Is there difficulty breathing? Altered mental status associated with difficulty in breathing may indicate lack of oxygen to the brain. Is there headache? Headache with altered mental status can indicate infection, tumour or bleeding. Is there vomiting/diarrhoea? Vomiting without diarrhoea can be a sign of increased pressure in the brain. Any source of dehydration, including vomiting and diarrhoea, may cause altered mental status from poor perfusion. Vomiting and diarrhoea can also cause hypoglycaemia leading to altered mental status. Has there been any dizziness or fainting? These may be signs of poor perfusion (lack of oxygenated blood) to the brain. When did the symptoms start? Do they come and go? How long do they last? Have they changed over time? Rapid onset of altered mental status may suggest infection, inflamation, bleeding or drugs/ toxic exposures. A more gradual onset (over weeks or months) may indicate a space- occupying lesion in the brain, such as a tumour or slow bleeding in the brain. Altered mental status that comes and goes with normal intervals between episodes may suggest other causes, such as seizures/convulsions or psychiatric disease. Has there been any recent fever? Any person with altered mental status and fever may have an infection. Brain infections often present with altered mental status and fever. In small children and the elderly, any serious infection, such as urine, lung, or blood infection can cause altered mental status. Also consider prolonged outdoor exposure, poisonings, medications and drugs as these may present with fever as well. Very high fever itself from any source may cause altered mental status. Is there any weakness, clumsiness or difficulty walking? Change in mental status with weakness or sensory loss in one area of the body, or problems with walking and balance, suggest that the altered mental status comes from a cause in the brain itself, such as a stroke or tumour. Is there neck pain or stiffness? Fluid that circulates around the brain also circulates around the spinal cord, meaning any bleeding, inflammation or infection in the brain (meningitis, encephalitis) can also cause neck pain and stiffness. Module 5: Approach to altered mental status 124 Is there a recent history of trauma or falls? Bleeding in or around the brain can cause altered mental status some days after an injury. Remember that chronic alcohol drinkers and the elderly are more prone to brain bleeding and may not remember falls. Always consider slow bleeding around the brain as a cause, even several days after a fall, and consider unwitnessed trauma in a patient who is found altered with no known cause. Has there been any recent depression or changes in behaviour? Drug and alcohol use or psychiatric problems can present as altered mental status. Always consider the possibility of a suicide attempt by poisoning. Does anyone else from the same family or location have symptoms? Gaseous poisoning, like carbon monoxide poisoning, can cause altered mental status in multiple people. Carbon monoxide poisoning is usually seen in cold climates when people use indoor heating. A: ALLERGIES Any allergies or recent exposure to a known allergen? Severe allergic reactions (anaphylaxis) may present with altered mental status due to low blood oxygen levels or poor blood circulation to the brain as a result of shock. M: MEDICATIONS Currently taking any medications? Many common medications can cause altered mental status as a side effect, including those for seizures/convulsions, pain and sleeping. Ask about new medications and changed doses, and consider medication interactions. A medication list should be collected and can provide clues for underlying disease (such as convulsions, liver disease, diabetes) if the person cannot communicate. Opioid medications (such as morphine, pethidine and heroin) can cause altered mental status. P: PAST MEDICAL HISTORY History of diabetes? In any patient with diabetes and altered mental status, suspect diabetic crisis, or low blood sugar caused by medications. Recent increase in urine output, increased thirst, and fast or deep breathing suggest diabetic crisis (diabetic ketoacidosis). History of heart disease? Heart attack can cause decreased blood flow and oxygen to the brain leading to confusion. Those with heart disease are also at an increased risk of stroke. SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 125 History of stroke? Altered mental status in a patient with a history of stroke may suggest an additional stroke or bleeding in the brain. Be sure to ask people who know the patient about his or her usual mental and neurological status. Symptoms of old stroke may return with severe illness of any kind. History of high blood pressure? High blood pressure increases the risk for bleeding in and around the brain (such as stroke). History of seizure/convulsion? Altered mental status in a patient with a history of seizures/convulsions may suggest that the patient is having or recovering from a convulsion. If there is a history of epilepsy (primary seizure/convulsion disorder), ask about regular medication and any recent dose changes or missed doses. With a witnessed convulsion, ask about fall or head trauma. Always ask if the convulsion was the same or different compared to prior. Remember that recovery of normal mental status after convulsions usually takes only a half hour to several hours at most, though patients may feel tired for longer. Longer altered mental status suggests another cause. History of HIV infection? Altered mental status in a person with HIV may suggest infection in or around the brain (meningitis, encephalitis). History of tuberculosis? Tuberculosis can infect the brain and cause altered mental status. History of liver or kidney failure? Liver or kidney failure can cause problems with the clearing of toxins and waste from the blood, which can lead to altered mental status. History of heavy alcohol use? Alcohol intoxication and alcohol withdrawal can present with altered mental status. People with a history of heavy alcohol use also have a high risk for head injury (and may not remember falls) and hypoglycaemia, both of which can cause altered mental status. Use of drugs of abuse? Several drugs of abuse cause altered mental status, including stimulants, sedatives and opioids. History of pregnancy? High blood pressure during pregnancy can lead to eclampsia (or seizures/convulsions and high blood pressure) during pregnancy. L: LAST ORAL INTAKE When did the person last eat or drink? Low blood glucose levels and dehydration can cause altered mental status. Module 5: Approach to altered mental status 126 E: EVENTS SURROUNDING ILLNESS Recent trauma? Both head injury and poor perfusion resulting from blood loss can cause altered mental status. Recent travel to areas where certain types of infections might be more common? Specific infections that can cause altered mental status may be more common in certain areas. Malaria is a key consideration in many areas. Recent exposures: contact with a sick person, recent bites, chemical exposures, hot or cold environments etc.? Sick contacts may suggest infectious cause. Chemical exposures (such as pesticides) or bites may suggest intoxication or envenomation. Altered mental status can be caused by both very low and very high body temperatures. Recent alcohol or drug use? Both alcohol intoxication and alcohol withdrawal can cause altered mental status. Methamphetamines and cocaine may cause severe agitation, while heroin (and other opioids) may cause lethargy and coma. See also “Past medical history” section above. Workbook question 1: Altered mental status Using the workbook section above, list seven questions about signs and symptoms you would ask about when taking a SAMPLE history. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ 6. ______________________________________________________________________ 7. ______________________________________________________________________ CHECK: SECONDARY EXAMINATION FINDINGS IN ALTERED MENTAL STATUS A person with altered mental status may be unable to answer questions, and clues to the cause may only be found during the physical examination. Always assess ABCDE first. The initial ABCDE approach identifies and manages life-threatening conditions. The secondary SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 127 examination looks for changes in the patient’s condition or less obvious causes that may have been missed during ABCDE. If the secondary examination identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it. Check for safety: Agitated and violent behaviour is a common presentation. It is very important to identify and treat the underlying cause if possible, while prioritizing the safety of the patient and providers. Keep calm and work as a team. Ensure that the space is safe from possible weapons and make sure that the patient is not between you and the door. Avoid making the patient feel threatened. Do not sit too close and speak with a calm, soft and sympathetic voice. Continually explain what is happening. Many aggressive patients will cooperate when faced with a team, so call for help and approach a patient as a group if necessary. Check vital signs, including temperature and glucose, and treat abnormalities. Call for help early and arrange handover/transfer to an advanced provider. Check and monitor level of consciousness with the AVPU scale: – A: Alert – V: Responds to Voice – P: Responds to Pain – U: Unresponsive AVPU tests the person’s ability to respond to stimuli. A person who is not intoxicated and who has no illness or injury affecting the brain will usually be alert without being prompted. Patients who only respond when prompted by voice or pain require further assessment of the neurological system. [See SKILLS] In trauma, check Glasgow Coma Scale: Check and monitor the Glasgow Coma Scale. [See SKILLS] Check the blood glucose level: Hypoglycaemia can cause altered mental status. Diabetic ketoacidosis can present with hyperglycaemia and altered mental status. Check the pupils: Very small pupils and slow breathing suggests opioid overdose. Very large (dilated) pupils suggest stimulant drug use. Unequal pupils suggest increased pressure on the brain. Check for orientation: If the patient is alert and responds to voice, ask simple questions (for example: What is your name? Where are you? What time is it? What day of the week is it?). Check for trauma: Any patient with altered mental status and history or evidence of trauma should be considered to have a possible head injury – even if the trauma occurred several days before. Bruising around the eyes, behind the ears, or leaking of clear fluid from the nose or ears suggests head injury with skull fracture. Check temperature: Fever should raise concerns about an infectious cause, and fever with stiff neck suggests an infection in or around the brain. Poisonings, medication overdoses, alcohol withdrawal Module 5: Approach to altered mental status 128 and changes in body hormones can also present with fever. Hypothermia may indicate infection, low body hormone levels (e.g., thyroid) or exposure to wet or cold environments. Check for stiff neck (Remember, if you suspect trauma, do not move the neck): Stiff neck is suggestive of infection (meningitis) or bleeding around the brain. If you suspect infection, anyone who comes in contact with the patient should wear a mask. Check strength and sensation: If the patient can follow commands, test for strength and sensation in face, arms and legs. Weakness or loss of sensation on one side suggests a mass, bleeding or blocked blood vessels in the brain (stroke), though hypoglycaemia can also present this way. Altered mental status with general muscle weakness may suggest salt (electrolyte) imbalance in the blood. Check for signs of dehydration: Dehydration can cause altered mental status. Check for dry mouth and abnormal skin pinch. Dehydration may also suggest diabetic ketoacidosis. Check the abdomen: Feel if the liver is enlarged or tender. A palpable or tender liver suggests liver disease. Check the skin: Cool, pale, and moist skin suggests shock or hypoglycaemia. Yellow skin (jaundice) suggests liver disease. Bruising suggests trauma. Rashes can indicate systemic infection. Check for bites and stings. Monitor for changes in mental status: People who are initially confused and rapidly return to normal without treatment may have had a seizure/convulsion or head trauma. People with altered mental status require close monitoring to make sure they do not worsen again. (This can happen in patients who have low blood sugar or head trauma). Workbook question 2: Altered mental status Using the workbook section above, list five secondary examination findings you would check for in a patient with altered mental status. 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 129 POSSIBLE CAUSES OF ALTERED MENTAL STATUS RAPIDLY REVERSIBLE CAUSES CONDITION SIGNS AND SYMPTOMS Hypoglycaemia • Sweating (diaphoresis) • Seizures/convulsions • Blood glucose <3.5 mmol/L • History of diabetes, malaria, or severe illness, especially in children • Mental status improves quickly with glucose Severe dehydration • Signs of poor perfusion • Abnormal skin pinch • Decreased ability to drink fluids, or fluid loss • Dry mucous membranes Heat stroke • Prolonged exposure to heat and sun • High body temperature, very warm skin • May or may not be sweating (diaphoretic) Hypoxia • Shortness of breath • Low blood oxygen levels • Cyanosis INFECTION CONDITION SIGNS AND SYMPTOMS Cerebral malaria • Fever • Rapid malaria test or smear positive • In or from an area with malaria Inflammation/infection around the brain (meningitis, encephalitis, brain abscess, bleeding) • Fever • Neck stiffness • Rash • Eye pain with looking at light/sensitivity to light • Headache • Known infectious epidemic or exposure • History of HIV or TB infection Severe infection • Fever • Tachycardia • Tachypnoea • May have hypotension • Signs of infection: visible infection in the skin, cough and crackles in one area of the lungs (often with tachypnoea), burning with urination or urine that is cloudy (not clear), or any focal pain in association with fever CONDITION SIGNS AND SYMPTOMS Rabies • Agitation • Fear of drinking (hydrophobia) • Drooling • Weakness • History of animal bite Module 5: Approach to altered mental status 130 METABOLIC CONDITION SIGNS AND SYMPTOMS Diabetic ketoacidosis (DKA) • History of diabetes • Rapid or deep breathing • Frequent urination • Sweet smelling breath • High glucose in blood or urine • Dehydration TOXIC CONDITION SIGNS AND SYMPTOMS Alcohol or drug intoxication or withdrawal • Known alcohol or drug use • Injection marks, drugs found on patients • Alcohol – breath smells of alcohol, reddened face – Acutely intoxicated (drunk) – Withdrawal (convulsions, confusion, tachycardia) – Chronic use (balance problems, confusion) • Opioids: – Acutely intoxicated (lethargy, very small pupils and slow breathing) – Withdrawal (agitation, sweating, diarrhoea, vomiting) • Other drugs may cause large pupils, agitation, sweating, fever Pesticide poisoning • History of exposure • Very small pupils • Diarrhoea • Vomiting • Diaphoresis Snake bite • Snake bite history • Bite marks in a setting with venomous snakes • Oedema • Blistering of the skin • Bruising • Hypotension • Paralysis • Seizures • Bleeding from wounds Medication reaction or dosing issue • New medications or recent change in dose Gaseous poisoning • History consistent with possible exposure • Multiple people with symptoms • Headache SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 131 OTHER CAUSES CONDITION SIGNS AND SYMPTOMS Seizures/convulsions • Known history of seizures/convulsions • Bitten tongue • Urinated on self • Gradual improvement over minutes or hours • If pregnant, consider eclampsia Increased pressure on the brain (trauma, tumour, bleeding or brain swelling) • Headache • Seizures/convulsions • Nausea, vomiting • Unequal pupils • Weakness on one side of the body or speech problems Liver disease • History of alcohol abuse or liver disease • Enlarged abdomen with thin arms, yellow coloring to the skin and eyes (jaundice), or hypoglycaemia Kidney disease • High blood pressure • Oedema or swelling in the legs • Decreased or no urine if severe Head trauma • Visual changes, loss of memory, vomiting, headache • History of recent trauma • Scalp lacerations and/or skull deformity • Bruising to head (particularly around eyes or behind ears) • Blood or clear fluid coming from nose or ears • Unequal pupils or weakness on one side of the body • Seizures/convulsions ADDITIONAL CONSIDERATIONS IN CHILDREN CONDITION SIGNS AND SYMPTOMS Ingestions of chemicals or toxins • Common in younger children • History of medications or substances found around child Module 5: Approach to altered mental status 132 Workbook question 3: Altered mental status Using the workbook section above, list the possible cause of altered mental status from the history and physical findings below. HISTORY AND PHYSICAL FINDINGS LIKELY CAUSE A 15-year-old girl presents with altered mental status, fever and: • neck stiffness • eye pain when looking at light • headache A 45-year-old man presents with altered mental status, and deep, rapid breathing and: • frequent urination • sweet-smelling breath • high glucose in blood or urine • dehydration DO: MANAGEMENT FIRST PERFORM ABCDE ASSESSMENT AND INTERVENE FOR LIFE-THREATENING CONDITIONS. NOTE: If the airway is clear, and there is no evidence of trauma, place the patient in the recovery position to avoid getting fluid or vomit in the lungs. [See SKILLS] CONDITION MANAGEMENT CONSIDERATIONS Hypoxia Give oxygen. Look for underlying cause. [See SKILLS] Hypoglycaemia Treat with glucose. [See SKILLS] Hyperglycaemia If concern for diabetic ketoacidosis, treat with IV fluids. [See SKILLS] A person with diabetic ketoacidosis is extremely ill and requires rapid transfer to a unit where IV infusion and close monitoring are available. Fever (hyperthermia) with altered mental status Start antibiotics. Severe infections may require treatment by an advanced provider. Include malaria testing and treatment in endemic areas. Also consider poisoning and envenomation. Treat high fever with paracetamol. [See SKILLS] For severe temperature elevation, spray with cool water mist, fan and give IV fluids. Avoid shivering. Hypothermia Move to warm environment, remove wet clothing, warm with blankets and warm IV fluid. SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 133 CONDITION MANAGEMENT CONSIDERATIONS Bleeding or other cause of increased pressure on the brain If no trauma, raise the head of the bed to 30 degrees. If trauma is suspected ensure spinal immobilization. [See SKILLS] Opioid overdose Administer naloxone. [See SKILLS] Naloxone effects last approximately 1 hour. Most opioids last longer and patients may need repeat naloxone dosing. Consider this when planning ongoing care and re-assess the person frequently. Active seizure/convulsion Treat with benzodiazepine and monitor the person closely to check for slow breathing. Check glucose or give glucose if you are unable to check. Place patient in recovery position if no trauma suspected. [See SKILLS] If the patient continues to seize or does not wake up between seizures, arrange for rapid transfer to an advanced provider and monitor the airway. Pregnant with active seizure/convulsion This could be eclampsia. Arrange rapid handover/transfer to a specialist unit and give magnesium sulphate. Monitor the patient closely for signs of toxicity. [See SKILLS] If any of these occur, do not give additional doses of magnesium. Alcohol withdrawal Always check glucose and give as needed. Treat withdrawal with a benzodiazepine. [See SKILLS] Monitor the airway closely. Poisoning or envenomation Try to identify the poison and refer to an advanced provider for specific treatments. If pesticide poisoning, make sure the patient has been decontaminated, and monitor the airway closely as the secretions can cause obstruction. Snake bites should be treated as described in the “Wound Management” section [see SKILLS] and referred as soon as possible for antivenom. Rabies There is no specific treatment for rabies. Symptomatic rabies is almost always fatal. See TRAUMA for management of suspected exposure from animal bite. Violent or very agitated patient Protect the patient from harming self or others. Ensure that staff have a clear exit path (do not place the patient between staff and the door). Remove potential weapons and unsafe objects. Call for help from colleagues, family members, and security if needed. Speak in a calm, soft, non-threatening tone. Explain what is happening at each stage of care. Do not confront or judge. Consider other causes: check glucose and vital signs including temperature and oxygen saturation. Treat abnormalities. Arrange for safe handover/transport to advanced provider. Trauma Assess GCS, immobilize the spine and evaluate for signs of increased pressure on the brain. [See SKILLS] Module 5: Approach to altered mental status 134 SPECIAL CONSIDERATIONS MANAGEMENT OF ACTIVE CONVULSIONS • Check ABCDE. • Maintain the airway – do not put anything in the mouth. • Give oxygen if concern for hypoxia or prolonged seizure/convulsion. • Place patient on his/her side, if possible. • Protect the patient from harm or further injury. • Check glucose or give glucose (if unable to check). • Give a benzodiazepine. • If pregnant and seizing, give magnesium sulphate. • If no response, give another dose of benzodiazepine (repeat three times if needed) and monitor for low blood pressure and slow breathing. • If the patient does not wake between seizure/convulsions, consider this a life-threatening condition. Arrange for rapid handover/transfer to an advanced provider. • If the seizures/convulsions stop, place patient in recovery position and monitor closely. Workbook question 4: Altered mental status Using the workbook section above, list what you would do to manage these patients. CONDITION MANAGEMENT A 3-year-old child presents with altered mental status and a blood glucose of 2 mmol/L. 1. ____________________________________________ A 25-year-old woman is brought in with jerky movements and you suspect an active seizure/ convulsion. 1. ____________________________________________ 2. ____________________________________________ 3. ____________________________________________ A 50-year-old man is brought in following a fall from a roof. He has a headache and altered mental status. 1. ____________________________________________ 2. ____________________________________________ SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 135 SPECIAL CONSIDERATIONS IN CHILDREN Children with altered mental status may have seemingly mild signs such as sleeping more than usual or being less interactive. Manage ABCDE first, and then look for and manage causes of altered mental status. Remember that very ill or injured children may have normal vital signs until they rapidly deteriorate. Hypoglycaemia occurs frequently in severely ill children and is a common cause of altered mental status in children. Check blood glucose (or give glucose if you are unable to check) in any child with altered mental status. Hypoxia can occur as a result of many conditions, including respiratory infections and shock; birth hypoxia is a consideration in newborns. Hyperthermia with altered mental status suggests infection, but can also be seen with excessive heat exposure, exercise, seizure/convulsion, hormonal imbalance and some medications and poisons. Hypothermia with altered mental status can also suggest infection, particularly in infants, but can be due to drug intoxication, exposure to cold or hormonal imbalance. Young infants are more affected by variation in temperature. Keep the child warm by using blankets and a hat to prevent heat loss and using skin-to-skin contact (also called “kangaroo care”) with a family member 24-hours per day while ill. Seizures/convulsions can be due to fever alone but (as in adults) can also suggest infection, hypoglycaemia or hyponatremia (low sodium). Do not delay antibiotics in patients with suspected serious bacterial infection. Always consider trauma. Infection in or around the brain can cause altered mental status. Look for a bulging or swollen fontanelle (in a child under 1 year) and/or rash to the legs and lower abdomen, which can indicate infection or increased pressure on the brain. Do not delay antibiotics in children with suspected serious bacterial infection. Flat fontanelle Bulging fontanelle page 31 Flat fontanelle Bulging fontanelle Poor perfusion can cause altered mental status. Children can become dehydrated very quickly. Check for signs of dehydration: abnormal skin pinch, dry mucous membranes (the inner, pink part of the mouth), irritability, sunken or depressed fontanelle (in a child under 1 year), slow capillary refill (greater than 3 seconds), cold extremities, tachycardia, and hypotension. Give IV fluids and re-assess frequently. [See SKILLS] Module 5: Approach to altered mental status 136 Malaria may be more severe in children than adults. Children with severe malaria may present with severe anaemia, seizure/convulsions, coma, and hypoglycaemia. Ingestion of chemicals or drugs is common in children. Try to identify the poison (talk to parents) and try to get a photograph of the package. Consult advanced provider immediately for management. Consider unwitnessed ingestions in children aged under 6 years (especially aged 1–3): • Ask about signs and symptoms depending on the substance ingested. • Take a thorough history from the family. • Examine the bottles of the ingested substance or medicine. • Determine what time it took place. • Ensure that no other children were involved. • Check for signs of burns in or around the mouth • Check for stridor (high-pitched noises) suggesting ingestion of chemicals that burned or damaged the airway and are causing swelling. • Children with ingestion of drugs or chemicals need to be monitored closely and may require handover/transfer to a referral unit for further management. Workbook question 5: Altered mental status Using the workbook section above, answer the following questions about altered mental status in children: How would you assess for brain infection in a child? ________________________________________________________________________ ________________________________________________________________________ Why does hypoglycaemia occur frequently in severely ill children? ________________________________________________________________________ Seizures/convulsions in young children can be a sign of what? ________________________________________________________________________ SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 137 DISPOSITION CONSIDERATIONS Disposition depends on the cause of altered mental status. Causes of altered mental status that cannot be rapidly corrected or which might return after medications wear off need management in a hospital setting. Any patient with altered mental status must be closely monitored for airway problems. Consider handover/transfer to a provider with advanced airway capabilities. If the underlying cause of the low blood glucose is not identified and treated, patients with hypoglycaemia who improved with glucose may develop low blood glucose again and may require repeat treatments. These patients need to be monitored closely. Naloxone (opioid reversal agent) effects only last approximately 1 hour. Many opioid medications are longer-acting and may need more doses of naloxone to reverse the opioid effects. Any patient treated with naloxone must be monitored closely. Make sure the new provider knows the patient has been given naloxone and may need additional doses. FACILITATOR-LED CASE SCENARIOS These case scenarios will be presented in small groups. One participant will be identified as the lead and will be assessed, while the rest of the group writes the responses in the workbook. To complete a case scenario, the group must identify the critical findings and management needed, and formulate a one-line summary for handover, including assessment findings and interventions. You should use the Quick Card for these scenarios while being assessed. CASE #1: ADULT WITH ALTERED MENTAL STATUS A 42-year-old man is brought in after he was found slumped over at a bus stop. When the bystanders went to him he was awake but very confused. They do not know him, but because he is so confused they brought him to you for care. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTION TO PERFORM: AIRWAY YES NO BREATHING YES NO Module 5: Approach to altered mental status 138 ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTION TO PERFORM: CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate one sentence to summarize this patient for handover. CASE #2: PAEDIATRIC PATIENT WITH ALTERED MENTAL STATUS A mother brings her 3-year-old child to you for evaluation after she had two seizures/ convulsions today. The child is wrapped in multiple blankets. The mother states that the child has been increasingly confused over the past 2 days and has had high fevers. 1. What do you need to do in your initial approach? 2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about look, listen and feel findings; use the Quick Card for reference as needed. ASSESSMENT FINDINGS INTERVENTION NEEDED? INTERVENTION TO PERFORM: AIRWAY YES NO BREATHING YES NO CIRCULATION YES NO DISABILITY YES NO EXPOSURE YES NO 3. Formulate one sentence to summarize this patient for handover. SHOCK BREATHING TRAUM A INTRO ABCDE AM S SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 139 MULTIPLE CHOICE QUESTIONS Answer the questions below. Questions and answers will be discussed in the session. 1. You are evaluating ABCDE on a 4-year-old boy who has a fever and a cough. He is not responding to you calling his name, but if you pinch the sole of his foot, he moans. What is his level on the AVPU scale? A. Alert B. Verbal C. Pain D. Unresponsive 2. A 37-year-old male is brought in by his wife with fever and confusion. She says since the fever began 3 days ago he has become increasingly confused. There has been no trauma. On examination you notice that his neck is stiff. What is the most likely cause of his altered mental status? A. Pneumonia B. Infection around the brain C. Stroke D. Drug use 3. A 46-year-old man comes in to check his blood pressure. His vital signs are: blood pressure 160/90, heart rate 120, respiratory rate 18, and blood glucose is 5 mmol/L. While you are examining him he has a seizure/convulsion. What treatment should you give? A. Benzodiazepine B. Glucose C. Antibiotics D. Naloxone 4. A 36-week pregnant woman is having a seizure/convulsion. She has a recent history of high blood pressure as well. What treatment should you give? A. Magnesium sulphate B. Glucose C. Nitroglycerin D. Nothing, the seizure/convulsion will stop on its own 5. You are assessing a 6-month-old infant and find a depressed fontanelle. What does this physical examination finding suggest? A. Infection in the brain B. Dehydration C. Pneumonia D. Hypoglycaemia 140 Notes ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS 141 PARTICIPANT WORKBOOK WHO BASIC EMERGENCY CARE [SKILLS]
AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 143 TABLE OF CONTENTS: SKILLS 1. AIRWAY SKILL STATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 BASIC AIRWAY MANOEUVRES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 • Adult head-tilt and chin-lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 • Paediatric head-tilt and chin-lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 • Adult and paediatric jaw thrust . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 MANAGEMENT OF CHOKING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 AIRWAY SUCTIONING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 BASIC AIRWAY DEVICE INSERTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Airway skill station assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 2. BREATHING SKILL STATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 BREATHING EXAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 GIVING SUPPLEMENTAL OXYGEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 BAG-VALVE-MASK VENTILATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 EMERGENCY NEEDLE DECOMPRESSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 MANAGEMENT OF OPEN PNEUMOTHORAX (SUCKING CHEST WOUND) . . . . . . . . . . . . . . . . . 157 HOW TO MAKE A SPACER FROM A PLASTIC BOTTLE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 Breathing skill station assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 3. CIRCULATION SKILL STATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 CIRCULATION EXAM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 EXTERNAL BLEEDING CONTROL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 • Direct pressure for external bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 • Deep wound packing for external bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 • Tourniquet technique for uncontrolled external bleeding . . . . . . . . . . . . . . . . . . . . . . . . 162 UTERINE MASSAGE FOR POSTPARTUM HAEMORRHAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 IV CANNULATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 • ADJUSTING FLUID VOLUME FOR SPECIAL CONDITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . 167 • IV FLUID ADMINISTRATION FOR SHOCK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 Circulation skill station assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 TABLE OF CONTENTS: SKILLS 144 4. EXTENDED PHYSICAL EXAMINATION SKILL STATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . 176 NEUROLOGIC EXAM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 • Glasgow Coma Scale (GCS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 • AVPU Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 SECONDARY SURVEY TRAUMA ASSESSMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 Extended physical examination skill station assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . 177 5. IMMOBILIZATION SKILL STATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 CERVICAL SPINE IMMOBILIZATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 LOG ROLL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 FULL SPINAL IMMOBILIZATION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 POSITIONING OF THE PREGNANT PATIENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 RECOVERY POSITION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 FRACTURE IMMOBILIZATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 • FRACTURE IMMOBILIZATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 • FRACTURE IMMOBILIZATION: OPEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 APPLYING A PELVIC BINDER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 Immobilization skill station assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 6. WOUND MANAGEMENT SKILL STATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 GENERAL WOUND MANAGEMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 BURN MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 • DETERMINE TOTAL BODY SURFACE AREA (TBSA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 • ESTIMATE DEPTH OF BURN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190 • FLUID RESUSCITATION IN BURN INJURY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 SNAKE BITE BANDAGING AND IMMOBILIZATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192 Wound management skill station assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192 7. Medication administration skill discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194 AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 145 SKILLS SKILL STATIONS are designed to allow you to practise new skills and demonstrate life- saving techniques. REMEMBER...ALWAYS WEAR PROPER PPE PRIOR TO CARING FOR A PATIENT AND PERFORMING ANY SKILL. 1. AIRWAY SKILL STATIONS AIRWAY SKILL STATION: BASIC AIRWAY MANOEUVRES Opening the airway: adult head-tilt and chin-lift To be used for patients with altered mental status who may not be able to protect the airway, with NO history of trauma: • Place person face up on flat, firm surface. • Tilt the head back with one hand and lift the chin with your fingers. – To do this, place one hand on the patient’s forehead and then place two fingers of the other hand on the chin. Rotate your hands, tilting the chin up away from the chest. • Remove foreign bodies if visible. • Use suction to remove any liquids or secretions from the airway if needed. • Hold the airway open – do not let the head drop back as this will close the airway. Opening the airway: paediatric head-tilt and chin-lift To be used with patients with altered mental status who may not be able to protect the airway, with NO history of trauma: • Remember, children’s heads are bigger than adults’ heads compared to body size, and their airways are softer and easier to block when the neck is bent. In older children, the airway can be opened by tilting the head backwards slightly (see figure). • Babies have the largest heads relative to their body size. Their heads should be placed in neutral (sniffing) position (see figure). • Inspect the mouth and remove visible foreign bodies. Take care not to push the foreign body deeper into the airway. Adult head-tilt and chin-lift page 1 Adult head-tilt and chin lift SKILLS 146 • Use suction to remove any liquids or secretions from the airway. • Hold the head as below in position to keep the airway open. Neutral position in infants Head-tilt and chin-lift in children (no trauma) Opening the airway: adult and paediatric jaw thrust Use when the patient has altered mental status and may not be able to protect the airway and there IS a history of trauma (cervical spine fracture is possible): • Ask an assistant to immobilize the cervical spine while you perform the jaw thrust. [See SKILLS] • Place fingers behind the angle of mandible (the curve on the jaw bone) on both sides of the jaw and push up so that the lower jaw moves. The head and neck should NOT move. • Inspect the mouth and remove foreign bodies if visible. • Use suction to remove any liquids or secretions from the airway if needed. • Hold the jaw in place to keep the airway open – do not let the jaw drop back as this will close the airway. Jaw thrust in children Jaw thrust in adults Head-tilt and chin-lift in children (no trauma) page 3 N utral position in infants page 2 Modified _02 Pediatric jaw thrust page 4_A AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 147 AIRWAY SKILL STATION: MANAGEMENT OF CHOKING Managing choking in an adult or larger child If respiratory distress occurs suddenly while eating, a person is clutching the throat, or there is silent coughing, cyanosis (skin turns blue in colour), stridor or noisy breathing, suspect a foreign body obstructing the airway. Encourage the person to speak or cough if possible and observe if the obstruction is removed. Do not perform the manoeuvres described below if the person is audibly coughing and/or able to make sounds. A person who is unable to speak or cough has complete airway obstruction and needs immediate help: • Tell the person that you are going to provide help. • Deliver five abdominal thrusts (see below for modifications for pregnant women). – Stand behind the person and lean the person forward. – Form a fist with one hand and place it in the centre of the abdomen between the umbilicus (belly button) and the bottom portion of breastbone. – Place your other hand over your fist. – NOTE: If the patient is pregnant, place the side of your fist in the center of the chest and pull sharply inward. – Pull in and up five times using hard, quick thrusts. This forces the air out of the patient’s lungs to try to “blow out” the obstruction. – If the obstruction persists, have the person bend at the waist and give five back blows (with the heel of your hand, strike the back between the shoulder blades in the direction towards the head). – Re-assess. – Repeat abdominal thrusts followed by back blows until patient speaks, coughs or becomes unconscious. – If the choking person becomes unconscious, lie him/her face up on a firm surface. Performing chest thrusts may relieve the obstruction. If a series of chest thrusts is not successful, continue with rescue breaths and chest compressions based on relevant CPR protocols. Chest thrusts for choking in late pregnancy page 6 Abdominal thrusts for choking adult page 5 Abdominal thrusts for choking adult Chest thrusts for choking in late pregnancy SKILLS 148 Managing choking in an infant or small child • Lay the infant on your arm or thigh in face down position with the head lower than the abdomen. • Give five back blows (with the heel of your hand, striking the back sharply between the shoulder blades in the direction towards the head). • If obstruction persists, turn the infant over. • Give five chest thrust with two fingers, just below the nipple line in the midline of the chest. • If obstruction persists, check infant’s mouth for any visible obstruction that can be removed. (Caution for biting.) • If necessary, repeat entire process until the foreign body is removed. Chest thrusts for choking in infants page 7 Back blows for choking in infants page 8 Chest thrusts for choking in infants Back blows for choking in infants AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 149 AIRWAY SKILL STATION: AIRWAY SUCTIONING The purpose of suctioning is to remove any liquids or secretions from the upper airway. Suctioning may be necessary to maintain an open airway if a person cannot clear secretions without help. • Check to see if your suction canister or handheld device is working. • Attach a rigid or soft suction catheter to the end of the suction tubing. • Explain what you are doing. • Insert the suction catheter into the back of the mouth (only as far back as you can see), cover the side hole on the catheter (NOT the tip of the catheter) to create suction. Suction only while pulling the catheter out and release suction when advancing the catheter forward (advancing the catheter further into the mouth while suctioning can cause injury). Repeat to suction all of the fluid in the back of the mouth. • Do not suction for more than 10 seconds at a time unless the airway is completely blocked with fluid. • To avoid trauma to the mouth, do not place the end of the suction tip directly against the soft tissue or hold it in just one place. Suction only in the oral cavity, do not suction up the nose. AIRWAY SKILL STATION: BASIC AIRWAY DEVICE INSERTION Oropharyngeal airway (OPA) insertion • An oropharyngeal airway (OPA) should only be inserted when the person is unconscious. A conscious person will not tolerate an OPA and will push it out. If the person resists, gags or vomits, remove the device immediately. • Always protect the cervical spine when there is a history of trauma. • Measure the appropriate size of the OPA by measuring from the tip of the earlobe to the corner of the mouth. • Open the person’s mouth using care not to insert your fingers between the teeth (to avoid accidentally being bitten). • Insert the OPA with the curved portion sideways and the tip pointing towards the cheek. • Push the OPA gently into the mouth and, when you can push no further, rotate the OPA 90 degrees, so that the tip now points down the throat and follows the curve of the tongue (see figure). • Push the OPA the remainder of the way in if necessary so that the flange (the wide, flat end) rests on the person’s lips. If you have to do this, be sure that the tip of the OPA does not push the tongue down to obstruct the back of the throat. • Check again to make sure the OPA did not push the tongue down and obstruct the airway. • Give oxygen if available. Oropharyngeal airway (OPA) insertion page 10 Oropharyngeal airway (OPA) insertion SKILLS 150 Nasopharyngeal airway (NPA) insertion Nasopharyngeal airways (NPA) are better tolerated in people who are semi-conscious or when there is a possibility of gagging with oropharyngeal airways. DO NOT use an NPA in people with head and facial trauma. • Assess the nasal passage for any obvious airway obstruction. • Determine the appropriate size NPA to insert. Measure from the base of the nostrils to the earlobe. The diameter of the NPA itself needs to be smaller than the person’s nasal passage. • Lubricate the NPA well and insert it into the nostril, directing it along the floor of the nose posteriorly towards the throat until the wide, flat portion (flange) of the tube rests against the nostril. • Give oxygen if available. Nasopharyngeal airway (NPA) insertion page 9 Nasopharyngeal airway (NPA) insertion Airway skill station assessments Skills station marking criteria 1st pass 2nd pass 3rd pass Safety: Personal protective equipment used or verbalized. BASIC AIRWAY MANOEUVRES Skill 1 – Open the airway: head-tilt and chin-lift List the indications for use – non-trauma cases only. Tilt the head with one hand on the forehead and lift chin with fingers. State that a baby must be placed in a neutral (sniffing) position. Remove foreign bodies if visible. Suction airway if required. Hold the airway open. Do not let the head drop back as this will close the airway. Comments: Skill 2– Open the airway: jaw thrust List the indications for using jaw thrust versus head-tilt and chin-lift (trauma with possible cervical spine injury). Ask for an assistant to immobilize the cervical spine. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 151 Place fingers behind the angle of mandible (the curve on the jaw bone) on both sides of the jaw and push up so that the lower jaw moves. Note that the head and neck should NOT move. Remove any visible foreign bodies. Hold the airway open – do not let the jaw drop back as this will close the airway. Comments: MANAGEMENT OF CHOKING Skill 3 – Choking: adult and larger child Be able to give the indication for abdominal thrusts (the person is unable to speak or cough). Tell the person what you are going to do. Stand behind the person and lean the person forward. Form a fist with one hand and place it in the centre of the abdomen between the umbilicus and the bottom portion of breastbone. Cover one fist with your other hand. Pull in and up five times using hard quick thrusts. This forces the air out of the patient’s lungs to try to “blow out” the obstruction. Assume the victim is still choking: have the person bend at the waist. Deliver five back blows with the heel of one hand between the shoulder blades, striking the back in the direction towards the head. State that you will re-assess the patient Repeat abdominal thrust then back blows until patient speaks or coughs or becomes unconscious. State how this would be modified for a pregnant woman: • Rather than abdominal thrust, place the side of fist in the centre of the chest, cover fist with other hand, and pull sharply inward. Comments: Skill 4 – Management of the choking infant and small child Lay the infant over your arm or thigh in the face down position with the head lower than the abdomen. Give five back blows to the infant’s back between the shoulder blades with the heel of one hand. If obstruction persists, turn the infant over. SKILLS 152 Give five chest thrusts with two fingers placed just below the nipple line in the middle of the chest. If obstruction persists, check infant’s mouth for any obstruction that can be removed. Repeat until obstruction is removed. Comments: Skill 5 – Suctioning the airway Check your suction canister or handheld device to make sure it is working. Attach a hard (yankauer) or soft suction catheter to the end of the suction tubing. Tell the person what you are doing. Insert the suction catheter into the back of the mouth (ONLY as far back as you can see) and cover the side hole on the catheter (NOT the tip of the catheter). Do not suction while inserting the catheter into the mouth. Suction only while pulling catheter out. State how long the patient should be suctioned for (no more than 10 seconds at a time unless the airway is completely covered with fluid). State the need to constantly move the suction catheter and not put the suction tip against the soft tissue. Comments: BASIC AIRWAY DEVICE INSERTION Skill 6 – Oropharyngeal airway (OPA) List the indication for using an oropharyngeal airway (person is unconscious with no gag reflex). Determine the appropriate size OPA to insert: (participant should explain how to do this out loud). • Measure from the earlobe to the corner of the mouth on that side. Open the mouth using care not to insert your fingers between the teeth (to avoid accidentally being bitten). Insert the OPA with the curved portion sideways and the tip pointing to the cheek. Once the OPA is in as a far as it will go, rotate the oropharyngeal 90 degrees so that the tip now points down the throat and the curve follows the tongue. Push the OPA the remainder of the way in so that the flange (the flat end) rests on the person’s lips. Check to make sure the OPA did not push the tongue down to obstruct the airway. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 153 State that oxygen will be given if available. Comments: Skill 7 – Nasopharyngeal Airway (NPA) List the indications for an NPA. (Better tolerated in a person who is semi-conscious or who may still have a gag reflex). State that NPAs should not be used in people with head and facial trauma. Assess the nasal passage for any obvious airway obstruction. Explain how to determine the appropriate size NPA to insert: • Measure from the external portion of the nostril to the bottom of the earlobe. • The diameter of the tube should not be bigger than the nostril (nasal passage). Lubricate the NPA. Lift up the tip of the nose. Insert the lubricated NPA into the nostril and gently push it along the floor of the nose until the flared-out base (flange) rests against the nostril. State that oxygen will be given if available. Comments: Competency demonstrated YES NO Remediation required YES NO Signature of facilitator: SKILLS 154 2. BREATHING SKILL STATIONS BREATHING SKILL STATION: BREATHING EXAM • Assess and count the rate of breathing (normal is between 10–20 breaths per minute in an adult. See ABCDE module for normal paediatric values). • Look for increased work of breathing (nasal flaring, retractions or chest in-drawing). • Feel for chest rise and chest wall tenderness. • Percuss the chest wall: – Place one hand on the chest with fingers separated (the middle finger should lie between the ribs). – With the other hand, tap on the middle finger of the first hand and listen for changes in tone (hollow or dull). • Listen to the chest: – Always expose the chest. Never listen through clothes. – Make sure your stethoscope is not too cold. – Place your stethoscope lightly on the chest wall. Ask the patient to open his or her mouth and take a complete deep breath in and out. Listen to the sounds of the breathing and compare the left side to the right. Listen in the upper zone, middle zone and lower zones and listen to the front of the chest and the back. – Normal breath sounds like wind moving in and out, while abnormal breathing sounds like air going through water, crumpling paper bags, or no air moving at all. [See DIB] – Respect modesty and avoid placing the stethoscope directly on the breasts when possible. BREATHING SKILL STATION: GIVING SUPPLEMENTAL OXYGEN Supplemental oxygen should be given when the patient has signs and symptoms of hypoxia – fast breathing, anxiety, excessive sweating, cyanosis or chest pain. Where available, a pulse oximeter should be used to measure oxygen saturation. • If hypoxia does not appear severe, lower levels of oxygen (24–40% oxygen) can be provided to children and adults through nasal cannula (nasal prongs), but monitor closely in case a mask is needed. (Remember, regular air is approximately 21% oxygen) – Nasal cannula should be about half the size of the nostril. – Position the cannula in each nostril, making sure that it does not extend too far back or press on the tissues. – Secure the tubing to the cheeks or loop the tubing over the ears so that the nasal prongs and the tubing are both on the front side of the patient’s body (never put the head through the loop in the tubing – if patients become confused and hypoxic, they can accidentally strangle themselves). – Oxygen is delivered at a low rate: max 5 L/min. • If hypoxia appears more severe (or if signs of hypoxia continue with maximum oxygen flow via nasal cannula), a simple facemask may be used. Simple facemask is usually used with oxygen flow rates of 6–10 L/min and can deliver approximately 40–60% oxygen. – The facemask is applied to the face, ensuring the bridge of the nose is covered and as little as possible leaks along the side. The mask should rest below the lower lip, but not past the chin. The elastic strap should be placed over the head to secure the mask. • For patients who appear extremely hypoxic or who still have signs of hypoxia with a simple facemask, oxygen can be delivered through a non-rebreather facemask. This provides close to 100% oxygen if the reservoir bag is full. – To prepare the non-rebreather facemask, put one finger over the valve at the top of the reservoir bag inside the mask to inflate the bag. Then apply the non-rebreather facemask in the same way as the simple facemask, ensuring as little leakage as possible. – Make sure that the oxygen is attached to the wall or cannister and that the flow rate is between 10–15 L/min depending on the pressure in your oxygen system and how fast and deep the patient breathes. If the patient is still hypoxic or the non-rebreather facemask bag does not fill, increase the oxygen flow rate. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 155 – NEVER put a non-rebreather facemask on before it is connected to oxygen. A true non- rebreather mask will not allow outside air in and can worsen difficulty in breathing and hypoxia if there is no oxygen flowing through the tubing. Nasal cannula/prongs Simple facemask Non-rebreather BREATHING SKILL STATION: BAG-VALVE-MASK VENTILATION Assess and manage airway and provide bag-mask-ventilation (BVM) for any patient who is not breathing or not breathing adequately (too slow for age or too shallow), any unconscious patient with abnormal breathing (slow, shallow, gasping or noisy), or any patient with a pulse who is not breathing (for patients without a pulse, follow relevant CPR protocols). CAUTION! Avoid over-aggressive ventilation (using bag-valve-mask too fast or with too much pressure) as this will damage the lungs. Children have smaller lungs that are especially fragile. When ventilating a child, be particularly careful to only give enough pressure to make the chest rise and be sure to allow enough time between breaths for exhalation (for the air to escape). Large volumes of air or high pressures may result in pneumothorax or irreversible lung damage. Bag-mask-ventilation steps: • If you have oxygen available, attach the BVM tubing and set the flow to the highest rate available. DO NOT DELAY bag-mask-ventilation to prepare oxygen. (Oxygen can be attached later.) • Place the mask over the patient’s mouth and nose (if you have two people available one person squeezes the bag and other holds the mask on the patient’s face and keeps the airway open). • Create a seal so that air does not leak out. Put your hand or hands in the “EC” position – your thumb and first finger should make a “C” around the top of the mask and push down evenly, your last three fingers should reach just under the bony part of the jaw (looking like an “E”) and pull the jaw upward to open the airway. – Think about pulling the face up to the mask (thus opening the airway) and pushing the mask down onto the face (creating a seal). – If you push down too hard without pulling the face up to the mask, you will block the airway and the patient will be difficult to bag. If you have problems ventilating, reposition your hands and the mask and try again. • If the patient is breathing on his or her own, deliver breaths when the patient takes a breath (during inspiration). Do not attempt to deliver a breath as the patient exhales. • If you are still unable to ventilate the person after repositioning the mask, consider the possibility of foreign body obstruction or air leak. Insert an oral or nasopharyngeal airway device if not already in place (See SKILLS). Nasal cannula/prongs Simple facemask Non-rebreather page 11 SKILLS 156 • Hold the bag in one hand and depress the bag enough to make the chest rise (to about one third of its volume for an adult – make sure you are using the appropriate-sized bag: an adult bag should have a volume of about 2 litres). • Squeeze bag over 1–2 seconds to provide chest rise (giving the breath faster can cause lung damage). • Give one breath every 6 seconds (10 breaths per minute) in an adult; one breath every 4 seconds (15 breaths per minute) in older children; or one breath every 3 seconds (20 breaths per minute) in infants. CAUTION with volume of breaths given in small children (see SKILLS). Giving large volume breaths can cause pneumothorax. • After each breath allow the chest to fall before giving another breath. • Watch the chest rising and falling evenly with each breath. BVM: One provider BVM: Two providers BVM: Child BREATHING SKILL STATION: EMERGENCY NEEDLE DECOMPRESSION Needle decompression of the chest is a life-saving emergency procedure for suspected tension pneumothorax (presence of air or gas in the cavity between the lungs and the chest wall causing excessive pressure on the opposite lung, the great vessels, and the heart). Patients can die very quickly from a tension pneumothorax. These patients need an emergent chest tube, but emergency needle decompression will relieve the immediate pressure and allow time for handover/transfer for chest tube. Emergency needle decompression should only be performed for tension pneumothorax. • Expose the chest and assess breathing. • A tension pneumothorax is identified if shock and the following are present: – Difficulty in breathing – Absence of lung sounds on the affected side – Hypotension – Distended neck veins – Hyperresonance with percussion on the affected side – Tracheal shift away from affected side • Insert a large-bore (14–16G preferred) IV cannula along the upper edge of the third rib through the second rib (intercostal) space in line with the midpoint of the clavicle on the affected side. – In tension pneumothorax, there will be a gush of expelled air • Give oxygen at high concentration (non-rebreather mask). • Start IV lines and give IV fluids. • Refer and transport to definitive care immediately. BVM: One provider BVM: Two providers BVM: Child page 12 AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 157 Chest tube should be placed as soon as possible following needle decompression (even if there was no rush of air) or for any suspected haemothorax. Needle decompression BREATHING SKILL STATION: MANAGEMENT OF OPEN PNEUMOTHORAX (SUCKING CHEST WOUND) An open pneumothorax is an open chest wall wound that sucks air in when the patient breathes in. Normally, when the chest wall is expanded, air is drawn into the lungs through the airway (through a vacuum effect). If there is another hole in the chest wall (due to trauma) air will also be drawn in that hole, but, rather than going into the lungs, it goes into the space between the chest wall and lungs, creating a pneumothorax. A 3-sided dressing is placed to prevent more air from coming in during inhalation, but to allow air from the pneumothorax to escape during exhalation to avoid developing a tension pneumothorax. To manage a sucking chest wound (open pneumothorax): • Give high flow oxygen. • Cover the sucking chest wound with petroleum gauze or other non-adhesive dressing such as the plastic wrapper from gauze packaging. • Tape three sides of the dressing, leaving one side un-taped to act as a flap valve. • These patients need to be transferred as soon as possible to a centre where a chest tube can be placed. (DO NOT place a chest tube through the injury.) Caution! There is a danger of the dressing becoming stuck to the chest wall with clotted blood. When this happens, air cannot escape from the chest cavity and pressure can build up, leading to a tension pneumothorax. Remove the dressing completely if there is worsening respiratory status or evidence of worsening perfusion. If the patient cannot be observed continuously, a three-sided dressing should NOT be placed. Needle decompression page 13 SKILLS 158 BREATHING SKILL STATION: HOW TO MAKE A SPACER FROM A PLASTIC BOTTLE The purpose of a spacer is to hold the medication (salbutamol) released from a metered dose inhaler so the person has time to effectively inhale the medication. (Without experience and proper training, it can be difficult to use a metered dose inhaler effectively and medication is often lost into the mouth or throat). Spacers should be made in advance, however. Do not delay salbutamol delivery to make a spacer. Spacer made from a plastic bottle • Use a clean 300–500ml plastic bottle (wash with detergent and rinse and dry well). • Take the cap off the metered dose inhaler and trace the shape of the opening of the inhaler on the base of the bottle directly opposite the mouth of the bottle. • Cut an opening into the base of the bottle slightly smaller than the traced shape. You can cut this with scissors or a heated paper clip. • Insert the inhaler into the spacer to check the size (the inhaler should fit tightly into the cut opening). • Always remember to prime the spacer with five puffs before use to clear the dead space. Breathing skill station assessments Skills station marking criteria 1st pass 2nd pass 3rd pass Safety: Personal protective equipment used or verbalized use. Skill 1– Assess breathing Assess and count rate of breathing. Look for increased work of breathing (nasal flaring, retractions). Feel for chest rise and chest wall tenderness. Percuss the chest wall. Listen to the chest (auscultate). Comments: Skill 2 – Supplemental oxygen administration State the indication for oxygen (hypoxia, indicated by fast breathing, anxiety, excess sweating, cyanosis (blue tinted skin), or chest pain). Spacer made from a plastic bottle page 14 AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 159 Explain when nasal cannula should be used (mild hypoxia). Demonstrate applying a nasal cannula with a nasal prong in each nostril. Secure the tubing to the cheek or loop over the patient’s ears. (The participant should NOT put the patient’s head through the loop in the tubing.) State that the oxygen flow rate should be no more than 5 l/min. If the patient still has signs of hypoxia, explain which oxygen delivery method should be used next. (Simple facemask) Apply simple facemask – mask over nose bridge and below lower lip. Ensure minimal air leak – adjust elastic to hold in place. Explain that the oxygen flow rate should be between 6–10 L/min. If the patient still has signs of hypoxia, explain which oxygen delivery method should be used next. (Non-rebreather facemask) To prepare the non-rebreather facemask, put one finger over the valve at the top of the reservoir bag inside the mask to inflate the bag. Ensure that the bag is inflated. Apply non-rebreather facemask – mask over nose bridge and below lower lip. Ensure minimal air leak – adjust elastic to hold in place. Turn on oxygen to 10–15 L/min depending on patient’s breathing. Adjust non-rebreather mask, and adjust flow to ensure bag is filled partially. Comments: Skill 3 – Bag-valve-mask ventilation State the indication for bag-valve-mask ventilation. State that if oxygen is available, connect it to the bag – but do not delay BVM to prepare oxygen. Ensure adequate mask-face seal. State correct rate of ventilation. State relevant cautions when ventilating a child. Verbalize that over-aggressive ventilation can damage lungs and cause vomiting. State or demonstrate correct volume of ventilation. Assess chest rise. If no chest rise, reposition airway. Consider OPA or NPA. Comments: SKILLS 160 Skill 4 – Emergency needle decompression State the indication for this procedure. Explain procedure to patient. Expose the chest and clean the skin. Identify landmark: second intercostal space (between the 2nd and 3rd ribs) in the midclavicular line. Insert 14–16G IV cannula into the identified location. Slide cannula over needle, and remove needle. State plan to handover/transfer for chest tube Give oxygen and assess respiratory rate, vital signs and oxygen saturation (if available). Start IV line and give IV fluids. Comments: Skill 5 – Management of open pneumothorax (sucking chest wound) Give high flow oxygen. Cover with petroleum gauze. Tape 3 sides of gauze. State the need for a chest tube to be inserted. Describe the risk of a clotted dressing blocking outflow of air. Comments: Competency demonstrated YES NO Remediation required YES NO Signature of Facilitator: AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 161 3. CIRCULATION SKILL STATIONS CIRCULATION SKILL STATION: CIRCULATION EXAM • Check for anxiety, confusion or altered mental status. • Feel for a pulse, assessing rate and quality (normal range is 60–100 beats per minute in adults. See ABCDE for normal paediatric values). • Assess capillary refill (checked by pushing on the fingernail, palms, or soles and releasing to see how long it takes for the colour to return to the skin). The normal range is less than 3 seconds. • Assess the skin colour and touch the skin to assess the temperature. • Measure other vital signs: respiratory rate and blood pressure (normal adult values: RR 10–20 breaths per minute and systolic BP greater than 90 mmHG. See ABCDE for normal paediatric values). CIRCULATION SKILL STATION EXAM: EXTERNAL BLEEDING CONTROL Direct pressure for external bleeding A wound that is deep and bleeding heavily may not stop bleeding on its own. Applying direct pressure with a clean dressing such as gauze can help to slow or stop the bleeding (see figure). • Put on gloves. • Use gauze or another clean non-adherent dressing. • Do not use bulky dressings as they can make it difficult to put enough pressure in the right place. • Apply firm pressure as directly as possible to the source of bleeding, usually with two or three fingers. • If the wound is on a limb, elevate the limb above the heart. • If the first dressing becomes soaked with blood, do not remove as this will dislodge any clots that have formed. Instead add another pad and apply firm pressure. • When bleeding stops, apply a bandage to keep the gauze/pad in place. • If bleeding does not stop, consider deep wound packing or tourniquet (see next section). Applying direct pressure to a wound Applying direct pressure to a wound page 15 SKILLS 162 Deep wound packing for external bleeding If the wound is deep or gaping and simple pressure does not stop the bleeding, deep wound packing may help. However, deep wound packing is a temporary procedure to stop the bleeding since it can lead to infection if left for more than 24 hours. • Put on gloves. • Always assess pulses, capillary refill and sensation before and after dressing or splinting any wound. • Thoroughly wash out the wound by flushing with at least a litre of clean water (under pressure when possible; see next section). • Use gauze or another clean, compact material to completely fill the space within the wound. • Use additional gauze on top of the wound surface and apply direct pressure with your gloved hand or a bandage wrapped firmly around the wound/limb. • For limb wounds requiring packing, apply a splint to reduce the risk of re-bleeding. • A deep wound pack should not be left in place for more than 24 hours because of the risk of infection. • If bleeding does not stop, consider tourniquet (see next section). Tourniquet technique for uncontrolled external bleeding You will not be expected to perform the tourniquet technique BUT you will be expected to know what life-threatening conditions it can be used for, the special considerations around use of a tourniquet and the ongoing care of the patient. Use this technique ONLY if all other bleeding control measures have failed AND haemorrhage is life-threatening. If you place a tourniquet, there is a possibility that tissues below the tourniquet will be permanently damaged and even require amputation. If you are considering using a tourniquet, CALL FOR HELP IMMEDIATELY and plan for handover/transfer to a unit where surgery is possible. • If available, use a pneumatic tourniquet (like a blood pressure cuff) over padded skin and inflate until bleeding stops. If not, use a thick band or piece of cloth or belt (the wider, the better), over padded skin. • Apply as close to wound as possible, but do not place over a wound or a fracture. • Apply enough pressure to make distal pulses disappear and re-assess bleeding. • If bleeding stops, leave dressing in place if already present or dress the wound and prepare for handover/transfer to a surgical care unit. • If the bleeding does not stop, increase tourniquet pressure until major bleeding ceases. • Record the exact time the tourniquet was applied in the notes AND write it on the patient’s skin or the tourniquet itself. • Consult advanced provider as soon as possible (and never more than 2 hours) after placing a tourniquet. • The tourniquet should be released every 2 hours for at least 10 minutes. Hold direct pressure to the bleeding area during this time. Do not re-apply the tourniquet unless evidence of continued active bleeding. • Location of the tourniquet: tourniquets should only be placed on extremities and should be placed above the level of the bleeding. Because of the relationship between the bones and blood vessels, tourniquets on the upper arm or leg are often more effective than tourniquets placed below the elbow or knee. • Make sure the tourniquet is clearly visible. • Remember tourniquet should be placed as a last resort. If you place a tourniquet, you are cutting off blood supply to the limb, so only do this for life-threatening bleeding. When tourniquet use is absolutely necessary, use a wide, yet constrictive, band. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 163 CIRCULATION SKILL: UTERINE MASSAGE FOR POSTPARTUM HAEMORRHAGE Some bleeding will occur with every delivery. After delivery, the uterus should contract, which compresses vessels and limits bleeding. Failure of the uterus to contract is the top cause of abnormal bleeding after delivery (postpartum haemorrhage). Call for help, arrange for rapid handover/transfer, start uterine massage and give oxytocin immediately. Postpartum Haemorrhage 1. Arrange immediate transfer to qualifi ed obstetric provider! 2. Attempt to control bleeding while arranging and during transfer. 3. Check: 4. Transfer immediately Heavy bleeding after delivery? Has the placenta delivered? Still bleeding? Is there a perineal or lower vaginal tear? Massage uterus until it is hard. Give oxytocin IM. Give IV uids and IV oxytocin. Empty bladder. Continue uterine massage. When uterus is hard, the placenta will likely deliver. Collect placenta and keep with patient. Continue oxytocin. Continue oxytocin for at least 1 hour after bleeding stops. Apply pressure with sterile gauze, put legs together. Continue to massage uterus until hard. Continue oxytocin. Continue IV uids with oxytocin. Insert second IV line. YES YES NO NO YES SKILLS 164 Performing uterine massage for postpartum haemorrhage • Explain to the woman what you will do and why. • The goal is to compress the uterus between your hand and bony structures behind the uterus (e.g. sacrum/lower back). • Place your hand on the woman’s abdomen. Through the abdominal wall, feel for the uterus and cup it with your hand. This will ensure it stays under your hand whilst you are massaging it. Do not simply squeeze the uterus, but ensure that you are applying strong pressure toward the patient’s back while massaging with a circular motion. • Massage the uterus until it is very firm. It should feel like a 10 cm rock in the lower abdomen when contracted. • Do not stop massaging until the uterus is contracted (hard). • Make sure the uterus does not become relaxed (soft) after you stop uterine massage. If it becomes relaxed, resume massage. • Continuously re-assess for vaginal bleeding. • Perform frequent vital signs. Uterine massage for postpartum hemorrhage Uterine massage for postpartum hemorrhage page 17 AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 165 CIRCULATION SKILL: IV CANNULATION Insertion of IV cannula (adult) Inserting an IV cannula is an essential skill required for the treatment of shock. If an adult displays any signs and symptoms of shock, insert two large-bore cannulae (14 or 16 gauge). • Prepare cannula, IV fluid of choice, tourniquet, gloves, dressing to cover the cannula and alcohol swab. • Put on gloves. • Place an elastic band or glove around the arm to function as a temporary tourniquet to help the veins engorge (this “tourniquet” is different from the one above and should not be so tight as to cut off arterial blood flow). Avoid placing an IV in any arm that might have a fistula for treatment of kidney disease. • Look and feel for a vein that is straight. Avoid blood vessels that have a pulse. If a person is in shock, it may be difficult to find a vein. In this case search for a vein in the antecubital fossa (where the elbow bends, see figure). IV in antecubital fossa • Use alcohol or other appropriate skin cleanser to wipe the skin around the vein you plan to use. • DO NOT insert an IV through skin that is broken or appears infected. • Prepare the cannula. Preparation may vary depending on local resources and types of cannula. • Tell the patient what you are doing. • Remove the safety covering over the cannula (the only thing that should be inserted is the needle with overlying plastic cannula). • Insert the needle directly over and in line with the vein as flat and parallel to the skin as possible. Watch for flashback (flash of blood in the cannula) when you enter the vein. – If blood has a regular pumping pattern, you have likely hit an artery and you should remove the needle/catheter and apply firm pressure to the site for at least 5–10 minutes. • After seeing the flash of blood, insert the needle a few millimeters further, then advance the plastic cannula over the needle fully into the patient’s vein. (Do NOT let the needle move forward when you start to move the plastic cannula.) • Hold the cannula in place, applying pressure to the base of the cannula (to occlude it and stop the flow of blood) and withdraw the needle, leaving the cannula positioned in the vein. If needed, withdraw blood to send for laboratory testing. • Remove the IV tourniquet and flush the cannula with normal saline. • Place a cap on the end of the cannula, secure the cannula well and dress the site. Document the date the cannula was inserted in the notes. • Ensure the needle is placed into a sharps container. Check IV site daily for signs of infections such as skin redness, pain and swelling. Ensure the cannula is still in the vein and not sitting in the skin next to the vein allowing fluid to be infused under the skin creating pain and swelling. If any sign of swelling or infection, remove the IV cannula and re-assess. IV in antecubital fossa page 16 SKILLS 166 Insertion of IV cannula (paediatric) Attempt to place the cannula in the hand of the child first. Other sites that can be used to insert a cannula include: • Scalp veins • External jugular veins • Antecubital veins • Femoral veins When preparing for IV cannulation in children ask another assistant or parent to help keep the child’s arm still. Veins in infants • Prepare a 21 or 23 gauge cannula. • When inserting the cannula into the back of the hand, keep the hand bent to obstruct venous return and make the veins visible. Place an “IV tourniquet” (as above) if needed. If you use an IV tourniquet, be sure you don’t forget to remove it. • Insert the cannula using the same technique used in adults. Again, be sure that the blood flows smoothly from the catheter and is not pumping. After insertion, withdraw blood if required for laboratory investigation. Remove the tourniquet and flush the cannula with a small amount of normal saline after insertion. • Secure the cannula well. Children will attempt to remove the cannula and will undo dressings. Avoid placing a single piece of tape (plaster) that goes all the way around an extremity as this may limit blood flow. • If the IV is placed near a joint (hand, antecubital fossa, femoral area) splint the joint to stop it from bending and preventing the IV fluid flowing in, and lightly bandage the IV site with bulky dressings to prevent the child from pulling at the adhesive dressing underneath. Veins in infants Scalp veins External jugular veins Antecubital veins Veins on dorsum of hand Femoral veins Ankle veins page 18 AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 167 Securing an IV in a child page 20 Securing an IV in a child Inserting IV in a small child's hand page 19 Inserting IV in a small child’s hand Check IV site daily for signs of infections such as skin redness, pain and swelling. Ensure the cannula is still in the vein and not sitting in the skin next to the vein allowing fluid to be infused into the skin creating pain, swelling and another source of infection. If any sign of infection, remove the IV cannula and re-assess. CIRCULATION SKILL: IV FLUID – ADJUSTING FLUID VOLUME FOR SPECIAL CONDITIONS Shock should be treated with IV fluids. Fluid volume must be adjusted for patients with three conditions: malnutrition, severe anaemia and fluid overload. When administering IV fluid to any patient, look for signs of new or worsening fluid overload: difficulty in breathing, crackles in the lungs, increasing respiratory rate or increasing heart rate. Stop IV fluids if there are any of these signs and plan for immediate handover to an advanced provider. Recognizing conditions needing IV fluid adjustment in patients with shock – fluid overload, malnutrition, and severe anaemia. 1. Is there fluid overload? In some patients, such as those with heart or kidney failure, there may be extra fluid in the tissues (for example, in the lungs or the soft tissues of the legs). These patients can be fluid “overloaded” even when they have poor perfusion (because the extra fluid is not in the blood vessels). These patients still need IV fluid if they are in shock, but IV fluid must be given more slowly with careful monitoring so that the fluid overload does not get worse. SKILLS 168 CHECK FOR: Signs of fluid overload. • Difficulty in breathing with crackles on chest exam • Lower body swelling (usually in the legs) • Unable to lie flat • Distended neck veins – If signs of fluid overload are present, you must adjust fluids: Small amount of fluids may be given (250–500 ml boluses in adults). Slow the rate of fluid administration. Monitor closely for worsening signs of fluid overload (increasing respiratory rate or heart rate, new or worsening difficulty breathing and increasing crackles in the chest). Stop IV fluids if any of these signs develop. REMEMBER: It is important to go slowly so you can stop for early signs of fluid overload. If you don’t stop IV fluid when these early signs develop, too much IV fluid can cause a patient’s lungs to fill with fluid and create severe difficulty in breathing, or even death. 2. Does the patient have severe anaemia? In patients with severe anaemia, IV fluid can dilute the blood and lower its capacity to carry oxygen to dangerous levels. Additionally, patients with severe anaemia tend to show signs of fluid overload more quickly with IV fluid administration. Remember: you should only give IV fluids to someone with severe anaemia if there are signs of shock (see figure). CHECK FOR: Signs of severe anaemia. • Severe pallor to the palms of the hands (compare to your own palm) or the mucous membranes. • Fast breathing or fast heart rate • Confusion or restlessness • May also have signs of heart failure/fluid overload • If these signs of severe anaemia are present, you must adjust fluids: Slow the rate of fluid administration. Monitor closely and stop IV fluids for worsening. Rapid handover/transfer to a centre capable of blood transfusion. 3. Is the patient severely malnourished? • IV fluid can cause life-threatening swelling and heart failure in malnourished patients and must be adjusted very carefully. Malnourished patients are also at very high risk of hypoglycaemia. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 169 CHECK FOR: Signs of malnourishment. • Visible wasting: a child with severe wasting does not look just thin, but is visibly bony with skin that appears too large for the body. The arms, legs and buttocks may be thin, and the head may appear relatively large because of wasting of the body. • Oedema of both feet: take shoes or socks off and assess both feet for oedema. Press the top of the foot gently with your thumb for a few seconds to see if a dent remains in the tissues. Remember that a severely malnourished child may not appear very thin if there is a lot of oedema. – If these signs of severe malnutrition are present, you must adjust fluids. [See FLUID ADMINISTRATION IN SHOCK (CHILD WITH SEVERE MALNUTRITION) for detailed fluid choice and administration rates] Oral fluid is preferred if the patient can tolerate it. Add dextrose: use dextrose-containing fluids or give a dose of dextrose with IV fluids. Slow the rate of fluid administration. Monitor closely and stop IV fluids for any signs of fluid overload. Switch to oral fluid as soon as possible. Visible severe wasting in a child: Assessing for bilateral oedema in severe malnutrition in children: • Skin looks too large for the body • There is no fat on the child • Outlines of ribs can be seen • Severe muscle wasting of the arms, legs and buttocks • The head may appear relatively large because of wasting of the body (see figure) Visible severe wasting in a child • Use your thumb to press gently for a few seconds on the top of each foot – the child has oedema if there is an impression when you lift your thumb • Repeat on the other foot (see figure) Assessing for pitting edema in children with malnutrition Visible severe asting in a child page 23 Assessing for pitting edema in children with malnutrition page 22 SKILLS 170 CIRCULATION SKILL: IV FLUID – ADMINISTRATION Fluid administration for shock in adults • Attach normal saline or Lactated Ringer’s solution to the cannula. • In adults give 1 litre over less than 30 minutes. • Assess response to fluid immediately after the fluid bolus. Assess perfusion (capillary refill, mental status, urine output), and check for pulse rate and blood pressure. If improving, the pulse rate should lower and the blood pressure should increase. Mental status may also improve. • Assess for fluid overload (see signs above). • If still in shock with no evidence of fluid overload, give another 1 litre bolus. • If still in shock after 2 litres of IV fluid, re-assess for ongoing blood loss (external and internal) or spinal injury, and call for advanced provider. If there is evidence of severe malnutrition, severe anaemia or fluid overload: • Patients with shock still need IV fluids, but it is important to re-assess frequently for signs of worsening overload. – For these adult patients who are at high risk for fluid overload, bolus with 500 ml IV fluid initially, then re-assess. If no signs of fluid overload or fluid in the lungs, give additional 500 ml. Fluid administration for shock in children The appropriate amount of fluid for critically ill children is controversial given recent evidence that bolus fluids can worsen outcomes in some children. In addition, relevant criteria for poor perfusion and shock may vary by context. The 2016 WHO guidelines for the care of critically ill children (see WHO Sources section) use the presence of three clinical features to define shock requiring bolus fluids: cold extremities, capillary refill greater than 3 seconds, and weak and fast pulse. For children with poor perfusion that is due to loss of fluid, such as those with bleeding, burns or severe diarrhoea/vomiting, bolus fluids are also recommended. For other children with evidence of poor perfusion, smaller amounts of fluids given more slowly may be safer. Country teams should consider the clinical presentation of the child, the capacity of providers to detect signs of fluid overload, and the availability of monitoring and support equipment when adapting recommendations to the national context. To give IV fluid resuscitation to a child in shock WITHOUT severe malnutrition, severe anaemia or overload: • Insert IV cannula as described above. • Weigh the child or ask the parents for a recent weight. • Give normal saline or Lactated Ringer’s: 10–20 ml per kilogram of body weight over 30 minutes. Re-assess the child after the first infusion. • If no improvement, repeat 10 ml per kilogram of body weight over 30 minutes. Call for help and plan to handover to an advanced provider and unit with the capacity for blood transfusion. IV fluid resuscitation for a child in shock WITH severe malnutrition Children that are in shock AND have severe malnutrition require specialized fluids (if available) with different rates of infusion. Children with severe malnutrition and shock are at very high risk of hypoglycaemia and will need sugar in addition to fluids. [See MEDICATIONS] If the child can take oral fluids, give oral rehydration with ReSoMal (unless the child is in shock due to cholera, then use ORS). If the child is lethargic, unconscious or not capable of taking oral fluids, then give IV fluids. CAUTION! Intravenous fluid administration can be dangerous in malnourished children. While giving fluid in any way, you must check every 5 minutes for the following danger signs: new or worsening DIB, respiratory rate increase of >5 per minute or heart rate increase of >15 beats per minute. Stop fluids if any danger sign develops. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 171 • Insert IV line as above. • Weigh the child. • Give 10–15 ml per kilogram of IV fluid over 1 hour. If specialized fluids are available, give one of the following according to availability: – Ringer’s Lactate with 5% glucose (dextrose) – Half-strength Darrow’s solution with 5% glucose (dextrose) – 0.45% normal saline with 5% glucose (dextrose). • If you do not have dextrose-containing fluids, then give one of the following: – Ringer’s Lactate AND give a separate oral or IV dose of dextrose [See MEDICATIONS] – Normal saline AND give a separate oral or IV dose of dextrose. [See MEDICATIONS] Re-assess the child after the first 5–10 minutes of the infusion and then every 5 minutes: If the child worsens during rehydration (increased difficulty in breathing, breathing rate increases by 5/min and pulse rate increases by 15/min or lung crackles develop): • Stop the fluids. • Call for help and plan for handover to an advanced provider. If there is no improvement after the first infusion: • Call for help. Plan for handover to an advanced provider at a centre with blood transfusion capabilities. • Give fluid at 4 ml per kilogram over 1 hour while awaiting transfer to the advanced provider. If the child displays signs of improvement (improved capillary refill, lower pulse rate and respiratory rate): • Switch to oral or nasogastric rehydration with ReSoMal (low sodium oral rehydration solution) 10 ml per kilogram per hour for up to 10 hours. • Transfer to a malnutrition unit. SPECIAL CONSIDERATIONS: Children with severe anaemia and poor perfusion need urgent handover to an advanced provider and unit with the capacity for blood transfusion. Children who need IV fluids, but in whom bolus fluids are not indicated should be given maintenance fluids. See the WHO Child Health publications page (www.who.int/maternal_child_adolescent/ documents/child/) for recommended maintenance fluid rates in children. Circulation skill station assessments Skills station marking criteria 1st pass 2nd pass 3rd pass Safety: Personal protective equipment used or states intent to use Skill 1 – Assess circulation Look for anxiety, confusion, AMS Feel for pulse: rate, quality Assess capillary refill: >3 seconds indicates poor perfusion Assess skin colour and temperature Verbalize to measure other vital signs: respiratory rate and blood pressure Comments: SKILLS 172 Skill 2 – Bleeding control: direct pressure Put on gloves Uses gauze or another clean, non-adherent dressing, apply firm pressure to the wound Verbalize to not use bulky dressings Apply firm pressure as directly as possible to the source of bleeding, usually with two or three fingers Demonstrate how to elevate a limb with a wound above the heart Verbalize to not remove the first dressing Apply second dressing with firm pressure when wound continues to bleed Apply bandage when bleeding ceased Verbalize the need to call for help Comments: Skill 3 – Bleeding control: deep wound packing Put on gloves Identify deep or gaping wound as an indication for deep wound packing Assesses pulses, capillary refill and sensation after dressing or splinting any wound Irrigate with 1L clean water before packing. Use gauze or another clean, compact material to pack the space within the wound Put additional gauze on top of the wound surface and apply direct pressure with your gloved hand or a bandage wrapped firmly around the wound/limb If a wound is on a limb and requires packing, consider applying a splint to reduce the risk of re-bleeding Assesses pulses, capillary refill and sensation after dressing or splinting any wound State that a deep wound pack should not be left in place for more than 24 hours because of the risk of infection Comments: Skill 4 – Bleeding control: tourniquet Identify continued bleeding as an indication for a tourniquet States intent to use a blood pressure cuff or thick band or piece of cloth or belt (the wider, the better) after padding skin Identifies appropriate location for tourniquet States to tighten tourniquet until the distal pulses disappear. Then re-assess the bleeding to see if it has stopped AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 173 States to secure tightened tourniquet in place States plan to release for 10 minutes every 2 hours. Only re-apply if bleeding resumes States documentation time of tourniquet placement States will not leave tourniquet on for more than 2 hours without consulting advanced provider Comments: Skill 5 – Uterine massage for postpartum haemorrhage States to call for help and initiate handover/transfer States the indication for performing uterine massage States the need to prepare oxytocin and IV fluid States that the goal is to compress the uterus between the hand and bony structures behind the uterus (e.g. sacrum/lower back) Demonstrates how to cup the uterus through the abdominal wall to ensure that it stays under the hand Demonstrates how to apply strong pressure toward the patient’s back while massaging with a circular motion States that massaging should not stop until the uterus is contracted (feels hard) States that the uterus should not become relaxed (soft) after uterine massage has stopped. If it does, resume uterine massage States to continuously re-asses for vaginal bleeding and perform frequent vital signs Comments: Skill 6 –Inserting an iv cannula Prepare equipment: gloves, IV cannula, administration set , fluids, IV tourniquet, swab Tell the patient what you are about to do Place IV tourniquet on limb Identify a straight vein Clean the skin over the vein Remove the safety covering and insert the cannula, keeping cannula flat and in line with vein When flashback is achieved, advance needle slightly and then slide cannula over needle into the vein Hold this in place and withdraw the needle while putting pressure over base of cannula Remove the IV tourniquet Flush with saline or connect IV line SKILLS 174 Secure with tape or dressing States to check IV site daily to assess for redness or signs of infection Disposes of any sharps appropriately Comments: Skill 7 – Recognizing conditions requiring IV fluid re-adjustment State the special considerations for fluid resuscitation: malnutrition/severe anaemia/fluid overload State how to assess for fluid overload: difficulty in breathing with crackles on chest exam, lower body swelling (usually in the legs), unable to lie flat due to shortness of breath, distended neck veins State ways to adjust fluids in patients in shock with fluid overload: • Small amounts of fluids (250–500 ml boluses in adults) • Slow the rate of fluids • Monitor closely for signs of worsening fluid overload Verbalize how to assess for signs of severe anaemia State ways to adjust fluids in patients with severe anaemia: • Slow the rate of fluids • Monitor closely for signs of fluid overload State need for rapid handover/transfer to a centre capable of blood transfusion Verbalize how to assess muscle wasting in severe malnutrition Demonstrate how to assess for bilateral oedema in the feet State ways to adjust fluids in patients with severe malnutrition: • Give oral fluids if possible • Add dextrose to IV fluids or give dextrose with IV fluids • Slow the rate of fluids • Monitor closely for signs of fluid overload Comments: Skill 8 – IV fluid resuscitation for shock Verbalize caution in administering IV fluid in a malnourished, anaemic or fluid-overloaded patient Insert an IV cannula as described above Attach the IV cannula to the correct fluid for administration Fluid administration for an adult should be normal saline or Ringer’s Lactate States fluid administration for shock in an adult should be 1L given over <30 minutes AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 175 Assess perfusion, if still in shock, give another 1L bolus over <30 minutes State that, if still in shock after 2 L IV fluids, suspect ongoing blood loss and plan for handover to higher-level care Give mechanism for modifying fluid for an adult if severe malnutrition, severe anaemia or fluid overload is present: give fluid in smaller boluses and re-assess frequently for signs of worsening fluid overload Signs of fluid overload are: Fluid in the lungs and difficulty in breathing • Oedema • Patient is unable to lie flat • Distended neck veins For a child in shock (WITHOUT severe malnutrition, anaemia or overload): • Obtain the child’s weight • Give 10–20 ml/kg normal saline or Lactated Ringer’s over 30 minutes • Re-assess after the bolus, if no improvement, repeat bolus • If shock persists, transfer For a child in shock (WITH severe malnutrition, anaemia or overload): • Weigh the child • State that these children need specialized IV fluids – Ringer’s Lactate with 5% glucose – Half-strength Darrow’s solution with 5% glucose – 0.45% (HALF) normal saline with 5% glucose • Give 10–15ml/kg IV fluid over 1 hour • Re-assess the child every 5–10 minutes while receiving fluids • State if no improvement, transfer Verbalize to stop IV fluid in any patient if signs of fluid overload develop Dispose of any sharps appropriately Comments: Competency demonstrated YES NO Remediation required YES NO Signature of Facilitator: SKILLS 176 4. EXTENDED PHYSICAL EXAMINATION SKILL STATIONS EXTENDED PHYSICAL EXAMINATION SKILL STATION: NEUROLOGIC EXAM Glasgow Coma Scale (GCS) The GCS is a 15-point scale for assessing and monitoring people with head injury. The person is assessed for eye opening, verbal and motor response, and given a score for the highest level of function in each area. The totals are combined to determine the overall score. The lower the score, the more severe the head injury may be. Please note that the lowest score a patient can receive is 3. Severe head injury – GCS 8 or less Moderate head injury – GCS 9–12 Mild head injury – GCS 13–15 Calculating The Glasgow Coma Score (GCS) Glasgow Coma Score (GCS) Function Response Score Eyes (4) Open spontaneously 4 Open to command 3 Open to pain 2 None 1 Verbal (5) Normal 5 Confused talk 4 Inappropriate words 3 Inappropriate sounds 2 None 1 Motor (6) Obeys command 6 Localizes pain 5 Flexes limbs normally to pain 4 Flexes limbs abnormally to pain 3 Extends limbs to pain 2 None 1 AVPU Scale The AVPU scale is a simplified assessment that can give you an indication of level of consciousness by assessing response to stimuli. The AVPU scale is particularly useful for children and infants. • A= Alert. People who are fully awake and interactive (even if not fully oriented) are alert. • V= Voice. Those who are not fully alert before stimulus (may have eyes closed or appear sleepy), but do respond to voice without being touched (the response may be words, moaning or movement). • P= Pain. Those who do not respond to voice, but do respond to pain: hard chest (sternal) rub in adults, pinch to the sole of the foot in children, or pinch to bridge of nose in suspected spinal injury. The response may be words, moaning or movement. • U= Unresponsive. Those who do not make any movement or verbal response to painful stimuli are unresponsive. • For any patient who is P or U on the AVPU scale, stop and return to the ABCDE as rapid intervention may be needed to protect the airway. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 177 EXTENDED PHYSICAL EXAM SKILL STATION: SECONDARY SURVEY TRAUMA ASSESSMENT A secondary survey (head-to-toe assessment) of an injured person is conducted ONLY when the ABCDE has been completed and life-threatening complications have been addressed. The purpose of a head-to-toe assessment is to identify all injuries, plan ongoing management and plan the appropriate disposition. If the person deteriorates during the head-to-toe assessment, stop and re-assess the ABCDE immediately. Ensure clothes have been removed but the person is kept warm with gown, sheet or blanket. For this session use the workbook section on secondary survey from the TRAUMA module. Extended physical examination skill station assessment Skills station marking criteria 1st pass 2nd pass 3rd pass Safety: Personal protective equipment used or verbalized use HEAD-TO-TOE TRAUMA ASSESSMENT Skill 1 – HEENT examination Look at scalp, face, eyes, and in mouth, nose, ears Listen for stridor, gurgling or other airway sounds Feel for abnormal facial bone or jaw movement, loose teeth, or crepitus. Comments: Skill 2 – Neck examination Look for neck wounds, trauma, haematoma or distended neck veins Feel for air in tissue or pain/deformity of the cervical spine Check for reduced ability to move neck or pain Comments: Skill 3 – Chest examination Look for bruising, uneven chest movement, burns Listen for breath sounds, muffled heart sounds Feel for crepitus Comments: Skill 4 – Abdominal examination Look for distension, wounds, bruising, burns Feel for rebound tenderness, guarding, location of pain Comments: SKILLS 178 Skill 5 – Pelvis and genitourinary examination Look for bruising, lacerations, blood, priapism, urine colour Feel for pelvis instability or tenderness Comments: Skill 6 – Extremity examination Look for swelling, bruising, deformity or open fractures, wounds, pale extremity Feel for pulses, cold extremity, tenderness, firm/painful muscle compartments Comments: Skill 7 – spine/back examination Log roll patient with assistance Look for bruising or deformity Feel for tenderness, deformity in spine and scapulae Comments: Skill 8 – Skin examination Look for bruising, abrasions, lacerations, burns Comments: Skill 9 – Neurologic examination Check level of consciousness (AVPU or GCS) Check movement and strength in each limb Check for priapism Check sensation on face, chest, limbs Comments: Competency demonstrated YES NO Remediation required YES NO Facilitator’s signature: AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 179 5. IMMOBILIZATION SKILL STATIONS Approach to spinal immobilization There are two types of spinal immobilization: cervical spine and thoracic/lumbar spine. Together, these are called full spine immobilization. Immobilization stabilizes the bones to avoid further injury to the spine. Provide spinal immobilization to any person with a history of polytrauma who is unconscious; or who is conscious and has neck pain, spine tenderness, numbness or weakness. Remember, immobilized patients cannot move normally and are at a higher risk of airway blockage (by secretions or vomit) and pressure sore development. Monitor closely. IMMOBILIZATION SKILL STATION: CERVICAL SPINE IMMOBILIZATION To immobilize the cervical spine: • Keep the patient flat on his or her back and face up on a level surface such as a bed. • Tell the patient what you are doing. • Hold the patient’s head in line with the spine with two hands on either side of the head. • Prevent the patient’s neck from moving with locally available materials (towel rolls, newspaper, sandbags, or bags of IV fluids) or cervical collar if available. These can be secured to the head with tape (plaster) but should never be secured to the bed. (If the patient vomits, you will not be able to turn him or her and if the patient falls, the tape (plaster) could cause a cervical spine injury.) • If the patient vomits, use the log-roll technique (see below) to turn the whole patient onto his or her side, keeping the head in line with the body. • Keep someone with the patient at all times to watch the airway. • Remember, a patient who has severe pain/injury elsewhere may not be able to feel neck pain, even if there is a fracture. A concerning mechanism should raise suspicion. SKILLS 180 IMMOBILIZATION SKILL STATION: LOG ROLL To move any immobilized patient or anyone with a suspected spine injury (e.g. if the patient has to vomit or needs to be transferred), use the log-roll technique (see figure): • Ask for assistance. Ideally, have one person at the head to hold the neck, one or two people to hold the body and one for the legs. • The provider at the head must keep the head, neck and torso aligned with the rest of the spine. The provider should place their forearms tightly alongside the head with hands gripping the shoulders to keep the head and neck in line with the rest of the spine. Keep this alignment when turning the patient. • The person controlling the head and neck leads the team and will say, “1–2-3 roll” to guide timing of the roll for all assistants. • Working together, roll the patient onto his or her side, keeping the spine in line. • During the roll, the person providing head and neck control must ensure the cervical spine remains aligned with the rest of the spine. The people rolling the body should also ensure that the rest of the spine stays in as straight a line as possible. • When the patient is turned onto one side, a provider can examine the back, place or remove a backboard and/or manage back wounds as needed. • To lie the patient flat again, the person controlling the head and neck uses the “1–2–3 roll” command to ensure coordinated movement. • Always remove a backboard as soon as possible using the log-roll technique. Time on a backboard increases the risk of pressure sores. Check pressure areas frequently using the log roll. Preparing for log roll page 24 Preparing for log roll AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 181 IMMOBILIZATION SKILL STATION: FULL SPINAL IMMOBILIZATION To immobilize the thoracic and lumbar spine (see previous section for cervical spine immobilization): • Immobilize the cervical spine as in previous section. • Keep the person on a flat surface with instructions to lie flat and not to move. • For transport, log roll the patient onto a flat surface (such as a backboard) to prevent movement of the spine. Do not attach the backboard to the bed, as you will be unable to log roll (see above) if needed. • Before immobilizing, be sure there is no glass or debris on or under the patient’s back. Use the log roll to check. Immobilized patients must be checked regularly to avoid pressure point wounds. • If the person needs to vomit, use the log-roll technique to roll the person to the side so that no vomit enters the airway. • Spine boards should ONLY be used to move patients. Leaving patients on spine boards for long periods of time can cause pressure sores. Remove patients from boards as soon as they arrive at the facility and can be laid flat. Spinal immobilization for moving a patient page 25 Spinal immobilization for moving a patient IMMOBILIZATION SKILL STATION: POSITIONING OF THE PREGNANT PATIENT • If a patient is over 20 weeks pregnant and needs spinal immobilization, immobilize the spine as above. Then place padding under the side of the board near the back and hips to tilt the patient onto her left side. This helps to prevent compression of the large internal blood vessels by the pregnant uterus which could decrease blood returning to the heart. SKILLS 182 IMMOBILIZATION SKILL STATION: RECOVERY POSITION • If the patient is unconscious or semiconscious and if there is NO TRAUMA, place the patient on his or her left side. Stabilize the patient by bending the top leg forward. The left arm should be straight with the patient’s head resting on the arm to elevate the head and position the mouth downward. This position will allow for vomit and other secretions to drain from the mouth with less risk of airway obstruction. This is called the recovery position (see figure). Recovery position page 26 Recovery position AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 183 IMMOBILIZATION SKILL STATION: FRACTURE IMMOBILIZATION FRACTURE IMMOBILIZATION Splints are used for immobilizing suspected fractured limbs, preventing pain caused by movement of broken bones and minimizing further bleeding and damage. Always assess and record perfusion of the limb beyond the fracture by assessing pulses and capillary refill time. Always assess pulses, capillary refill and sensation before AND after dressing or splinting any wound. • If no perfusion (limb cold, pale, no pulse, slow or no capillary refill), rapid re-alignment (reduction) of the limb is required to restore circulation. • If there is still no perfusion after re-alignment of the limb, splint and plan for rapid handover/ transfer to a specialist unit. • If you cannot re-align the limb, rapidly handover/transfer to an advanced provider. Goal of fracture management: • Restore circulation • Treat and reduce pain • Prevent further injury and bleeding • Re-align bony fragments so that healing and union can take place and normal function is restored Splinting materials include: • Padding to protect the skin and allow swelling • Pre-formed splint for base or modified local resources • Bandages to secure the splint • Adhesive tape (plaster) Before applying a splint, tell the person what you are doing and give pain relief. • Remove clothing to clearly see the injury. • Remove all jewelry. • Check pulses, capillary refill, sensation and movement of the limb. Document this before and after application of the splint. • Size the splint to immobilize the joint above and below the fracture site. • If the limb is visibly deformed and pulses beyond the fracture are weak or absent, first straighten (reduce) the fracture prior to applying the splint. Do not force realignment of a deformed limb if the limb has a good pulse. • Place the joint in the desired position and if the injury involves fingers or toes, pad between toes and fingers. • If stocking gauze is available, place it over the limb without wrinkles to avoid skin damage. • Pad the side of the splint that will be in contact with the skin, and pad the limb, especially bony protrusions (like the elbow). • Wrap the limb and splint with a bandage to hold the splint. Ask the patient how it feels to ensure it is not too tight. The splint should be secure, but remember that the limb will swell, so it is important that the splint and bandaging are not too tight. • Check pulses, sensation and movement of the limb following the application of the splint and every hour afterward. SKILLS 184 FRACTURE IMMOBILIZATION: OPEN Consider an open fracture if there is a wound near a fracture site. Open fracture sites can often be contaminated and will require cleaning and potentially surgical debridement before the fracture can be fixed. If an open fracture is suspected, plan for handover/transfer to a surgical or orthopaedic unit after splinting. • Give pain relief prior to splinting. • Control haemorrhage with direct pressure. In limb amputation, if bleeding is uncontrolled apply tourniquet (see above), commence fluid resuscitation and plan for rapid handover/transfer. • Straighten (reduce) the limb if there are signs of poor perfusion or absent pulses in the limb. • Remove any dirt, grass, obvious glass or other debris from the wound and irrigate the wound with 2 litres of normal saline. • Cover the wound with saline-soaked gauze. • Splint as above, but leave a window so you can continue to monitor the wound. • In amputation, cover wound with sterile, saline-soaked gauze or towel. • Give tetanus vaccination. • Begin IV antibiotics. IMMOBILIZATION SKILL STATION: APPLYING A PELVIC BINDER Pelvic fractures can cause life-threatening haemorrhage by damaging blood vessels adjacent to the fractures. If a person has been injured and has pain in and around the pelvis, apply a binder (see figures). As the pelvis is shaped in a ring, the binder will bring together the displaced bones and help limit internal bleeding. Signs of pelvic fractures include pain or abnormal movement of the pelvis on exam; bruising around the hips, at the top of legs, or to the genitals; and signs and symptoms of shock. • Place bed sheet or similar under the pelvis. If the bed sheet is wide, fold it over so that it spans from the lower back to the end of the buttocks. • You may need to log roll the patient in order to get the binder in position. • The sheet should be centered over the greater trochanters (hip bones, as demonstrated by the instructor) and firmly cross-over at the front. • Pull firmly and tie, but do not cause the person undue pain. It should feel firm but not overly painful. • Document what time the pelvic binder was applied. • Check the binder each hour. Confirm that the binder is still applying pressure around the pelvis. Ensure that that skin is intact where the binder has been applied and around the genitals. Normal pelvis Open pelvic fracture page 27 Normal pelvis Open pelvic fracture AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 185 Pelvic immobilization page 28 Pelvic immobilization Immobilization skill station assessments Skills station marking criteria 1st pass 2nd pass 3rd pass Safety: Personal protective equipment used or verbalized use Skill 1 – Cervical spinal immobilization Keep the patient lying flat. Tell the patient what you are doing. Hold the patient’s head in line with the spine using your two hands on either side of the head. A partner should use rolled sheets, shoes, or IV fluid bags on either side of the head. May be secured with tape (plaster) but do not secure to the bed. State that if the patient vomits, log-roll technique will be used to protect the airway, keeping the head aligned with the rest of the body. Comments: Skill 2 – Log roll State indications for a log roll. Ask for assistance. Place one person at the head to hold the neck, one or two people to hold the body and one for the legs. The person with head control must hold the cervical spine firmly aligned with the rest of the spine before and during the roll. When the provider at the head and neck instructs, roll the patient onto the side. Use “1–2–3 roll” to guide the roll. The person controlling the head and neck uses the “1–2–3 roll” to return the patient to his or her back. SKILLS 186 State that the patient should be removed from the backboard as soon as possible to prevent pressure sores. Comments: Skill 3 – Full spine immobilization State indication for full spine immobilization. Ask for assistance to help with the movement. Perform log roll on to backboard for transfer. Ensure no glass or debris on or under the patient’s back. Secure patient to backboard device for transfer (Do NOT attach backboard or patient to bed). State to log roll if patient needs to vomit. Skill 4 – Positioning of the pregnant patient Verbalize the indications for positioning (greater than 20 weeks pregnant and needs spinal immobilization). Left lateral position with cervical spine immobilization and a pillow or wedge under the backboard or bed. Comments: Skill 5 – Recovery position Verbalize the indications. Controlled manoeuver into left lateral position ensuring open airway. Appropriately position the patient (top leg bent forward, left arm straight with the patient’s head resting on the arm to elevate the head and position the mouth downward). Comments: Skill 6 – Fracture immobilization Remove clothing to clearly see the injury, remove all jewelry. Check pulses, sensation and movement of the limb and document findings. Size the splint against the limb. Immobilize the joint above and below the injury. Identify special considerations: • Straighten the limb if signs of poor perfusion or absent pulses in the limb. • Control haemorrhage as needed. • Remove debris and irrigate an open fracture wound with 2 L of normal saline. • Cover open fractures with sterile saline gauze. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 187 Place the joint in the desired position. Pad in between toes and fingers if injury involves digits. If stockinette is available, place it over the limb without wrinkles or pad the side of the splint that will be in contact with the skin. Pad the patient’s limb, especially bony prominences. Wrap the limb and splint with a bandage to hold the splint. Check pulses, sensation and movement of the limb following the application of the splint. State patients with an open fracture will require tetanus vaccination, if not up to date, and antibiotics. Comments: Skill 7 – Applying a pelvic binder Identify pelvic pain after trauma. Place bed sheet under the pelvis. If bed sheet is wide, fold it over so that it is the size of the pelvis (lower back to end of buttocks). Push the binder under the small of the back and pull it into position or log roll patient onto binder. Centre over the great trochanters (hip bones) and firmly cross over at the front. Pull firmly and tie, but do not cause the person undue pain. It should feel firm but not overly painful. Document the time the pelvic binder was applied. Comments: Competency demonstrated YES NO Remediation required YES NO Signature of facilitator: SKILLS 188 6. WOUND MANAGEMENT SKILL STATIONS WOUND MANAGEMENT: GENERAL WOUND MANAGEMENT • Haemorrhage control: stop bleeding as above. • Prevent infection: – Clean wound of blood clots, dirt, dead or dying tissue, foreign bodies. – Clean skin around the wound thoroughly with soap and water or antiseptic. – Thoroughly wash out wound by flushing with at least 1 litre of clean water. The water should be under pressure to thoroughly clean the wound. To create a high pressure stream, use a syringe (with 14 g needle or IV catheter attached) or poke a small hole in a clean bottle and squeeze the bottle. Be sure to use the entire litre. – If not vaccinated or not up to date, give tetanus vaccination. • Dressing wounds: – Dress wound with sterile gauze if available. – Use a pressure dressing if the wound is still bleeding. – Check perfusion (capillary refill and/or distal pulses) and sensation beyond the wound before AND after dressing wounds. • Pain management: – Give local anaesthetic before cleaning the wound if staff and equipment are available. – Splint large lacerations and fractures. WOUND MANAGEMENT: BURN MANAGEMENT It is important to cover burns early in order to keep the area moist and reduce the risk of infection. Burns can be very painful so ensure you give pain relief. • Use sterile technique and normal saline to clean the burn. • Carefully remove any loose, dead skin and broken, tense or infected blisters. • Apply a non-adherent dressing to the burn to provide a moist healing environment. Clean clear plastic wrap can be used over the burn as an interim measure and if you are transferring the person to a surgical unit shortly. • Ensure the entire burn is covered with the dressing. • If the person has presented with an old burn that is now infected, apply a topical antibiotic (such as bacitracin or silver sulfadiazine). This person may also require IV or intramuscular antibiotics. • If there is delay in handover or transfer, ensure the dressings are changed daily. Always give pain control with dressing changes. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 189 ADULT BURN MANAGEMENT: DETERMINE TOTAL BODY SURFACE AREA (TBSA) This is used to calculate the fluids needed using the Parkland Formula. Use the Rule of Nines body chart for adults and modified chart for children and infants (see figure). The body is divided into portions that each make up 9% of the total body surface. Children have different percentages due to the different body proportions, such as a larger head and smaller limbs (see figures). • Assess the person using the diagram below. • Note the areas of burn and shade them in on the diagram. • Next to where you are shading, write the burn depth (see burn depth estimate below). • Once you have marked the diagram (front and back) with all the burns you have assessed on the person, add the percentages. • This will give you the total burn surface area (TBSA). Burn surface area in adults 4.5%4.5% 18% 18% 9% 9%9% 9% 4.5%4.5% 4.5% 4.5% 1% page 29 Burn rface area in adults SKILLS 190 Burn surface area in children 13% A D C B C B F E F E 2% 2% 2% 2% 13%2% 2% 2% 2% 1% 2% 2% 2% 2% 1% 1% 1% 1% page 30 Area Head (A/D) Thigh (B/E) Leg (C/F) 10% 3% 2% 7% 4% 3% 6% 5% 3% 9% 3% 3% By age in years 0 1 5 10 Burn surface area in children PAEDIATRIC BURN MANAGEMENT: DETERMINE TOTAL BODY SURFACE AREA (TBSA) Area By age in years 0 1 5 10 Head (A or D) 10% 9% 7% 6% Thigh (B or E) 3% 3% 4% 5% Leg (C or F) 2% 3% 3% 3% BURN MANAGEMENT: ESTIMATE DEPTH OF BURN The best way to estimate burn depth is by gently pressing two fingers onto the burn to assess capillary refill. • Put gloves on. • With care, press down on the centre of the burn with two fingertips for 3–4 seconds, and then let go. The faster the capillary refill the more superficial the burn is. • Now assess the outer edge of the burn (burn depth can vary for different areas of the burn). • Use the chart below to guide your assessment findings. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 191 Burn type Skin findings Superficial (formerly first degree) • Red or pink • Painful, skin intact, no blisters • When pressed, skin is pink with quick capillary refill Partial thickness (formerly second degree) • Red or mottled red • Intact or broken blisters, wet • Painful • May temporarily turn white when pressed then red colour returns Full thickness (formerly third degree) • White or black • Leathery and dry • No sensation • When pressed, no change in colour BURN MANAGEMENT: FLUID RESUSCITATION IN BURN INJURY As discussed in the TRAUMA module, an adult or child with a burn injury may require fluid resuscitation. Start fluid resuscitation in the following cases: • Full or partial thickness burns greater than or equal to 15% total burn surface area in adults. • Full or partial thickness burns greater than or equal to 10% total burn surface area in children. BURN MANAGEMENT: PARKLAND FORMULA CALCULATION FOR THE FIRST 24 HOURS 4 ml IV fluid X weight in kilograms X % total burn surface area* *% total burn surface area = % partial thickness burn area + % full thickness burn area (% superficial burn area is NOT used in the calculation) The Parkland Formula is a fluid resuscitation management strategy for the initial 24 hours following a burn. Patients presenting beyond 24 hours after the initial burn will also need fluid resuscitation, but the Parkland Formula is not used beyond 24 hours. • The first half of the fluid should be given within the first 8 hours after the burn (NOT after arrival to care). • The second half is to be given over the subsequent 16 hours. • For adults, give normal saline or Ringer’s Lactate. • For children, use a dextrose-containing fluid (Ringer’s Lactate with 5% dextrose or normal saline with 5% dextrose for initial resuscitation). If no dextrose-containing fluids are available, give an additional dose of dextrose (either IV or orally) with IV fluids (see MEDICATIONS). For ongoing care of children, the Parkland emergency resuscitation fluids calculated above MUST BE ADDED to any required maintenance fluids based on hospital care protocols (see WHO Pocket book of hospital care for children, 2013). Your facilitator will review examples using the Parkland Formula. REMEMBER: Patients with serious burns to >15% of their body, burns involving the hand, face, groin area, joints, or burns that go completely around the body or a body part need to be transferred/ handed over for specialized care. SKILLS 192 WOUND MANAGEMENT: SNAKE BITE BANDAGING AND IMMOBILIZATION Note: When possible, take a picture of the snake and send with the patient. Immobilizing a limb after a snake bite is important to reduce movement and absorption of venom. • Always assess pulses, capillary refill and sensation before and after dressing or splinting any wound. • You may choose to use a broad pressure bandage and wrap upwards from the lower portion of the bite. The bandage should be firm, but should not cut off pulses in the limb. Extend the bandage as high up the limb as possible. – This is recommended if the snakes in your area produce a toxin that damages the nerves, causes paralysis, causes the person to become very ill or if there will be prolonged transport time. – This is NOT recommended if the snakes in your area produce toxins that primarily cause tissue damage near the wound and do not cause body-wide symptoms. • Bind a splint to the limb to immobilize as much of the limb as possible. • Note the time the bandage was placed. • Keep the person still and lying down. • DO NOT put a tourniquet around the snake bite or limb. • DO NOT cut the bite out as this will lead to unnecessary bleeding. • DO NOT suck on the bite to remove the venom. Wound management skill station assessments Skills station marking criteria 1st pass 2nd pass 3rd pass Safety: Personal protective equipment used or verbalized use SKILL 1– General wound management Haemorrhage control: stops bleeding as per earlier taught skill. Preventing infection Cleans wound of blood clots, dirt and foreign bodies. Cleans skin around the wound thoroughly with soap and water or antiseptic. Thoroughly washes out wound by flushing with water (state 1 litre of clean water or more). Gives tetanus vaccination as needed. Dressing wounds Assesses pulses, capillary refill and sensation before dressing or splinting any wound. Dresses wound with sterile gauze if available. Applies pressure dressing if the wound is still bleeding. Checks perfusion beyond the wound (capillary refill and/or distal pulses) before and after dressing wounds. Pain management AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 193 Gives local anaesthetic before cleaning the wound if staff and equipment are available. Splints large lacerations and fractures. Assesses pulses, capillary refill and sensation after dressing or splinting any wound. Comments: BURN MANAGEMENT Skill 2 – Burn wound management Uses a sterile technique and normal saline to clean the burn. Removes any loose, dead skin and broken, tense or infected blisters. Applies a non-adherent dressing to the burn to provide a moist healing environment. Ensures the entire burn is covered with the dressing. Considers antibiotics. States transfer or handover plan. Comments: Skill 3 – Fluid resuscitation in burn injury Correctly states indications: • Partial or full thickness burns greater than or equal to 15% total burn surface area in adult. • Partial or full thickness burns greater than or equal to 10% total burn surface area in children. Estimates depth of burn. Determines total body surface area (TBSA). Calculates Parkland Formula. Explains delivery of fluids. (First half in first 8 hrs; second half in next 16 hrs) Chooses correct fluid for initial bolus. (Children weighing less than 20 kg: Ringer’s Lactate with 5% dextrose, normal saline with 5% dextrose) Comments: Skill 4: Snake bite bandaging and immobilization Uses a broad pressure bandage and wrap upwards from the lower portion of the bite. Extends the bandage as high up the limb as possible. SKILLS 194 Immobilize as much of the limb as possible with a splint. Notes the time the bandage went on. Keeps the person still. States DO NOT put a tourniquet around the snake bite or limb. States DO NOT cut or suck on the bite wound. Comments: Competency demonstrated YES NO Remediation required YES NO Facilitator’s signature: 7. Medication administration skill discussion The table below summarizes the medications discussed in this course, which represent only a very basic set of treatments for emergency conditions. They have been included based on their wide availability, their appropriateness for use by all of the frontline providers targeted by this course, their feasibility of use in pre-hospital or facility settings, and for their potential importance as early treatments for emergency conditions. Be sure to check locally available drug concentrations, as these can vary. The most common concentrations are used in this table for dosing reference. Almost every condition discussed will require additional treatments beyond these, and many important emergency treatments that may be used by advanced providers are not included here. Table: Medications used in the Basic Emergency Care course Drug indication Dosage Adverse effects Adrenaline (Epinephrine) Anaphylaxis/severe allergic reaction and severe wheezing [see ABCDE, DIB] Solution: 1 mg in 1 ml ampoule (1:1000) Note: • The doses below are for intramuscular not IV administration. • The preferred site for injection is the outer mid-thigh. Adults: Intramuscular(IM): 50 kg or above: 0.5 mg IM (0.5 ml of 1:1000) 40 kg: 0.4 mg IM (0.4 ml of 1:1000) 30 kg: 0.3 mg IM (0.3 ml of 1:1000) • May repeat at 5-minute intervals Paediatrics: Anaphylaxis: 0.15 mg IM (0.15 ml of 1:1000), repeat every 5–15 minutes as needed Severe asthma: 0.01 mg/kg IM up to 0.3 mg, repeat every 15 minutes as needed • Anxiety/fear • Palpitations • Tachycardia (elevated heart rate) • Dizziness • Sweating • Nausea • Vomiting • Hyperglycaemia (elevated blood glucose) • Chest pain • High blood pressure • Tissue necrosis at injection site AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 195 Drug indication Dosage Adverse effects Antibiotics Specific drugs in this category will be determined by local treatment protocols and availability. These should include a broad-spectrum regimen for life-threatening infections that can be used empirically (before the infectious source is definitively identified) in very ill patients. • Allergic reactions • Gastrointestinal upset • Other specific effects vary by antibiotic Acetylsalicylic acid (Aspirin) Suspected heart attack Tablet: 100 mg, 300 mg Oral: 300 mg (preferably chewed or dispersed in water) given immediately as a single dose. Do NOT give aspirin until evaluated by an advanced provider if there is: 1. any active bleeding, or 2. chest pain that is sudden, maximum at onset, sharp and tearing, and radiating to the back (can indicate a tear in the aorta). • Gastrointestinal irritation with blood loss • Tinnitus • Anaphylaxis Benzodiazepines – Diazepam Seizures/convulsions [see AMS] Tablet: 2 mg, 5 mg Solution: 5 mg/1 ml ampoule Adults: First dose: 10 mg slow IV push OR 20 mg rectally Second dose after 10 minutes: 5 mg slow IV push or 10 mg rectally Maximum IV dose: 30 mg Children: First dose: 0.2 mg/kg slow IV push or 0.5 mg/kg rectally. Can repeat half of first dose after 10 minutes if seizures/convulsions continue. Maximum IV dose: 20 mg Do not give second dose if respiratory rate is less than 10 breaths per minute. Do not give diazepam intramuscularly (unpredictable absorption). How to give rectal diazepam: • Draw up the dose from an ampoule of diazepam into a small syringe (tuberculin if available). Base the dose on the weight of the child, when possible. • Remove the needle. • Insert the syringe 4–5 cm into the rectum, and inject the diazepam solution. • Hold the buttocks together for a few minutes. • Sedation • Respiratory depression • Low blood pressure • Bradycardia (low heart rate) • Nausea and vomiting • Abdominal cramps SKILLS 196 Drug indication Dosage Adverse effects Glucose (dextrose) Hypoglycaemia (low blood sugar) [see ABCDE, ALTERED MENTAL STATUS] Solution: 50% dextrose (D50), 25% dextrose (D25), 10% dextrose (D10) NOTE: Dextrose should NEVER be given intramuscularly as it may cause serious tissue damage. Adults and children greater than 40 kg: 25–50 ml IV of D50, or 125–250 ml IV of D10 Children up to 40 kg: 5 ml/kg IV 10% dextrose (D10) • Hyperglycaemia (high blood glucose) • Dizziness • Skin necrosis if injected outside the vein D10 is preferred in children under 40 kg. If D10 is not available, you can use the Rule of 50 to remember the equivalent amount of dextrose in another solution. All of the following contain the same amount of dextrose: 5 ml of D10 2 ml of D25 1 ml of D50 If no IV access: Place 2–5 ml of 50% dextrose in buccal space (inside the cheek) OR Give sugar solution (1 level teaspoon of sugar moistened with water every 10–20 minutes) in buccal space AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 197 Drug indication Dosage Adverse effects Magnesium sulphate Eclampsia or pregnant with seizure/convulsion [see ALTERED MENTAL STATUS] Solution forms: 1 g in 2 ml ampoule (50%) 5 g in 10 ml ampoule (50%) To give IV, make a 20% solution: *add 3 ml of sterile saline to the 2 ml ampule OR *add 15 ml of sterile saline to the 10 ml ampoule. Loading dose (IV + IM): * 4 g IV (dilute to a 20% solution and give 20 ml slowly over 20 minutes) AND *10 g IM (intramuscular): 5 g (10 ml of 50% solution) with 1 ml of 2% lidocaine in upper outer quadrant of each buttock. Magnesium can cause low blood pressure; monitor carefully. IF unable to give IV, give 10 g IM injection only (as above, 5 g in each buttock). If seizures/convulsions recur: after 15 minutes give an additional 2 g (10 ml of 20%) IV over 20 minutes. If transport delayed, continue treatment: Give 5 g of 50% solution IM with 1 ml of 2% lidocaine every four hours in alternate buttocks. • Low blood pressure • Respiratory depression • Drowsiness • Confusion • Loss of reflexes • Muscle weakness • Nausea • Vomiting • Flushed skin • Thirst STOP if: • Respiratory depression (respiratory rate <16) develops. Toxicity: • Low blood pressure • Respiratory depression • Loss of knee jerk • Urine output <100 ml/4 hours Naloxone Opioid overdose [see ABCDE, ALTERED MENTAL STATUS, DIFFICULTY IN BREATHING] Solution: 400 mcg/ml (hydrochloride) in 1 ml ampoule IV: 100 mcg single dose OR IM: 400 mcg in single dose May repeat every 5 minutes as needed. May require continuous infusion at 0.4 mg/ hour for several hours for long-acting opioids. • Hypertension (high blood pressure) • Cardiac arrhythmias • Hyperventilation • Difficulty in breathing • Agitation *** Naloxone effects only last 1–3 hours. Many opioid medications are longer- acting and may need more doses of naloxone or a naloxone infusion. Any patient treated with naloxone must be monitored closely*** SKILLS 198 Drug indication Dosage Adverse effects Oxytocin Treatment of postpartum haemorrhage Solution: 10 IU in 1 ml ampule Initial dose: Give 10 IU IM AND start IV fluids with 20 IU/L at 60 drops/minute. Once the placenta is delivered, continue IV fluids with 20 IU/L at 30 drops/minute if still bleeding. If placenta has to be manually removed or uterus does not contract: Repeat 10 IU IM. Continue IV fluids with 20 IU/L at 20 drops/ minute for 1 hour after bleeding stops. Max Dose: 3 L of IV fluids containing oxytocin. • Nausea/vomiting • Headache • Rash • Anaphylaxis • Uterine spasm (at low doses) • Uterine hyperstimulation (at high doses) Paracetamol (acetaminophen) Mild to moderate pain, fever and headache Tablet: 250 mg, 500 mg Rectal suppositories: 250 mg, 500 mg Adults: 500mg – 1 g every 6 hours Max 4 g daily or max 2 g daily if liver impairment, cirrhosis Children: 10–15 mg/kg up to six times a day • Rash • Liver damage following overdoses Salbutamol (albuterol) Severe wheezing [see ABCDE, DIFFICULTY IN BREATHING] Where available, can use nebulizer with appropriate dose. Inhaler: 100 mcg per puff Inhaler with spacer Adult: Prime with five puffs and give two puffs via spacer every two minutes until improved. Child: Prime with five puffs and give two puffs into spacer. Keep spacer in the child’s mouth for three to five breaths. Repeat until six puffs of the drug have been given to a child < 5 years or 12 puffs for > 5 years of age. Repeat regularly until condition improves. In severe cases, 6 or 12 puffs can be given several times in an hour. • Palpitations • Fine tremor • Headache • Tachycardia (high heart rate) Remember: child must be able to seal mouth around spacer opening. Babies will likely require spacer mask or nebulizer. Nebulizer: (ADULT) 5mg in 5 ml sterile saline. (CHILD) 2.5mg in 3 ml sterile saline. For severe wheezing, above doses can be given several times in an hour. Tetanus vaccination Solution: 5 units per 0.5 ml IM 0.5 ml Give to all injured children whose vaccinations are not up to date and in all adults who have not had this vaccination in the past 5 years. If immunization status is unknown, give vaccination. • Pain to injection site • Allergic reaction • Fever • Nausea AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 199 8. Transfer and handover skills discussion This course is intended for providers working in the field, on ambulances and in health-care facilities. Transferring patients from the scene to first facility, or between facilities, require special attention to destination planning, ongoing management and handover. DESTINATION PLANNING Many patients treated on the scene will require transport to a health-care facility for further management. Additionally, patients already at a facility may require transfer to a different facility for more advanced care. For example, a pregnant woman with seizures will need handover for advanced care and emergency delivery; a patient with severe burns will require transfer for advanced airway management and surgical care; a patient in shock from blood loss will require handover to a centre capable of blood transfusion. When planning any transport, make sure that: the level of services at the destination facility matches the needs of the patient (e.g. there is an operating theatre if surgery is needed); that the expected resources are currently available (e.g., the operating theatre is running, and there is blood for transfusion); and that the destination can be reached in the necessary time frame given the patient’s condition. Do not delay transport for tests or interventions that are not critical to patient safety if they can be performed at the receiving facility. Follow local transfer and destination protocols where they exist. Where there are no clear protocols, balance transport times with facility capabilities – the goal is to reach needed care as soon as possible. It is usually better to have a longer initial transport time than to arrange a second transfer because appropriate care was not available at the first destination. Once the appropriate facility has been determined, communication with a provider at the receiving facility is essential (see ‘Handover’ below). This will allow the receiving centre to prepare for the patient’s arrival and arrange resources (e.g. blood, operating theatre preparation). Follow specific local communication protocols where they exist. Wherever possible, formal protocols for both pre-hospital transport and transfer between facilities should be in place. These should include explicit criteria for when a patient should be transferred. TRANSPORT Transfer includes two aspects: transporting the patient and caring for the patient at all times during transport. One person cannot do both jobs. During transport, at least one provider should always be in the same part of the vehicle as the patient to allow for ongoing monitoring, assessment and management. The ABCDE approach should be used to assess and re-assess ALL patients during transportation; vital signs (including AVPU or GCS) should be checked every 15 minutes, and patients should be closely monitored for response to treatments and for signs of worsening. Remember to plan overall transportation time and route, and check road conditions and weather. This is essential in order to anticipate the patient’s needs during transport (e.g. IV fluid and medication needs). Ensure that the patient and family are aware of the transport plan. Allow a family member to accompany children whenever possible. SKILLS 200 HANDOVER Formal handover should be given any time care is transferred to a new provider, including: between providers within a facility, to or from transport providers, or remotely from a sending facility to a receiving facility provider. In addition to a verbal report at the time a patient is handed over to a new provider, written documentation of the clinical condition and treatment should accompany the patient at all times. You will practise handover summaries throughout the course in the case scenarios. The Situation, Background, Assessment, Recommendations (SBAR) format is a structured way of communicating key information and can be used for all of the handovers mentioned above. SBAR components and examples are: SITUATION Basic patient information (e.g. age, sex). Chief complaint (the patient’s initial description of the problem, such as difficulty in breathing for 3 days, or arm pain after a fall, etc.). BACKGROUND The 2–4 most important and relevant aspects of the patient’s case and/or condition (these may be elements of the history, physical exam, or testing results, depending on the case). Include any important ABCDE findings/interventions. ASSESSMENT What you think is wrong with the patient. The reason for the handover/transfer. RECOMMENDATIONS Specific things the new provider should prepare for: – next steps in the treatment plan; – potential worsening of the patient’s condition (e.g. need for close airway observation if inhalation burn is suspected); – cautions regarding prior therapies or interventions (e.g. time of last adrenaline dose to anticipate return symptoms, need to monitor mental status if sedating medications have been given, need to monitor 3-way dressing for clotting, etc.). Examples: Case 1: A 22 year-old man was riding a motorcycle when he crashed into another vehicle at high speed. He was thrown from his motorcycle and was not wearing a helmet. His airway is open; he has normal breath sounds on both sides of his chest; his pulses are strong and around 90 beats per minute; he is only responsive to pain and has a femur fracture with bone visible in an open wound; there are abrasions on his forehead. You have immobilized his spine, started an IV and splinted the fracture. You and your colleague have transported him from the scene of injury and are handing him over to a hospital provider. AM S SHOCK BREATHING TRAUM A INTRO ABCDE SKILLS GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 201 Handover summary: This is a 22-year-old man who was in a motorcycle crash, was not wearing a helmet and was thrown from his motorcycle; he is only responsive to pain and has an open femur fracture, but is currently protecting his airway and has no evidence of shock. We are concerned for his altered mental status, and open femur fracture, but are unable to tell if he has a spinal injury. He needs transfer for surgical management and further neurological assessment. Spinal immobilization should be maintained and he should be monitored for worsening bleeding and mental status changes. Case 2: A 14-year-old girl had a seizure/convulsion at school. She was brought to you by her teachers because she did not stop seizing. You administered a benzodiazepine, which caused the seizures to stop. After, you were able to perform the ABCDE survey and then a complete head-to-toe exam. She does not have a fever; she has a normal heart rate, blood pressure, and respiratory rate. She responds to voice. Her tongue is bitten and she urinated on herself; she has no other injuries or rashes. Handover summary: This is a 14-year-old girl who had a prolonged convulsion and was convulsing on arrival; her seizures were stopped with one 10 mg dose of diazepam and now she remains sleepy, has normal vital signs and no fever. She is being transferred for further evaluation of her seizure. Monitor the airway as she has received sedating medications (diazepam). Case 3: A 75-year-old man had chest pain while walking home from the market. He was brought to you by taxi. He says that the chest pain started 30 minutes ago and felt like a lot of pressure in the centre of his chest. He has no allergies. He takes a blood pressure medication, but cannot recall the medication’s name. He had a heart attack 2 years ago that felt very much like the pain he was having today. His last meal was 6 hours ago. The pain started while he was walking home carrying several heavy bags, though he now has no pain. His vital signs, ABCDE survey, and head-to-toe examination are normal. You have given aspirin and started an IV line and will now handover to an inpatient provider. Handover summary: This is a 75-year-old man with a history of a heart attack who has had chest pain similar to his prior heart attack. The pain started while he was walking and lasted for more than 30 minutes, but is now gone. He has received aspirin and has an IV line. I am concerned he might have problems with his heart. He should be monitored for change in ABCDE or return of the chest pain. 202 Notes ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE GLOSSARY REFS & QUICK CARDS 203 PARTICIPANT WORKBOOK GLOSSARY ABCDE The initial steps of any patient assessment, which includes assessing and treating Airway, Breathing, Circulation, Disability and Exposure. Accessory muscle use Use of muscles other than the diaphragm to assist in breathing (commonly the neck, chest wall, and abdominal muscles). May appear as indrawing/retractions between the ribs, or in the neck muscles. Altered mental status (AMS) Term used for a range of presentations from changes in behaviour or memory, to disorientation, confusion and coma. AMS See altered mental status. Anaemia Decreased concentration of red blood cells, leading to a decreased ability to carry oxygen. Anaphylaxis A severe allergic reaction that can cause shock. Asthma A condition causing mucus production and intermittent spasm in the bronchial airways, resulting in narrowing that causes wheezing. AVPU A system to assess level of consciousness: Alert, Verbal, Pain, and Unresponsive. Bag-valve-mask (BVM) device A manual handheld device consisting of an air-filled bag connected to a mask. The bag is compressed by hand to deliver a breath as the mask is held to the patient’s face. Bolus A defined volume of fluid or other substance given rapidly, usually intravenously. Bradycardia Heart rate lower than normal range. BVM See “bag-valve-mask device”. GLOSSARY 204 Capillary refill A marker of perfusion, checked by pushing on the fingernail, palms or soles and releasing to see long it takes for the colour to come back to the skin (blood flow to return). The normal range is less than 3 seconds. Cardiopulmonary resuscitation (CPR) Performing chest compressions and ventilation with the goal of resuscitating a patient with no pulse. Cervical spine (C-spine) The part of the spine in the neck, containing the first seven vertebrae. Circumferential burn Burns that extend around a body part can act like a rigid band and may limit blood supply (to a limb) or breathing (burn around the chest or abdomen). Cholera Bacterial infection causing a profound watery diarrhoea, often described as rice-water stools. Chronic obstructive pulmonary disease (COPD) Term describing breakdown of lung structure (emphysema) and chronic inflammation causing spasm of the lower airways and wheezing. Coma Prolonged state of unconsciousness. Compartment syndrome A condition of increased pressure from swelling in an area of the body that cannot expand, such as compartments in the forearm or lower leg. Compartment syndrome reduces blood flow to the area and may result in severe pain as well as damage to nerves and other tissues. Confusion Problems with clarity, recall and organization of thought. Convulsion See Seizure. CPR See cardiopulmonary resuscitation. Crackles High pitched sound, like crumpling of a paper bag, heard with a stethoscope. Crackles are caused by fluid in the airspaces of the lungs. Also called rales or crepitations (creps). SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 205 Crepitations See “Crackles”. Crepitus Crackling or popping when pressing on the skin or bones. Cyanosis Blue colouring to the skin or lips, resulting from low blood oxygen levels. Decontamination Removing a dangerous substance, such as chemicals, toxins or infectious materials, from a person’s skin or clothes. Depending on the substance, this is done by brushing off the substance or irrigating with water. Deep wound packing Tight packing of a large or gaping wound with clean, compact gauze to ensure that external pressure can effectively compress an area of bleeding that is too large or too deep to compress otherwise. Defibrillator Machine that delivers high-energy electrical current to convert abnormal heart rhythms. Dehydration Decreased fluid in the body. Delirium Rapidly changing state of confusion, characterized by agitation, loss of focus and inability to interact appropriately. Dementia Chronic condition characterized by abnormal mental state, including loss of memory and problems with thinking. There is often no change in ability to focus on the present. Destination planning Planning the choice of destination facility for transport or transfer in order to best match transport time and the level of services available at the receiving facility to the patient’s clinical needs. Diabetic ketoacidosis (DKA) A condition occurring in diabetics in which lack of insulin causes elevated blood sugar, leading to severe dehydration and build-up of acid in the blood. Diaphoresis Sweating. DIB See difficulty in breathing. GLOSSARY 206 DKA See Diabetic Ketoacidosis. Dilation (of blood vessels) The enlargement or stretching of a part of the body (e.g. blood vessels). Difficulty in breathing (DIB) The feeling of difficulty in breathing (sometimes also called shortness of breath, or SOB) can result from many causes, including problems with the lungs, problems with oxygen, airway blockage, fast breathing, weak respiratory muscles. Direct pressure A way to control external bleeding (haemorrhage) from a wound by applying firm pressure with two or three fingers at the site of bleeding. Disposition The next step in care of a patient – this may be handover of care to another provider through admission or transfer, or discharge to home. Drowning Compromise of breathing from water in the lungs, usually resulting from prolonged time under water. Eclampsia A condition when a pregnant or newly delivered woman has seizures, high blood pressure, and protein in the urine. It can progress to coma and is life-threatening. (“Pre-eclampsia” is diagnosed based on specific criteria and identifies a woman at high-risk of progression to eclampsia.) Ectopic pregnancy A pregnancy outside of the uterus, most often in the fallopian tubes. As an ectopic embryo grows, it may damage the surrounding structures, causing sudden severe bleeding. Ruptured ectopic pregnancy is a surgical emergency. Envenomation The process by which venom is injected by the bite (or sting) of a venomous animal. Escharotomy A surgical procedure to cut and release burned tissue that may restrict breathing or blood supply to a limb. Flail chest When multiple rib fractures in more than one place cause a segment of the rib cage to be separated from the rest of the chest wall and prevent normal breathing movement. SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 207 Fluid status The level of fluid in the body. It can be low (dehydration), normal, or high (fluid overload and/ or oedema). Fontanelle A gap (soft spot) between the developing bones of the skull in babies – changes in the volume of fontanelles may reflect fluid status. Fontanelles normally close between 12 and 18 months of age. Foreign body An object from outside the body (e.g. a foreign body in the airway). Fracture A broken or cracked bone. GCS See Glasgow Coma Scale. Gastroenteritis Infection or inflammation of the stomach and intestine that can cause vomiting, diarrhoea and abdominal pain. Glasgow Coma Scale (GCS) A system of assessing the neurologic function of a trauma patient. It is a score ranging from 3 (unresponsive) to 15 (normal) that assesses responsiveness based on eye movement, verbal response and motor response. Guarding Voluntary or involuntary contraction of the abdominal wall muscles when pressing on the abdomen. Handover A brief summary of critical patient information given by the current provider any time a patient is transferred to a new provider. Handover summarizes the clinical presentation, the care the patient has received, and alerts the new provider of any potential complications. Handover should always be given to transport providers, in addition to receiving-facility providers. Handover should also be given even when care is transferred to a new provider within the same facility. Haemorrhage Large volume bleeding. It may occur externally or within the body. Haemorrhagic shock A state of poor perfusion due to substantial blood loss. GLOSSARY 208 Haematoma Bleeding or a collection of blood within the tissues, outside of the vascular space. Also called bruising. Haemothorax Blood in the space between the chest wall and the lungs. Heart attack (Also called myocardial infarction). Death of heart muscle due to a lack of oxygen-rich blood getting to the heart. Heart failure When the heart fails to pump enough blood to perfuse the organs, usually resulting in oedema in the lungs or extremities. Hives Multiple itchy, red and raised areas on the skin suggestive of an allergic reaction. Human Immunodeficiency Virus (HIV) A virus that weakens the immune system and can lead to AIDS, a syndrome of multiple infections. Hyperthermia High body temperature. Hyperventilation Increased (fast) rate of breathing. Hyperresonance Hollow sounds with percussion. Hypoglycaemia Low blood sugar. Hypothermia Low body temperature. Hypotension Blood pressure lower than the normal range. Hypovolaemic shock Poor perfusion due to low blood volume, which may result from decreased fluid intake or severe fluid or blood loss. Hypoxia Low levels of oxygen in the blood. SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 209 Inflammation Redness and swelling that may result from trauma, infection, allergy or other causes. Ingestion Swallowing a substance – generally used for dangerous substances or doses. Inhalation injury Inflammation or oedema of the airways or lungs resulting from breathing hot gases or irritating chemicals (most commonly smoke inhalation in the setting of fire). Intubation Placing a breathing tube through the mouth, down the throat, and through the vocal cords to allow ventilation of the lungs by bag device or ventilator. Ischaemia Inadequate oxygen and blood supply to tissues that can lead to tissue death (myocardial ischaemia, or lack of oxygen to the heart muscle, is an example). IV (abbreviation for intravenous) Often used to refer to an intravenous catheter, or for the intravenous route of administration of a medication or fluid. Kangaroo care Using skin to skin contact between a newborn infant and mother and covering the child’s head and exposed body, to prevent hypothermia and promote bonding. Laceration A cut or slice to the tissues. Large-bore IV A large IV catheter is needed for rapid volume resuscitation. Ideally, these catheters should be placed in larger blood vessels (that tend to be closer to the heart, like the antecubital fossa in the arms or large veins in the neck). In adults, this is usually defined as 14- or 16-gauge, though in some settings, 18 may be the largest available gauge. Level of consciousness Describes the level of responsiveness or alertness to the environment. Lethargy Excessive drowsiness and slowness to respond. Log roll A method of rolling a person to the side while preventing the spine from bending. Usually performed when spinal injury is suspected to prevent additional damage. GLOSSARY 210 Nasal flaring The widening of nostrils during breathing – it results from increased effort, and is a sign of difficulty in breathing. Nasopharyngeal airway (NPA) A rubber tube inserted through the nostril that reaches to the opening of the throat to allow air to pass. Needle decompression Insertion of a needle into the chest wall to relieve the pressure of a tension pneumothorax. Oedema Abnormal swelling or fluid build-up in the body tissues, outside the vascular space. Oral rehydration solution (ORS) A water, glucose, and salt mixture given by mouth or nasogastric tube to dehydrated patients to replace fluid losses. Orientation Describes a person’s relationship to the surrounding world, including the ability to accurately identify one’s own name and location, as well as the current time and date. Oropharyngeal airway (OPA) A plastic device inserted through the mouth that reaches to the opening of the throat to prevent the tongue from blocking the airway and allows air to pass. ORS See “Oral rehydration solution”. Oxygen (O2) saturation Percent of oxygen in the blood. Parkland Formula A formula used to estimate the amount of IV fluid needed for resuscitation of a burn patient over the first 24 hours after the burn. It is: 4 ml fluid X weight in kilograms X total burn surface area. Half should be given over the first 8 hours, and half over the next 16 hours. Percussion Tapping on the chest wall to assess the lungs. The quality of the sound on tapping may indicate fluid or air in the lungs. Perfusion The delivery of blood to body tissues. Pericardial effusion Fluid in the sac around the heart (the pericardium). SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 211 Pericardial tamponade A critical build-up of fluid in the sac around the heart (the pericardium) that compresses the heart and interferes with normal pumping of blood to the body, leading to shock. Personal protective equipment (PPE) Equipment meant to be worn by a person to protect from infection or injury. This can include gloves, goggles, and protective clothing such as aprons or fluid resistant gowns. Pleural effusion Abnormal fluid collection around the lung that can cause difficulty in breathing and even lung collapse. Common causes include tuberculosis and other infections, heart failure and cancer. Pleuritic pain Pain that is worse with breathing, usually caused by inflammation. Pneumonia Infection of the lungs. Pneumothorax Air in the space between the lungs and the chest wall (pleural space) that causes the lung to collapse. Pre-eclampsia See Eclampsia. Priapism Persistent, abnormal erection of the penis. Psychosis Broadly defined as loss of contact with reality. Pulmonary embolism Blood clot travelling to and blocking the vessels of the lungs. The most common source is the legs. Pulse oximeter Device that detects oxygen saturation (the percentage of red blood cells saturated with oxygen). Rabies A virus that is transmitted through animal bites that affects the brain and nerves and can cause altered mental status. Rebound tenderness Pain that occurs when releasing pressure on the abdomen (as opposed to when pressing on the abdomen). GLOSSARY 212 Resuscitation Time-sensitive interventions performed in an attempt to manage life-threatening conditions. Retractions (sometimes also called “in-drawing” or “recessions”) The visible pulling in of tissues between the ribs or around the collarbones with strained inspiration. Retractions are a sign of serious difficulty in breathing. SAMPLE history An approach to asking key history findings for all patients. SAMPLE stands for: S – Signs and Symptoms, A – Allergies, M – Medications, P – Past history, L – Last oral intake, E – Events surrounding the illness or injury. Seizure Also called convulsions or fits. Abnormal electrical activity in the brain, often seen as altered mental status with abnormal repetitive movements. Seizures may be a primary condition or may be caused by infection, injury, toxins or chemical balance problems. Shock A state where organs do not get enough blood and oxygen (poor perfusion), leading to organs not working properly. Skin pinch testing An easy way to check hydration status in children by pinching the skin, usually on the abdomen. Well-hydrated skin should return to normal in less than 2 seconds. Sprain A stretched, pulled, or torn ligament. Stridor A high pitched sound on breathing in that is caused by swelling or a physical obstruction of the upper airway. Stroke Death of brain tissue due to ischaemia from either blood clot or haemorrhage. Sucking chest wound A wound in the chest wall that allows air in and out of the chest cavity, indicating an open pneumothorax. Tachycardia Heart rate faster than normal range. Tachypnoea Rapid breathing. SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE GLOSSARY REFS & QUICK CARDS PARTICIPANT WORKBOOK 213 Tension pneumothorax Occurs when a pneumothorax causes sufficient pressure inside the chest cavity that blood vessels collapse (reducing the amount of blood that can return to the heart, and the heart cannot fill or pump enough blood to maintain perfusion of the organs). Tracheal shift Describes a change in the position of the trachea to either side of midline, a finding sometimes associated with tension pneumothorax. Trauma primary survey The trauma primary survey is another term for the ABCDE approach in injured patients. It includes initial assessment of an injured person and management of all immediately life- threatening injuries, in order of priority. The primary survey consists of the ABCDE: Airway, Breathing, Circulation, Disability and Exposure. Trauma secondary survey The head-to-toe (front and back) examination of the trauma patient that includes taking a SAMPLE history. The purpose of this survey is to identify and treat all injuries, with priority given to any hidden life-threatening conditions that were missed by the primary survey. Tripod position Sitting upright with neck extended but leaning slightly forward with hands on knees. People with severe difficulty in breathing will often sit in this position. Wheezing A whistling sound made when breathing out due to inflammation in the lungs, suggestive of lower airway swelling. WHO sources 214 WHO sources Emergency Triage Assessment and Treatment (ETAT). Geneva: World Health Organization; 2005. June 2016 update. Integrated Management of Adolescent and Adult Illness (IMAI) District Clinician Manual. Volume 1 and 2. Geneva: World Health Organization; 2011:Chapter 2–4; 6–8. Pocket book for hospital care of children. Second edition. Geneva: World Health Organization; 2013. GLOSSARY SKILLS AM S SHOCK BREATHING TRAUM A INTRO ABCDE REFS & QUICK CARDS PARTICIPANT WORKBOOK 215 Basic Emergency Care Quick Cards
217 ABCDE APPROACH REMEMBER... Always check for signs of trauma [see also TRAUMA card] ASSESSMENT FINDINGS IMMEDIATE MANAGEMENT Airway A Unconscious with limited or no air movement If NO TRAUMA: head-tilt and chin-lift, use OPA or NPA to keep airway open, place in recovery position or position of comfort. If possible TRAUMA: use jaw thrust with c-spine protection and place OPA to keep the airway open (no NPA if facial trauma). Foreign body in airway Remove visible foreign body. Encourage coughing. • If unable to cough: chest/abdominal thrusts/back blows as indicated • If patient becomes unconscious: CPR Gurgling Open airway as above, suction (avoid gagging). Stridor Keep patient calm and allow position of comfort. • For signs of anaphylaxis: give IM adrenaline • For hypoxia: give oxygen Breathing B Signs of abnormal breathing or hypoxia Give oxygen. Assist ventilation with BVM if breathing NOT adequate. Wheeze Give salbutamol. For signs of anaphylaxis: give IM adrenaline. Signs of tension pneumothorax (absent sounds / hyperresonance on one side WITH hypotension, distended neck veins) Perform needle decompression, give oxygen and IV uids. Will need chest tube Signs of opiate overdose (AMS and slow breathing with small pupils) Give naloxone. Circulation C Signs of poor perfusion/shock If no pulse, follow relevant CPR protocols. Give oxygen and IV uids. Signs of internal or external bleeding Control external bleeding. Give IV uids. Signs of pericardial tamponade (poor perfusion with distended neck veins and mu ed heart sounds) Give IV fl uids, oxygen. Will need rapid pericardial drainage Disability D Altered mental status (AMS) If NO TRAUMA, place in recovery position. Seizure Give benzodiazepine. Seizure in pregnancy (or after recent delivery) Give magnesium sulphate. Hypoglycaemia Give glucose if <3.5 mmol/L or unknown. Signs of opiate overdose (AMS with slow breathing with small pupils) Give naloxone. Signs of life-threatening brain mass or bleed (AMS with unequal pupils) Raise head of bed, monitor airway. Will need rapid transfer for neurosurgical services Exposure E Remove wet clothing and dry skin thoroughly. Remove jewelry, watches and constrictive clothing Prevent hypothermia and protect modesty. Snake bite Immobilize extremity. Send picture of snake with patient. Call for anti-venom if relevant. If cause unknown, remember trauma: Examine the entire body and always consider hidden injuries [see also TRAUMA card] REMEMBER: PATIENTS WITH ABNORMAL ABCDE FINDINGS MAY NEED RAPID HANDOVER/TRANSFER. PLAN EARLY. 218 SPECIAL CONSIDERATIONS IN THE ASSESSMENT OF CHILDREN A • Children have bigger heads and tongues, and shorter, softer necks than adults. Position airway as appropriate for age. • Always consider foreign bodies. B • Look for signs of increased work of breathing (e.g. chest indrawing, retractions, nasal aring). • Listen for abnormal breath sounds (e.g. grunting, stridor, or silent chest). AGE RESPIRATORY RATE (breaths per minute) <2 months 40–60 2–12 months 25–50 1–5 years 20–40 C • Signs of poor perfusion in children include: slow capillary re ll, decreased urine output, lethargy, sunken fontanelle, poor skin pinch • Look for signs of anaemia and malnourishment (adjust uids). • Remember that children may not always report trauma and may have serious internal injury with few external signs. AGE (in years) NORMAL HEART RATE (beats per minute) <1 100–160 1–3 90–150 4–5 80–140 D • Always check AVPU • Hypoglycaemia is common in ill children. • Check for tone and response to stimulus. • Look for lethargy or irritability. E INFANTS AND CHILDREN HAVE DIFFICULTY MAINTAINING TEMPERATURE • Remove wet clothing and dry skin thoroughly. Place infants skin-to-skin when possible. • For hypothermia, cover the head (but be sure mouth and nose are clear). • For hyperthermia, unbundle tightly wrapped babies. DANGER SIGNS IN CHILDREN • Signs of airway obstruction (unable to swallow saliva/ drooling or stridor) • Increased breathing e ort (fast breathing, nasal aring , grunting, chest indrawing or retractions) • Cyanosis (blue colour of the skin, especially at the lips and ngertips) • Altered mental status (including lethargy or unusual sleepiness, confusion, disorientation) • Moves only when stimulated or no movement at all (AVPU other than “A”) • Not feeding well, cannot drink or breastfeed or vomiting everything • Seizures/convulsions • Low body temperature (hypothermia) ESTIMATED WEIGHT in KILOGRAMS for CHILDREN 1–10 YEARS OLD: [age in years + 4] x 2 NORMAL ADULT VITAL SIGNS Pulse rate: 60–100 beats per minute Respiratory rate: 10–20 breaths per minute Systolic blood pressure >90 mmHg Estimating systolic blood pressure (not reliable in children and the elderly): Carotid (neck) pulse SBP ≥ 60 mmHg Femoral (groin) pulse SBP ≥ 70 mmHg Radial (wrist) pulse SBP ≥80 mmHg SAMPLE History Signs & Symptoms Allergies Medications PMH Last oral intake Events APPROACH TO THE PATIENT WITH TRAUMA Key findings from the Trauma Primary Survey [see also ABCDE card] ASSESSMENT FINDINGS IMMEDIATE MANAGEMENT Airway A Not speaking, with limited or no air movement Use jaw thrust with c-spine protection. Suction if needed, remove visible foreign objects. Place OPA to keep the airway open. Signs of possible airway injury (neck haematoma or wound, crepitus, stridor) Give oxygen. Monitor closely-- swelling can rapidly block the airway. Will need advanced airway management Signs of possible airway burns (soot around the mouth or nose, burned facial hair, facial burns) Give oxygen. Monitor closely-- swelling can rapidly close the airway. Will need advanced airway management Breathing B Signs of tension pneumothorax (hypotension with absent breath sounds/hyperresonance on one side, distended neck veins) Perform needle decompression. Give oxygen, IV uids. Will need chest tube Open (sucking) chest wound Give oxygen, place 3-sided dressing, monitor for tension pneumothorax. Will need chest tube Breathing not adequate Give oxygen, assist ventilation with BVM. Large burns of chest or abdomen (or circumferential burn to limb) Give IV uids per burn size, give oxygen, remove constricting clothing/jewelry. May need escharotomy Signs of ail chest (section of chest wall moving in opposite direction with breathing) Give oxygen. May need advanced airway management and assisted ventilation Signs of haemothorax (decreased breath sounds on one side, dull sounds with percussion) Give oxygen, IV uids. Will need chest tube Circulation C Signs of shock (capillary re ll >3 sec, hypotension, tachycardia) Give oxygen, IV uids, control external bleeding, splint femur/pelvis as indicated. Uncontrolled external bleeding Apply pressure, deep wound packing or tourniquet as indicated. Signs of tamponade (poor perfusion, distended neck veins, mu ed heart sounds) Give IV uids, oxygen. Disability D Signs of brain injury (AMS with wound, deformity or bruising of head/face) Immobilize cervical spine, check glucose, give nothing by mouth. Will need neurosurgical care Signs of open skull fracture (as above, with blood or uid from the ears/nose) As above, and give IV antibiotics per local protocol. REMEMBER: INJURED PATIENTS WITH ABNORMAL ABCDE FINDINGS MAY NEED RAPID HANDOVER/TRANSFER TO A SURGICAL SERVICE. PLAN EARLY. 219 APPROACH TO THE PATIENT WITH TRAUMA Key fi ndings from the Trauma Primary Survey [see also ABCDE card] ASSESSMENT FINDINGS IMMEDIATE MANAGEMENT Airway A Not speaking, with limited or no air movement Use jaw thrust with c-spine protection. Suction if needed, remove visible foreign objects. Place OPA to keep the airway open. Signs of possible airway injury (neck haematoma or wound, crepitus, stridor) Give oxygen. Monitor closely-- swelling can rapidly block the airway. Will need advanced airway management Signs of possible airway burns (soot around the mouth or nose, burned facial hair, facial burns) Give oxygen. Monitor closely-- swelling can rapidly close the airway. Will need advanced airway management Breathing B Signs of tension pneumothorax (hypotension with absent breath sounds/hyperresonance on one side, distended neck veins) Perform needle decompression. Give oxygen, IV uids. Will need chest tube Open (sucking) chest wound Give oxygen, place 3-sided dressing, monitor for tension pneumothorax. Will need chest tube Breathing not adequate Give oxygen, assist ventilation with BVM. Large burns of chest or abdomen (or circumferential burn to limb) Give IV uids per burn size, give oxygen, remove constricting clothing/jewelry. May need escharotomy Signs of ail chest (section of chest wall moving in opposite direction with breathing) Give oxygen. May need advanced airway management and assisted ventilation Signs of haemothorax (decreased breath sounds on one side, dull sounds with percussion) Give oxygen, IV uids. Will need chest tube Circulation C Signs of shock (capillary re ll >3 sec, hypotension, tachycardia) Give oxygen, IV uids, control external bleeding, splint femur/pelvis as indicated. Uncontrolled external bleeding Apply pressure, deep wound packing or tourniquet as indicated. Signs of tamponade (poor perfusion, distended neck veins, mu ed heart sounds) Give IV uids, oxygen. Disability D Signs of brain injury (AMS with wound, deformity or bruising of head/face) Immobilize cervical spine, check glucose, give nothing by mouth. Will need neurosurgical care Signs of open skull fracture (as above, with blood or uid from the ears/nose) As above, and give IV antibiotics per local protocol. REMEMBER: INJURED PATIENTS WITH ABNORMAL ABCDE FINDINGS MAY NEED RAPID HANDOVER/TRANSFER TO A SURGICAL SERVICE. PLAN EARLY. 220 MANAGEMENT OF SPECIFIC CONDITIONS Facial fracture Immobilize cervical spine if indicated, give IV antibiotics for open fractures, avoid nasal airway/ nasogastric tubes. Penetrating eye injury Avoid pressure on the eye, stabilize but do not remove foreign objects, give antibiotics and tetanus, elevate head of bed. Open abdominal wound Give IV uids, nothing by mouth. Cover visible bowel with sterile gauze soaked in sterile saline, give antibiotics. Pelvic fracture Give IV uids, stabilize with sheet or pelvic binder. Fracture with poor limb perfusion Reduce fracture, splint. Open fracture Irrigate well, dress wound, splint, give antibiotics, rapid handover for operative management. Penetrating object Leave object in place and stabilize it to prevent further injury. Crush injury Give IV uids, monitor urine output, monitor for compartment syndrome. Burn injury Assess size and calculate uid needs, give IV uids and oxygen, monitor for airway oedema. Blast injury Give oxygen, treat burns as below, give IV uids, monitor closely for delayed e ects of internal injury. REMEMBER: INJURED PATIENTS WITH WOUNDS, INCLUDING BURNS AND OPEN FRACTURES, NEED TETANUS VACCINATION. HIGH-RISK MECHANISMS AND INJURIES High-Risk Mechanisms High-Risk Injuries • Pedestrian or cyclist hit by a vehicle • Motorcycle crash or any vehicle crash with unrestrained occupants • Falls from heights greater than 3 metres (or twice a child’s height) • Gunshot or stabbing • Explosion or re in an enclosed space. • Penetrating injuries to head, neck or torso • Blast or crush injuries • Flail chest • Two or more large bone fractures, or pelvic fracture • Spinal injury • Limb paralysis • Amputation above wrist or ankle SPECIAL CONSIDERATIONS IN CHILDREN • Children can look well but then deteriorate quickly. • Children have more exible bones than adults and can have serious internal injuries with few external signs. • Use caution when calculating uid and medication dosages. Use exact weight whenever possible. • Watch carefully for hypothermia and hypoglycaemia. DISPOSITION Conditions that require handover or transfer to a specialist unit include: • ABCDE nding that has required intervention • Evidence of internal bleeding • Any pneumothorax or sucking chest wound • Shock, even if treated successfully • Altered mental status • Trauma during pregnancy • ABCDE abnormalities or any chest /abdomen injury in a child • Signi cant burn injuries Considerations for transfer: • Any patient who has required oxygen should have oxygen during transport and after handover. • For signs of shock, ensure IV uid started and continued during transfer. • Control any external bleeding and monitor site closely during transport. APPROACH TO THE PATIENT WITH DIFFICULTY IN BREATHING Key ABCDE Findings (Always perform a complete ABCDE approach rst!) IF YOU FIND... REMEMBER... Choking, coughing Foreign body Stridor Partial airway obstruction due to foreign body or in ammation (from infection, chemical exposure or burn) Facial swelling Severe allergic reaction, medication e ect Drooling Indicates a blockage to swallowing Soot around the mouth or nose, burned facial hair, facial burns Smoke inhalation and airway burns – rapid swelling can block the airway Signs of chest wall trauma Rib fracture, ail chest, pneumothorax, contusion, tamponade Decreased breath sounds on one side Pneumothorax (consider tension pneumothorax if with hypotension and hyperresonance to percussion), haemothorax, large pleural e usion/pneumonia Decreased breath sounds and crackles on both sides Pulmonary oedema, heart failure Wheezing Asthma, allergic reaction, COPD Fast or deep breathing DKA Low blood pressure, tachycardia, mu ed heart sounds Pericardial tamponade Altered mental status with small pupils and slow breathing Opioid overdose Key Findings from the SAMPLE History and Secondary Exam IF YOU FIND... REMEMBER... DIB worse with exertion or activity Heart failure, heart attack DIB that began with choking or during eating Foreign body, allergic reaction History of fever, cough Pneumonia, infection Pesticide exposure Poisoning Recent fall or other trauma Rib fracture, ail chest, pneumothorax, contusion, tamponade Known allergies, allergen exposure, bite or sting Allergic reaction Recent medication or dose change Allergic reaction or side e ect History of opioid or sedative drug use Overdose History of wheezing Asthma or COPD History of diabetes DKA History of tuberculosis or malignancy Pericardial tamponade, pleural e usion History of heart failure Pulmonary oedema History of sickle cell disease Acute chest syndrome 221 APPROACH TO THE PATIENT WITH DIFFICULTY IN BREATHING Key ABCDE Findings (Always perform a complete ABCDE approach rst!) IF YOU FIND... REMEMBER... Choking, coughing Foreign body Stridor Partial airway obstruction due to foreign body or in ammation (from infection, chemical exposure or burn) Facial swelling Severe allergic reaction, medication e ect Drooling Indicates a blockage to swallowing Soot around the mouth or nose, burned facial hair, facial burns Smoke inhalation and airway burns – rapid swelling can block the airway Signs of chest wall trauma Rib fracture, ail chest, pneumothorax, contusion, tamponade Decreased breath sounds on one side Pneumothorax (consider tension pneumothorax if with hypotension and hyperresonance to percussion), haemothorax, large pleural e usion/pneumonia Decreased breath sounds and crackles on both sides Pulmonary oedema, heart failure Wheezing Asthma, allergic reaction, COPD Fast or deep breathing DKA Low blood pressure, tachycardia, mu ed heart sounds Pericardial tamponade Altered mental status with small pupils and slow breathing Opioid overdose Key Findings from the SAMPLE History and Secondary Exam IF YOU FIND... REMEMBER... DIB worse with exertion or activity Heart failure, heart attack DIB that began with choking or during eating Foreign body, allergic reaction History of fever, cough Pneumonia, infection Pesticide exposure Poisoning Recent fall or other trauma Rib fracture, ail chest, pneumothorax, contusion, tamponade Known allergies, allergen exposure, bite or sting Allergic reaction Recent medication or dose change Allergic reaction or side e ect History of opioid or sedative drug use Overdose History of wheezing Asthma or COPD History of diabetes DKA History of tuberculosis or malignancy Pericardial tamponade, pleural e usion History of heart failure Pulmonary oedema History of sickle cell disease Acute chest syndrome 222 CRITICAL ACTIONS FOR HIGH-RISK CONDITIONS CHOKING unable to cough, not making sounds STRIDOR high pitched sounds on breathing IN WHEEZING high pitched sounds on breathing OUT SEVERE INFECTION TRAUMA Remove any visible foreign body Perform age- appropriate chest/ abdominal thrusts or back blows CPR if becomes unconscious Keep patient calm and allow position of comfort IM adrenaline for suspected allergic reaction Oxygen if concern for hypoxia Early handover/ transfer for advanced airway management Give salbutamol IM adrenaline for suspected allergic reaction Oxygen if concern for hypoxia Oxygen Antibiotics Oral/IV uids as appropriate Oxygen Needle decompression and IV uids for tension pneumothorax Three-sided dressing for sucking chest wound Rapid transfer to surgical service SPECIAL CONSIDERATIONS IN CHILDREN THE FOLLOWING ARE DANGER SIGNS IN CHILDREN WITH BREATHING COMPLAINTS: • Fast breathing • Increased breathing e ort (chest indrawing/retractions) • Cyanosis • Altered mental status (including lethargy) • Poor feeding or drinking, or vomits everything • Seizures/convulsions, current or recent • Drooling or stridor when calm • Hypothermia Wheezing in children is often caused by an object inhaled into the airway, viral infection or asthma. Stridor in children is often caused by an object stuck in the airway or airway swelling from infection. Fast or deep breathing can indicate diabetic crisis (DKA), which may be the rst sign of diabetes in a child. FAST BREATHING MAY BE THE ONLY SIGN OF A SERIOUS BREATHING PROBLEM IN A CHILD. DISPOSITION Salbutamol and IM adrenaline e ects last for about 3 hours, and life-threatening symptoms may recur. Monitor closely, always have repeat dose available during transport and caution new providers at handover. Naloxone lasts approximately 1 hour, and most opioids last longer. Monitor closely, always have repeat dose available during transport and caution new providers. Following immersion in water (drowning), a person may develop delayed breathing problems after several hours. Monitor closely and caution new providers. Never leave patients with di culty in breathing unmonitored during handover/transfer. Make transfer arrangements as early as possible for any patient who may require intubation or assisted ventilation. 223 CRITICAL ACTIONS FOR HIGH-RISK CONDITIONS CHOKING unable to cough, not making sounds STRIDOR high pitched sounds on breathing IN WHEEZING high pitched sounds on breathing OUT SEVERE INFECTION TRAUMA Remove any visible foreign body Perform age- appropriate chest/ abdominal thrusts or back blows CPR if becomes unconscious Keep patient calm and allow position of comfort IM adrenaline for suspected allergic reaction Oxygen if concern for hypoxia Early handover/ transfer for advanced airway management Give salbutamol IM adrenaline for suspected allergic reaction Oxygen if concern for hypoxia Oxygen Antibiotics Oral/IV uids as appropriate Oxygen Needle decompression and IV uids for tension pneumothorax Three-sided dressing for sucking chest wound Rapid transfer to surgical service SPECIAL CONSIDERATIONS IN CHILDREN THE FOLLOWING ARE DANGER SIGNS IN CHILDREN WITH BREATHING COMPLAINTS: • Fast breathing • Increased breathing e ort (chest indrawing/retractions) • Cyanosis • Altered mental status (including lethargy) • Poor feeding or drinking, or vomits everything • Seizures/convulsions, current or recent • Drooling or stridor when calm • Hypothermia Wheezing in children is often caused by an object inhaled into the airway, viral infection or asthma. Stridor in children is often caused by an object stuck in the airway or airway swelling from infection. Fast or deep breathing can indicate diabetic crisis (DKA), which may be the rst sign of diabetes in a child. FAST BREATHING MAY BE THE ONLY SIGN OF A SERIOUS BREATHING PROBLEM IN A CHILD. DISPOSITION Salbutamol and IM adrenaline e ects last for about 3 hours, and life-threatening symptoms may recur. Monitor closely, always have repeat dose available during transport and caution new providers at handover. Naloxone lasts approximately 1 hour, and most opioids last longer. Monitor closely, always have repeat dose available during transport and caution new providers. Following immersion in water (drowning), a person may develop delayed breathing problems after several hours. Monitor closely and caution new providers. Never leave patients with di culty in breathing unmonitored during handover/transfer. Make transfer arrangements as early as possible for any patient who may require intubation or assisted ventilation. APPROACH TO THE PATIENT WITH SHOCK Key ABCDE Findings (Always perform a complete ABCDE approach fi rst!) IF YOU FIND... REMEMBER... Di culty breathing, stridor/wheezing, skin rash, swelling of mouth Severe allergic reaction Hypotension with absent breath sounds and hyperresonance on one side, distended neck veins Tension pneumothorax Distended neck veins, mu ed heart sounds, tachycardia, hypotension Pericardial tamponade Sweet smelling breath, deep or rapid breathing DKA History of trauma or no known cause Hidden sources of signi cant blood loss (stomach, intestines, intra-abdominal, chest, long-bone trauma) or spinal injury Key Findings from the SAMPLE History and Secondary Exam IF YOU FIND... REMEMBER... Vomiting and diarrhoea Ask about contacts and report cases per protocol. Black or bloody vomit or stool Stomach or intestinal bleeding Rapid or deep breathing, dehydration, high glucose, sweet- smelling breath, history of frequent urination or known diabetes Diabetic ketoacidosis Burns Severe uid loss (calculate uid needs based on burn size) Fever or HIV Infection Recent fall or other trauma Internal AND external bleeding Pale conjunctiva or malnutrition Severe anemia (adjust uids) Chest pain Heart attack (give aspirin if indicated) Vaginal bleeding Pregnancy and non-pregnancy related bleeding Numbness, weakness or shock that does not improve with uids Spinal shock (immobilize spine if indicated) CRITICAL ACTIONS FOR HIGH-RISK CONDITIONS For all shock: • Give oxygen • Give IV uids – ADULTS: 1 liter RL or NS bolus – CHILDREN with NO severe anaemia, NO malnutrition, NO uid overload: 10–20 ml/kg bolus – CHILDREN with malnutrition or severe anaemia: give 10–15 ml/kg dextrose-containing uid over 1 hour and assess for uid overload every 5 minutes. – For suspected heart attack with shock, give smaller boluses, and monitor closely for uid overload. • Monitor vital signs, mental status, breathing and urine output AND for speci c conditions: SEVERE ALLER- GIC REACTION TENSION PNEUMO- THORAX TAMPONADE FEVER WATERY DIARRHOEA POSTPARTUM BLEEDING DKA TRAUMA IM adrenaline Monitor for recurrence, may need repeat doses Rapid needle decompression Transfer for chest tube Rapid transfer to advanced provider for drainage Antibiotics (and anti- malarials if indicated) Assess for source of infection Full contact precautions Monitor output and continue uids Assess for cholera and notify public health authorities Oxytocin and uterine massage Direct pressure for perineal and vaginal tears Rapid transfer to advanced obstetric care Close monitor- ing for uid over- load in children Handover/ transfer for insulin Control external haemorrhage with direct pressure, wound packing, tour- niquet if indicated Calculate uid needs based on burn size Rapid transfer for sur- gery/transfusion as needed 224 SPECIAL CONSIDERATIONS IN CHILDREN IV FLUID IMMEDIATELY AVAILABLE? IV FLUID AVAILABLE NEARBY? START ORS via NG NASOGASTRIC TUBE REASSESS IMMEDIATELY AFTER BOLUS DID PERFUSION IMPROVE? TRANSFER IMMEDIATELY CONTINUE ORS VIA NG YES YES YES YES No No No No DID PERFUSION IMPROVE? IV FLUIDS REASSESS IMMEDIATELY AFTER BOLUS CONTINUE E <30 MINUTES <30 MINUTES START IV FLUIDS RE-BOLUS GIVING FLUID IN SHOCK NO malnutrition, overload or severe anaemia DISPOSITION Patients with shock should be at a unit capable of providing IV uid resuscitation, blood transfusion, and/or surgery, depending on the type of shock. Maintain uids during transport. Repeat ABCDE approach and monitor perfusion and breathing closely at all times. ASSESSING SHOCK IN CHILDREN The 2016 WHO guidelines for the care of critically ill children use the presence of three clinical features to de ne shock: • Cold extremities • Weak and fast pulse • Capillary re ll greater than 3 seconds Additional important considerations include: • Young children may not be able to drink enough uid on their own. • Children have larger surface area to volume ratio and can lose uids more quickly than adults. • For a child in shock WITH severe malnutrition or uid overload, add dextrose and reduce uids to 10–15 ml/kg over 1 hour. Other important signs of poor perfusion include: • Sunken eyes; sunken fontanelles in infants • Abnormal skin pinch test • Pallor (dehydration with anaemia is more di cult to treat) • Decreased and dark urine (number of nappies for infants) • Low blood pressure • Fast breathing • Altered mental status • Very dry mouth and lips • Lethargy (excessive drowsiness, slow to respond, not interactive) In children without severe malnutrition, severe anaemia or uid overload, give uid resuscitation over 30 minutes. WEIGHT (kg) FLUID VOLUME (15ml/kg) 4 60 6 90 10 150 14 210 20 300 30 450 APPROACH TO THE PATIENT WITH ALTERED MENTAL STATUS (AMS) Key ABCDE Findings (Always perform a complete ABCDE approach fi rst!) IF YOU FIND... REMEMBER... Tachypnoea Hypoxia, DKA, toxic ingestion Poor perfusion/shock Infection, internal bleeding Tachycardia with normal perfusion Alcohol withdrawal Coma Hypoxia, high or low blood glucose, DKA and toxic ingestion Hypoglycaemia Infection, medication side e ect (eg, diabetes medications, quinine) Very small pupils with slow breathing Opioid overdose Seizure/convulsion Abnormal glucose, infection, toxic ingestion (eg, TB meds) or withdrawal (eg, alcohol). Consider eclampsia if current pregnancy or recent delivery. Weakness on one side or unequal pupil size Brain mass or bleed Signs of trauma or unknown cause of AMS Consider brain injury (with possible spine injury) Key Findings from SAMPLE History and Secondary Exam IF YOU FIND... REMEMBER... History of wheezing Severe COPD crisis can cause AMS History of diabetes High or low blood sugar, DKA History of epilepsy Post-seizure confusion and sleepiness should improve over minutes to hours. Prolonged AMS or multiple convulsions without waking up in between require further workup. History of agricultural work or known pesticide exposure Organophosphate poisoning History of regular alcohol use Alcohol withdrawal History of substance use or depression Acute intoxication, accidental or intentional overdose History of HIV Infection, medication side e ect Rash on the lower abdomen or legs or bulging fontanelle in infants Brain infection (meningitis) Fever/Hyperthermia Infectious, toxic, and environmental causes 225 APPROACH TO THE PATIENT WITH ALTERED MENTAL STATUS (AMS) Key ABCDE Findings (Always perform a complete ABCDE approach fi rst!) IF YOU FIND... REMEMBER... Tachypnoea Hypoxia, DKA, toxic ingestion Poor perfusion/shock Infection, internal bleeding Tachycardia with normal perfusion Alcohol withdrawal Coma Hypoxia, high or low blood glucose, DKA and toxic ingestion Hypoglycaemia Infection, medication side e ect (eg, diabetes medications, quinine) Very small pupils with slow breathing Opioid overdose Seizure/convulsion Abnormal glucose, infection, toxic ingestion (eg, TB meds) or withdrawal (eg, alcohol). Consider eclampsia if current pregnancy or recent delivery. Weakness on one side or unequal pupil size Brain mass or bleed Signs of trauma or unknown cause of AMS Consider brain injury (with possible spine injury) Key Findings from SAMPLE History and Secondary Exam IF YOU FIND... REMEMBER... History of wheezing Severe COPD crisis can cause AMS History of diabetes High or low blood sugar, DKA History of epilepsy Post-seizure confusion and sleepiness should improve over minutes to hours. Prolonged AMS or multiple convulsions without waking up in between require further workup. History of agricultural work or known pesticide exposure Organophosphate poisoning History of regular alcohol use Alcohol withdrawal History of substance use or depression Acute intoxication, accidental or intentional overdose History of HIV Infection, medication side e ect Rash on the lower abdomen or legs or bulging fontanelle in infants Brain infection (meningitis) Fever/Hyperthermia Infectious, toxic, and environmental causes 226 CRITICAL ACTIONS FOR HIGH-RISK CONDITIONS (Always check blood glucose in AMS, or give glucose if unable to check.) HYPOGLYCAEMIA OPIOID OVERDOSE LIFE-THREATENING INFECTIONS SEVERE DEHYDRATION TOXIC EXPOSURE OR WITHDRAWAL Give glucose Evaluate for infection Monitor for return of hypoglycaemia Naloxone Monitor need for repeat doses (many opioids last longer than naloxone) IV uids Antibiotics For AMS with fever or rash, consider brain infection (meningitis) – isolate patient and wear mask. Cool if indicated for very high fever (avoid shivering). IV uids Assess for infection Consider DKA Gather history and consult advanced provider for locally- appropriate antidotes. Treat alcohol withdrawal with benzodiazepine. Decontaminate for chemical exposures (eg, pesticides). PAEDIATRIC CONSIDERATIONS ALWAYS consider unwitnessed toxic ingestion Ask about any medications in the household, and any chemicals (eg cleaning products, antifreeze) in or near the house. Check and regularly re-check blood glucose Low blood glucose is common in ill young children. High blood glucose can present with AMS and dehydration. AVOID hypothermia Keep skin-to-skin with mother, cover child’s head. Uncover only the parts you need to see, one at a time, during exam. Danger signs with ingestions • Stridor • Oral chemical burns Monitor closely and arrange handover/transfer for advanced airway management. Monitor uid status closely Paediatric patients are more susceptible to both uid losses and uid overload. DISPOSITION CONSIDERATIONS Patients with AMS who may not be able to protect the airway should never be left alone. Monitor closely and give direct handover to new provider. Naloxone lasts approximately 1 hour. Most opioids last longer-- always alert new providers that patients may need repeat doses. Hypoglycaemia often recurs. Alert new providers to monitor blood glucose frequently in any patient who has been treated for hypoglycaemia. 227 MEDICATIONS MEDICATION DOSAGE INDICATION Adrenaline (Epinephrine) Solution: 1mg in 1ml ampoule (1:1000) Adults: 50 kg or above: 0.5 mg IM (0.5 ml of 1:1000) 40 kg: 0.4 mg (0.4 ml IM of 1:1000) 30 kg: 0.3 mg (0.3 ml IM of 1:1000) Repeat every 5 minutes as needed Children: Anaphylaxis: 0.15 mg IM (0.15ml of 1:1000). Repeat every 5–15 minutes as needed Severe Asthma: 0.01 mg/kg IM up to 0.3mg. Repeat every 15 minutes as needed Anaphylaxis/severe allergic reaction and severe wheezing Acetylsalicylic acid (Aspirin) Oral Tablet: 100 mg, 300 mg 300 mg (preferably chewed or in water) immediately as single dose. Suspected heart attack Diazepam Oral Tablet: 2 mg, 5 mg Solution: 5 mg /1 ml ampoule Adults: First dose: 10 mg slow IV push or 20 mg rectally Second dose after 10 minutes: 5 mg slow IV push or 10 mg rectally Maximum IV Dose: 30 mg Children: First dose: 0.2 mg/kg slow IV push or 0.5 mg/kg rectally. Can repeat half of rst dose after 10 minutes if seizures/convulsions continue. Max IV Dose: 20 mg MONITOR BREATHING CLOSELY in all patients given diazepam. Seizures/ convulsions Glucose (Dextrose) Solution: 50% dextrose (D50), 25% dextrose (D25), or 10% Dextrose (D10) Adults and children greater than 40kg: 25–50 ml IV of D50, or 125–250 ml IV of D10 Children up to 40kg: 5 ml/kg IV of D10 (PREFERRED) 2 ml/kg IV of D25 1 ml/kg IV of D50 If no IV access: 2–5 ml of 50% Dextrose OR sugar solution in buccal space Hypoglycaemia (low blood sugar) Magnesium Sulphate Solution: 1 g in 2 ml ampoule (50% or 500 mg/ml), 5 g in 10 ml ampoule (50% or 500 mg/ml) Give 4 g IV (dilute to a 20% solution and give 20ml) slowly over 20 minutes AND give 10 g IM: 5 g (10 ml of 50% solution) with 1 ml of 2% lidocaine in each buttock. If unable to give IV, give 10 g IM injection only (as above, 5 g in each buttock). If seizures/convulsions recur: after 15 minutes give additional 2 g (10 ml of 20%) IV over 20 minutes. If transport delayed continue: Give 5 g of 50% solution IM with 1 ml of 2% lidocaine every 4h in alternate buttocks. Eclampsia or Pregnant with seizure/convulsion Naloxone Solution: 400 mcg/ml (hydrochloride) in 1 ml ampoule IV: 100 mcg single dose OR IM: 400 mcg single dose May repeat every 5 minutes as needed. May require 0.4 mg/hr infusion for several hours for long-acting opioids. Opioid overdose 228 MEDICATION DOSAGE INDICATION Oxytocin Solution: 10 IU in 1ml ampule Initial Dose: Give 10 IU IM AND start IV uids with 20 IU/L at 60 drops/minute. Once placenta is delivered, continue IV uids with 20 IU/L at 30 drops/minute if still bleeding. If placenta has to be manually removed or uterus does not contract: Repeat 10 IU IM. Continue IV uids with 20 IU/L at 20 drops/minute for one hour after bleeding stops. Max Dose: 3 L of IV uids containing oxytocin. Treatment of postpartum haemorrhage Paracetamol (acetaminophen) Oral Tablet: 250 mg, 500 mg. Rectal Suppositories: 250 mg, 500 mg Adults: 500 mg–1 g oral/rectal every 6hrs Max 4 g daily or max 2 g daily if liver impairment, cirrhosis Children: 10–15 mg/kg oral/rectal up to six times per day Mild to moderate pain, fever, headache Salbutamol (Albuterol) Inhaler: 100 mcg per pu • Adult: Prime with 5 pu s and give 2 pu s via spacer every 2 minutes until improved. • Child: Prime with 5 pu s and give 2 pu s into spacer. Keep spacer in mouth for 3–5 breaths. Repeat until 6 pu s given for < 5 years, or 12 pu s for > 5 years. Nebulizer: (ADULT) 5 mg in 5 ml sterile saline. (CHILD) 2.5 mg in 3 ml sterile saline. For severe wheezing, above doses can be given several times in an hour. Severe wheezing Tetanus Vaccine IM Injection: 0.5 ml (Give for children not up to date; adults with none in 5 years; or status unknown) Wounds (including burns and open fractures) 229 MEDICATION DOSAGE INDICATION Oxytocin Solution: 10 IU in 1ml ampule Initial Dose: Give 10 IU IM AND start IV uids with 20 IU/L at 60 drops/minute. Once placenta is delivered, continue IV uids with 20 IU/L at 30 drops/minute if still bleeding. If placenta has to be manually removed or uterus does not contract: Repeat 10 IU IM. Continue IV uids with 20 IU/L at 20 drops/minute for one hour after bleeding stops. Max Dose: 3 L of IV uids containing oxytocin. Treatment of postpartum haemorrhage Paracetamol (acetaminophen) Oral Tablet: 250 mg, 500 mg. Rectal Suppositories: 250 mg, 500 mg Adults: 500 mg–1 g oral/rectal every 6hrs Max 4 g daily or max 2 g daily if liver impairment, cirrhosis Children: 10–15 mg/kg oral/rectal up to six times per day Mild to moderate pain, fever, headache Salbutamol (Albuterol) Inhaler: 100 mcg per pu • Adult: Prime with 5 pu s and give 2 pu s via spacer every 2 minutes until improved. • Child: Prime with 5 pu s and give 2 pu s into spacer. Keep spacer in mouth for 3–5 breaths. Repeat until 6 pu s given for < 5 years, or 12 pu s for > 5 years. Nebulizer: (ADULT) 5 mg in 5 ml sterile saline. (CHILD) 2.5 mg in 3 ml sterile saline. For severe wheezing, above doses can be given several times in an hour. Severe wheezing Tetanus Vaccine IM Injection: 0.5 ml (Give for children not up to date; adults with none in 5 years; or status unknown) Wounds (including burns and open fractures) TRANSFER AND HANDOVER Arrange transfer • Check that patient needs match the available services at the destination facility (eg, operating theatre open, blood available) • Communicate directly with an accepting provider at the receiving facility prior to departure • Ensure that destination facility can be reached in time given patient condition • Ensure that patient and family are aware of reasons, plan, and destination for transport • Record family contact name and number in sending facility chart and in paperwork sent with patient • Secure patient valuables for transport (whenever possible, leave with family) • A brief written record (including name, date of birth, clinical presentation and all interventions) should ALWAYS accompany the patient. Prepare for needs during transport • PPE for sta • Airway equipment and suction (check if working before departure) • Adequate oxygen (with replacement tank if needed) and bag valve mask (BVM) • IV access: Check that IV is secured prior to transport; consider second IV or backup supply • Medications: Bring additional doses of medications and uids, and consider other medications that may be needed • Prepare for new or recurrent symptoms. • Seizure/convulsion patients: place pads/pillows around patient to limit injury from a seizure during transport. • Watch for vomiting and ensure that airway remains clear, particularly for those with cervical spine immobilization. • Check that there is adequate fuel for transport. • Ensure that telephone or radio is present in vehicle and working Patient positioning • Position patient for best airway opening and breathing. • Use recovery position if no trauma. • If >20 weeks pregnant and NO spine injury: Place pillows along the length of her right back to tilt patient onto her left side. This avoids compression of the large blood vessels by the pregnant uterus. • Check that cervical spine has been immobilized if indicated. • Possible spine injury: use backboard and log-roll manoeuvre to move patients. Check for pressure spots every 2 hours; pad areas with soft material as needed. If >20-weeks pregnant: Tip backboard slightly to the left using a wedge or other materials. • Splint or immobilize fractures to protect soft tissues and decrease pain and bleeding. On-going care during transport • Re-assess the ABCDE approach at least every 15 minutes, including repeat vital signs and glucose checks if patient has been hypoglycaemic • Control bleeding prior to transport and monitor site for new bleeding • Perform regular re-assessment of any splinted extremity • Continue necessary treatments (e.g. oxygen, IV uids, oxytocin, glucose) • Keep the patient from getting too hot or too cold during transport. 230 Paediatric Considerations • Prepare appropriate size equipment and weight-adjusted dosages of critical medications. • Bring a family member or friend, and tell the receiving facility who is accompanying the child. • Remember that critically ill or injured children can look well initially and then worsen quickly. Monitor closely. • Hypothermia and hypoglycaemia are common in children. Monitor closely. SBAR handover • Situation: Basic patient information (e.g. age, sex); chief complaint (the patient’s initial description of the problem, such as di culty in breathing for 3 days, or arm pain after a fall) • Background: 2–4 most important and relevant aspects of patient’s case and/or condition; important ABCDE ndings/ interventions. • Assessment: What you think is wrong with the patient; reason for the handover/transfer. • Recommendations: next steps in treatment plan; potential worsening of the patient’s condition (e.g. need for close airway observation if inhalation burn is suspected); cautions regarding prior therapies or interventions (e.g. time of last adrenaline dose to anticipate return symptoms, need to monitor mental status if sedating medications have been given, need to monitor 3-way dressing for clotting, etc.).
ISBN 978-92-4-151308-1 World Health Organization Avenue Appia 20 1211 Geneva 27 Switzerland Email: emergencycare@who.int B A SIC EM ER G EN C Y C A R E: A pproach to the acutely ill and injured
ن گا ه ند کن ک ترا ش ل ا م ع ال ور ست د ب تا ک مراقبت های ابتدایی عاجل عملکرد با مریضان و مجروحان حاد مراقبت های اولیه عاجل: رویکرد مواجهه با فرد به شدت مریض و مجروح © کمیته بین المللی صلیب سرخ (CRCI)، 3202 بعضی از حقوق محفوظ است. این اثر تحت مجوز -laicremmocnoN – noitubirttA snommoC evitaerC ekilAerahs 0.3 AS-CN-YB CC) OGI 0.3 -cn-yb/sesnecil/gro.snommocevitaerc//:sptth ;OGI as/0.3/ogi) در دسترس قرار دارد. شما میتوانید این اثر را تحت شرایط این مجوز برای مقاصد غیرتجاری کاپی، توزیع مجدد و اقتباس نمایید، مشروط بر این که به شکل مناسب و به نوعی که در ذیل بیان شده است به اثر اصلی اشاره کرده باشید. در هر نوع استفاده از این اثر، نباید بیان کننده تایید سازمان صحت جهانی (OHW) از کدام سازمان، محصولات یا خدمات مشخصی باشد. استفاده از لوگوی سازمان صحت جهانی و کمیته بین المللی صلیب سرخ مجاز نمیباشد. اگر شما از این اثر اقتباس میکنید، شما هم باید اثرتان را را تحت همان مجوز snommoc evitaerC یا معادل آن قرار دهید. اگر شما ترجمه ای از این اثر را ترتیب نموده اید، باید سلب مسئولیت ذیل را به همراه ارجاع پیشنهاد شده اضافه کنید: "این ترجمه توسط سازمان صحت جهانی یا کمیته بین المللی صلیب سرخ ترتیب نشده است. سازمان صحت جهانی و کمیته بین المللی صلیب سرخ مسئولیتی در قبال محتوا یا صحت این ترجمه ندارند. نسخه اصلی انگلیسی نسخه معتبر و لازم الاجرا میباشد". هرگونه میانجیگری مربوط به اختلافات برخواسته از این مجوز باید مطابق با قواعد میانجیگری سازمان جهانی مالکیت فکری انجام شود. (selur/noitaidem /ne/cma/tni.opiw.www//:ptth) ارجاعات پیشنهادی. مراقبت های اولیه عاجل: رویکرد مواجهه با فرد به شدت مریض و مجروح. جنیوا: کمیته بین المللی صلیب سرخ 3202. مجوز: AS-CN-YB CC 0.3 OGI. مواد مربوط به شخص ثالث. اگر شما میخواهید از مطالب این اثر که به شخص ثالث نسبت داده شده است مانند جداول، ارقام یا تصاویر استفاده مجدد نمایید، این مسئولیت شماست که تعیین کنید آیا برای استفاده مجدد از آن به مجوز نیاز است یا خیر و از دارنده حق طبع و نشر اجازه بگیرید. خطر ادعاهای برخواسته از نقض هرگونه اجزای مرتبط به شخص ثالث در اثر صرفا ًبر عهده استفاده کننده میباشد. عناوین به کار رفته و ارائه مطالب در این نشریه به معنای ابراز نظر سازمان صحت جهانی، کمیته بین المللی صلیب سرخ یا فدراسیون بین المللی خدمات صحی عاجل در مورد وضعیت حقوقی کدام کشور، قلمرو، شهر یا ساحه یا مقامات آن ویا در مورد تعیین حدود مرز های آن نمیباشد. خطوط نقطه دار بر روی نقشه نشان دهنده خطوط مرزی تقریبی میباشد که امکان دارد تا کنون توافق کاملی برای آنها وجود نداشته باشد. ذکر اسم شرکت های مشخص یا تولیدکنندگان محصولات مشخص به این معنی نیست که آنها توسط سازمان صحت جهانی، کمیته بین المللی صلیب سرخ یا فدراسیون بین المللی خدمات صحی عاجل در مقابل شرکت ها یا تولیدکنندگان مشابه که اسم آنها ذکر نشده است، تایید و یا توصیه شده باشند. به استثنای اشتباهات و حذفیات، نام محصولات اختصاصی با حروف اول بزرگ مشخص شده است . تمام اقدامات احتیاطی مورد نیاز توسط سازمان صحت جهانی، کمیته بین المللی صلیب سرخ و فدراسیون بین المللی خدمات صحی عاجل برای تایید معلومات موجود در این نشریه اتخاذ شده است. با این حال، مطالب منتشر شده بدون کدام تضمین صریح یا ضمنی توزیع میگردد. مسئولیت تفسیر و استفاده از مطالب بر عهده خواننده است. به هیچ عنوان سازمان صحت جهانی، کمیته بین المللی صلیب سرخ یا فدراسیون بین المللی خدمات صحی عاجل در قبال خسارات برخواسته از استفاده از آن مسئول نمیباشند. دیزاین توسط moc.noitacinummocsini.www - noitacinummoC sínI مراقبت های ابتدایی عاجل | مشارکت کننده گان تصحیح کننده گان: تیری رینولد، نیکي رودي، اندی تینر، هایکي گیدلد . سایر مشارکت کنندگان مطالب نوشتاری کالی دو- ماگیوری، ویجی کنان، سین کیولهن، نلسن اولم، ماکس ریتزبرگ، ستاس سلارینو اماتو، مورگان بروکولي، فرح کاشف پور، هارلد وین، لی ولیاس. همکاران مرور کننده انیت الینیو، جان براون، ایمیلی کلیولو، برینارد کار، کیگان چیکت، ماتیو کوک، میگان کوکس، انی کریتن، روکلی دیکر، شهیم دی ویریس، ستیفن دنلوپ، راجیت الوالا، جورج اتوندی، صابریا فضا، سکات فرهان، نکولاس گلوب، رینی هسا، کرستنا هوور، موهومپا کافوامافا، جوزف کلنزي، گامیل خلیفه، اولییي کوبوسینگیا، کلفرد من، ادگاردو منندز، جمعه مفینگا، نی کوفی مولاد میلمن ، هاني موفوا، اندریو مک، بریتني موری، مارکوس مسافر، تریسیا اولسوینگن، گیرارد و ریلی، تام پوتوکر، جنید رزاق، انتونی ریدموند، اندریس روبینو، کیلی شکیمدت، کرست ستین ، جانس توپسیس، وکاس کپیل، بنیامن وچیرا. اعضای ذیل کمیته ارتباط بین المللی احیا )ROCLI( راجع به معاینه توانائی خاص اطفال را در مورد بخش های مربوطه ارائه کردند: نیگ کی چونگ ، الن دی سان، این موکوناچي او ریمگیو ویز. اعضای ذیل کمیته اجرایی فدراسیون بین المللی طبی عاجل، بررسی دقیق ضروری را ارائه کردند: پیتر کامرون، جیمز دوچرمي، جم هولیمن، باب شکرفرمایر او اندریو سنگر. گروه تمرکز و مطالعات نمونه ئی ما از پرستاران و دوکتوران شفاخانه ملی موهیمبلی (ilibmihuM( در دارالسلام، تانزانیا، برای کمک ارزشمند شان در گروه های تمرکز اولیه تشکر می کنیم: الی ایم، اکربي، پروسپر جی باشاکا، ایولینا این جمبه، جنفر جمسن، خدیجه ایچ جمعه، برنارد کیفا، سید کلیندیمو، جوزفین لازارو، ویندی لوکوامبای، پیتر ایس مابولا، دیوگراتس مالی، شزنکاندار مروا، جمعه مبوگی، فلیکس دی مالی، ویکتوریا ملیلی، بریتنی موری، کیسا ماوابگما، میرا ناریدرا، کترین آر شری، پاتریک جی شاو، شازمه سلیمان، رینوتورس تاریمو، تیتو ویلیام. ما از فدراسیون طبی عاجل آفریقا برای هماهنگی کلی راهنماها (stoliP( در سال های 5102-7102 سپاسگزاریم. راهنماهای )stoliP( دوره یو گاندا که توسط جوزف کلنزی هدایت می شدند و تسهیل کنندگان کورس بودن عبارت اند از : الیگا کلیف اشر، چارمین کانینگهم ، هایک گدولد، نمگانگا کیزگا، ناماگاندا لوکیا، گریس مگامبو، الکس ماکوپ، جوما مباگی، جوزفین نابولیما، انیت الییو نگابیرانو، موزازا نتیلی. اشتراک کننده گان : حلیمه آدم، دوگلاس اکیبا، موهزا اموس، بیاتریس بایبری، اندریو بالیندا، ایوانس بونابانا، کامارا فرانسس، الیلی فرانکو، مودا گریس، جگوا حکیم، هینری کاگابا، شاهده کگوا، اندریو کگوا، پتر کوما، وینني کیبریکي، بازبو موسی کیریکا، برایان کیسمبو، ناکاییما مارگرت، ادورد موگیشا، لیندا نالوگیا، گیتوردی نامدیمبی، جونیتا نامدو، دینس اونیانگ، ایما توکاهیو. راهنماهای (stoliP( دوره تانزانیا که توسط هندری ساوا هدایت می شدند و داکتران دوره عبارت اند از: چرمن کننگام، جیمي ارنست، اپندو جورج، نیمگانگا کیزگو، دیوگراتس مالی، جمعه مبگی، جمعه مفنگا، فلکس مالی، برتلی ایل میری، سوزانه نگله، نیکي رودي. اشتراک کننده گان: نتولی ابراهیم، توماس بیوري، حمزه حاجي، اگریپینا هوگو، ستیلاابراهیم، فیلومینا جومانی، تیونیلا کامبا، توماس بیوري، ستیلا ابراهیم فیلمومنا جمعه، تینولا کومبا، نیما کایمبو، سکوداني کشمنی، کلیسمنی لومباو، ریموند ماکونا، ریسموری ماریشی، ریشیدي ماتیو، واسینت موبایی، اریک ماهیکي، راشید مهینا، اشا مکوچا، فرانک ملگوزی، لیونداز موتاکوس، پینسی شزننبیولا، کیوهومبو فیم، میری شوراتینگا او نادمبا شیگوندا. راهنماهای )stoliP( زامبیا توسط موفومیو کفوامفوا هدایت می شدند و تسهیل کنندگان دوره عبارتند از: نامیسوکا شیمي، چیپویا چپی، ناگدو حسن، ماندوما کابوکو، ارنی لوفندی،الکس مکوپي، مزازی نیتلی. اشتراک کننده گان : گلوریا چامبیشي، ماورین چکاوا، ازیلنا چولو، ماونازا جکسن، یوسلیا جیرا، تینا مالونگا، پیدیني ماری، مابلی نکزاوی ملینگا، جوی جوی مویش، چیکو سایمای، ایوان سنیولانی او فرانکو زولو. میخواهیم از مورگان بروکولی، سیمون چیری، کترین هافیلي، فرح کاشف پور برای کمک به طراحی بصری و تصویرسازی، و از تین جونگ در مجموع برای تصاویر اصلی ، تشکر کنیم. فهرست مقدمه....................................................................................................................................................................................... 1 مودل 1: عملکرد EDCBA و اخذ تاریخچه ELPMAS........................................................................................... 31 مودل دوم : رسیدگی به صدمات ویا تروما.................................................................................................................... 93 مودل 3 : عملکرد با مشکلات تنفسی............................................................................................................................ 97 مودل چهارم: عملکرد با شاک ..................................................................................................................................... 201 مودل 5: عملکردبا تغییر وضعیت شعوری.................................................................................................................. 721 مراقبت های اولیه عاجل سازمان جهانی صحت OHW )مهارتها( ....................................................................... 351 واژه نامه............................................................................................................................................................................. 412 منابع سازمان جهانی صحت.......................................................................................................................................... 622 مراقبت های ابتدایی عاجل کارت های سریع ........................................................................................................... 722 VI کتاب دستور عملیات اشتراک کننده گان 1 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE مقدمه مرور کلی واقعات عاجل صحی هر روز و در همه جا اتفاق می افتد. آنها بزرگسالان و کودکان را متاثر می سازد و شامل جروحات و انتانات، حملات قلبی و سکته مغزی، اختلاطات حاد حاملگی و مریضی های مزمن می شوند. گرچه مراقبت های تخصصی ممکن است هرگز در همه زمان ها در دسترس نباشد، در حالیکه یک عملکرد سیستماتیک در شرایط اضطراری جان انسان ها را نجات می دهد. پروژه اولویت های کنترول مریضی تخمین می زند که تقریبا ًنیمی از مرگ و میرها و یک سوم ناتوانی ها در کشورهای با درآمد کم و متوسط ناشی از شرایطی است که می توان با مراقبت های اضطراری به آنها رسیدگی کرد. سازمان جهانی صحت (OHW(، با همکاری کمیته بین المللی صلیب سرخ (CRCI( و فدراسیون بین المللی عاجل طبی (MEFI(، دوره مراقبت های عاجل اولیه (CEB( را برای ارائه دهندگان خط مقدم که مدیریت حاد زندگی را در شرایط تهدید کننده با منابع محدود دارد، ایجاد کرده است. اینها ممکن است شامل دانشجویان، پرستاران، تکنیشن های ماقبل شفاخانه یی، کارکنان کلینیکی و داکتران باشد که در ساحه )ماقبل شفاخانه یی( یا شفاخانه کار می کنند. فراهم کننده گان مراقبت های عاجل باید به مریضان « تریاٰژ ناشده »، آنهایی که علایم حاد دارند و ممکن است علت آن مشخص نباشد، پاسخ دهند. این دوره یک عملکرد سیستماتیک را برای مدیریت شرایط حاد، بالقوه تهدید کننده زندگی، حتی قبل از اینکه مرض آن تشخیص شود، معرفی می کند. CEB یا مراقبت های اساسی عاجل بر اساس توصیه های کلینیکی سازمان جهانی صحت ) OHW ( راهنمای دوکتوران منطقه ) IAMI ( ، کتاب جیبی سازمان جهانی صحت مراقبت های شفاخانه برای کودکان، ارزیابی و تداوی تریاژ عاجل )(TATE و مدیریت درست حاملگی و ولادت طبق رهنمود OHW تشکیل شده است. این شامل نمونه هایی در مورد: عملکرد تاریخچه EDCBA و ELPMAS، ضربه یا صدمه، مشکل در تنفس، شاک، و وضعیت ذهنی تغییر یافته است. بخش مهارت های عملی، مداخلات حساس به زمان ضروری برای این ارائه های حاد کلیدی را پوشش می دهد. بسته CEB سازمان جهانی صحت شامل موارد ذیل اند: کتاب تمرین شرکت کننده: منبع اصلی مرجع برای شرکت کنندگان، این کتاب تمرین تعاملی تمام محتوای دوره لازم را ارائه می کند و شامل راهنمای عمیق مهارت های ضروری، لست اصطلاحات، سؤالات مروری و سناریوهای مسایل است. کارت های سریع: این کارت های مرجع ساده نکات کلیدی ارزیابی و مدیریت را برای استفاده در دربخش های کلینیکی حتا فراتر از موضوعات این کورس را در بر میگیرد. اینها در انتهای هر مودیول یا موضوع در انتهای کتاب تمرین یافت می شوند. قمدقم 2 رهنمای تسهیل کننده: این یک نسخه مشروح از کتاب تمرین CEB است که برای تسهیل کننده گان در نظر گرفته شده است. مفاهیم چالش برانگیز برجسته شده و یادداشت هایی در مورد استراتیژی تدریس و آماده سازی لکچر در هر صفحه ارائه شده است. این جلد همچنین شامل یک بخش هماهنگ کننده با اطلاعات برنامه ریزی دوره و تدارکات است و راهنمایی برای انتخاب و آموزش دهندگان ارائه می دهد. مجموعه سلاید های برای ارائه کردن: این مجموعه ها همهمودیول و یا موضوعات کورس را پوشش می دهند و برای ارایه کورس کمک کننده است. دوره CEB ممکن است به روش های مختلفی برای رفع نیازهای محلی اجرا شود، اما یک برنامه 5 روزه توصیه شده به طور مفصل در بخش rotanidrooC راهنمای تسهیل کننده توضیح داده شده است. محتوای CEB همچنین ممکن است در چند هفته به عنوان یک نمونه در برنامه های درسی نرسنگ یا مقطع لیسانس طبی پخش شود. بسته CEB برای حمایت از تلاش های دولت ها، مؤسسات آموزشی، انجمن های حرفه ای و سایرین برای آموزش ارائه کننده گان مراقبت های عاجل که در محدوده کاری تعیین شده شان عمل می کنند، طراحی شده است. سازمان جهانی صحت، استادان یا ارائه کننده گان کورس را تصدیق یا اعتبار نمی دهد. هدف دوره پیشکش های حاد کلیدی این موضوعات ها عملکرد عملی و سیستماتیک را به چهار بخش حاد و بالقوه تهدید کننده زندگی آموزش می دهند: صدمه یا صدمات مشکلات تنفسی شاک تغیر وضعیت شعوری بیشتر شرایط تهدید کننده زندگی، خواه علت اصلی داخله باشد یا جراحی، انتان یا آسیب، با یکی از این موارد ظاهر می شود. در بعضی موارد، تشخیص ممکن است شناخته شده باشد، در حالی که در بعضی دیگر، ممکن است به دلیل محدودیت منابع تشخیصی، اما اغلب به دلیل شدت مریضی، قبل از انجام تشخیص نیاز به مداخله باشد. این نمونه ها یک عملکرد سیستماتیک را برای ارزیابی و مدیریت معرفی می کنند که میتواند مورد استفاده قرار گیرد، چه تشخیص داده شده باشد یا نه. ارائه دهندگان خدمات صحی خط مقدم با ارائه های بسیار بیشتری نسبت به آنچه در این دوره پوشش داده شده است، مواجه خواهند شد. این مطالب برای پوشش دادن همه شرایط حاد نیست، بلکه برای کمک به ارائه دهندگان برای عملکرد باشرایط حساس به زمان است که مداخله زودهنگام پتانسیل نجات جان افراد را دارد. این کورس برای ارزیابی اساسی و مدیریت عاجل بشکل وسیع ایجاد و طراحی شده است. بسیاری از شرکت کتاب دستور عملیات اشتراک کننده گان 3 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE کنندگان ممکن است قبًلا یا بعدا ً برای ارائه مراقبت فراتر از آنچه در اینجا توضیح داده شده است آموزش ببینند. توصیه هایی برای رجعت دهی به یک « مرکز صحی پیشرفته » به منظور نشان دادن نیاز به مراقبت فراتر از محدوده این دوره است. در بعضی موارد، خود شرکت کنندگان ممکن است قبًلا برای ارائه این مراقبت اضافی آموزش دیده باشند. پیشکش های عاجل دیگر شکایات دیگری وجود دارد که ممکن است نشان دهنده یک وضعیت تهدید کننده زندگی باشد که نیاز به مراقبت عاجل دارد حتی قبل از اینکه به هر یک از تظاهرات حاد کلیدی ذکر شده در بالا برسد. این شامل: مشکلات صدر مسمومیت / بلع / قرار گرفتن در معرض مسمومیت ) نیش / گزیدن ( هر دردی شدید ازمنبع نامشخص تقلصات صدری، درد یا خونریزی در اواخر حاملگی این شکایات ممکن است نشان دهنده مرحله اولیه یک مریضی وخیم باشد که نیاز به مداخله سریع دارد، حتی زمانی که فرد نسبتا ًخوب به نظر می رسد. ارزیابی و مدیریت کامل این شرایط خارج از محدوده این دوره است، اما آنها همیشه باید به حمل و نقل یا مشاوره با یک مرکز صحی پیشرفته را آغاز کنند. علاوه بر این، قرار گرفتن در معرض انتان خاصی وجود دارد که نیاز به وقایه عاجل از نگاه زمانی )تداوی وقایوی( دارد که ممکن است موثریت آنها با تاخیر کاهش یابد. این شامل: وخزه شدن کارمند صحی عمل جنسی غیر محافظوی، از جمله در زمینه تجاوز جنسی قرار گرفتن در معرض بزاق دهن حیوان مشکوک به انتان seibaR )انتان سگ دیوانه(. این واقعات باید در اسرع وقت در مرکزی که قادر به ارائه پیشگیری به موقع باشد، ارزیابی شود. قمدقم 4 ملاحظات خاص برای تب تب یک شکایت بسیار شایع است و ممکن است نشانه ای از یک وضعیت تهدید کننده زندگی باشد یا صرفا ً نشانه ای از یک مریضی خفیف باشد که خود به خود برطرف می شود. از آنجا که تب به طور قابل اعتمادی یک وضعیت اضطراری را نشان نمی دهد، در اینجا در یک مودل جداگانه به آن پرداخته نشده است، اما در هر یک از مودل های اصلی پوشش داده شده است. هنگامی که با یافته های غیرطبیعی ) EDCBA( مراجعه شود به بخش « عملکرد به مریض عاجل»(، یا هر یک از تظاهرات حاد بالا )صدمه، مشکل تنفسی، شاک، تغییر وضعیت ذهنی(، تب میتواند سرنخ مهمی برای مریضی شدید باشد. بسیار جدی گرفته شود. علل تب بیشتر از آن چیزی است که بتوان در این دوره ابتدایی پوشش داد، اما بیشتر علل تب که نیاز به تداوی عاجلی دارند با یکی از چهار تظاهرات حاد کلیدی مرتبط هستند. هیچ عملکرد واحدی برای تب وجود ندارد که برای همه موارد اضطراری مناسب باشد، اما اصول کلی وجود دارد که میتواند در ارزیابی و مدیریت مریضان عاجل کمک کند. همیشه انتان را در فردی که تب دارد )مانند مالاریا، مننژیت، سینه و بغل( در نظر بگیرید. هرگز از نبود تب برای رد انتان استفاده نکنید. افراد مبتلا به انتانات شدید یا مشکلات سیستم ایمنی ممکن است نتوانند تب ایجاد کنند و ممکن است حرارت بدن طبیعی یا پایین داشته باشند. تب با علایم حیاتی غیرطبیعی و/یا هر یک از چهار مریضی حاد کلیدی ذکر شده در بالا احتمالا ًنیاز به تداوی زودهنگام انتی بیوتیکی )و/یا ضد مالاریا( دارد. همیشه در نظر داشته باشید که آیا پروتوکول ها برای تشخیص شیوع امراض ساری )مانند تب های خونریزی دهنده( نیاز به اقدامات بیشتر )مثًلا گزارش یا مدیریت خاص( در فرد مبتلا به تب دارد یا خیر. ولادت و احیای نوزادان مدیریت ولادت و احیای نوزادان موضوعات مهمی هستند که در جاهای دیگر در مواد موجود OHW تحت پوشش قرار می گیرند و در این دوره پوشش داده نمی شوند. برای مطالب آموزشی در مورد این موضوعات به وبسایت بخش صحت مادر، نوزاد، کودک و نوجوان _lanretam/tni.ohw.www//:ptth( OHW ne/stnemucod/tnecseloda_dlihc/( مراجعه کنید. سطح دانش قبلی اشتراک کننده گان مورد نظر این دوره دارای دانش بنیادی در زمینه های زیر است: استفاده از تجهیزات محافظت فردی اناتومی اساسی انسان گرفتن تاریخچه اولیه مهارت های اولیه معاینه فیزیکی، شامل گرفتن علایم حیاتی، شنیدن صدا های صدری و ارزیابی بطنی استفاده از گلوکومتر کتاب دستور عملیات اشتراک کننده گان 5 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE تنظیم تطبیق مایعات وریدی تزریق ادویه از طریق عضلی مصؤن یا بی خطر احیای قلبی ریوی )RPC( احیای قلبی ریوی (RPC) تصمیم گیری در مورد مناسب بودن یا نبودن RPC برای یک مریض خاص به عوامل زیادی بستگی دارد، از جمله درک علت مریضی، آگاهی از منابع موجود، و آگاهی از پروتوکول ها و اقدامات سازمانی مرتبط. حالات زیادی وجود دارد که ممکن است شروع و سپس پایان دادن به RPC پس از یک مدت زمان مشخص مناسب باشد و در بعضی حالات ممکن است شروع RPC مناسب نباشد. در حالی که این دوره به چندین جنبه از احیا می پردازد، پروتوکول کلی RPC را پوشش نمیدهد، زیرا ممکن است با تنظیم بسیار متفاوت باشند. مجریان دوره باید شرکت کنندگان را به منبع مناسب برای پروتوکول های RPC مربوطه هدایت کنند. ادویه ادویه جاتی مورد بحث در این دوره به طور گسترده در دسترس هستند و برای استفاده توسط ارائه دهندگان خط مقدم که دوره برای آنها طراحی شده است مناسب است. آنها را می توان در تاسیسات قبل از شفاخانه یی یا مبتنی بر تسهیلات استفاده کرد و تداوی های اولیه مهم برای شرایط اضطراری هستند. ادویه جاتی ارائه شده بنیاد برای مراقبت های اولیه عاجل فراهم می کنند، اما تقریبا ًهر شرایطی که در این کتاب تمرین مورد بحث قرار می گیرد، به تداوی های فراتر از موارد ذکر شده نیاز دارد. بسیاری از تداوی های مهم عاجل که توسط فراهم کننده گان پیشرفته استفاده می شود در این دوره گنجانیده نشده است. رجعت دهی / انتقال این کورس برای کمک به فراهم کننده گان طراحی شده است تا مدیریت اولیه شرایط حاد و تهدید کننده زندگی را شناسایی و تامین کننند. اکثر مریضان مبتلا به مریضی حاد به مراقبت فراتر از این مرحله اولیه نیاز دارند. این ممکن است مراقبت روزمره یی باشد که توسط همان فراهم کننده تامین میشود، اما بیشتر اوقات به تامین کننده یا مرکز پیشرفته تری طبی نیاز دارد. این پروسه تصمیم گیری در مورد وضعیت مناسب - یا مرحله بعدی مراقبت - برای مریض حاد، بخش مهمی از مراقبت های عاجل است. انتخاب انتقال درست شامل ارزیابی دقیق مریض است. تخمین سرعت پیشرفت مریضی؛ در نظر گرفتن اینکه آیا انتقال برای یک مداخله خاص )مانند جراحی، انتقال خون( مورد نیاز است یا خیر. و شناسایی هر گونه خطر خاص بر اساس تشخیص مشکوک یا شناخته شده )مانند خطر تشنج/اختلاج مکرر، یا بدتر شدن بندش طرق هوایی(. ملاحظات ویژه برای هر تظاهرات حاد کلیدی و تشخیص های مرتبط با آن در بخش ها پوشش داده شده است. برنامه ریزی برای رجعت دهی/انتقال مستلزم برقراری ارتباط اطلاعات ضروری با مرکز دریافت کننده، ایجاد یک طرح حمل و نقل و اطمینان از در دسترس بودن تجهیزات لازم برای محافظت از ارائه دهندگان و مراقبت از مریضان است. این جز به طور مفصل در «انتقال و رجعت دهی» در بخش مهارت ها پوشش داده خواهند شد. قمدقم 6 تریاژ (egairT) تریاژ پروسه سیستماتیک طبقه بندی مریضان بر اساس دقت برای اطمینان از بهترین تطابق بین منابع موجود و نیازهای کاربر است. تریاژ یکی از اجزای ضروری مراقبت های عاجل در شرایط عادی و عاجل است و شروع این پروسه از سطح رهبری مرکز صحی شروع میشود که برای همه مریضان اعمال می شود و امکان ارزیابی هر مریض را در زمینه فراهم می کند. به این ترتیب، در این کورس آموزش به آن پرداخته نمی شود، اما اغلب به طور همزمان تدریس می شود. OHW و CRCI، با همکاری داکتر بدون مرز )FSM( و تیم امتیاز تریاژ آفریقای جنوبی )STAS(، مجموعه ای از ابزارهای تریاژ یکپارچه و یک مودل آموزشی دسترسی آزاد مرتبط را توسعه داده اند. برای درخواست این مواد با tni.ohw@eracycnegreme تماس بگیرید. رسیدگی با مریض عاجل کورس CEB برای طیف گسترده ای از فراهم کننده گان خط مقدم در نظر گرفته شده است و یک عملکرد ابتدایی برای حالات تهدید کننده زندگی تامین میکند. شرایط عاجل اغلب نیاز به مداخله فوری مدت ها قبل از ایجاد تشخیص دارند و یک عملکرد مرتبط به شرایط برای مدیریت موثر مریضان ضروری است. بخش ها یا مودل های این کورس اجزای یک عملکرد کلی را آموزش می دهند که میتواند برای هر مریض عاجل استفاده شود. عملکرد EDCBA امکان ارزیابی و مداخله سریع برای تهدیدات زندگی را با استفاده از کتگوری های ذیل فراهم می کند: A: طرق هوایی B: تنفس C: دوران خون D: ناتوانی E: در معرض قرار گرفتن ملاحظات اساسی EDCBA در مودل ها برای هر یک از چهار پیشکش کلیدی فهرست شده است. تاریخچه ELPMAS روش برای جمع آوری سریع شرح حال حیاتی برای مدیریت مریض مبتلا به مریضی حاد است. اجزای تاریخچه ELPMAS عبارتند از: S: اعراض و علایم A: الرژی (حساسیت) M: ادویه جات P: تاریخچه طبی گذشته L: آخرین مصرف خوراکی E: واقعات مرتبط به مریضی سوالات ضروری ELPMAS در مودل ها برای هر یک از چهار پیشکش کلیدی فهرست شده است. کتاب دستور عملیات اشتراک کننده گان 7 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE بررسی ثانوی یک معاینه فیزیکی کامل بر اساس شرایط خاص است. اجزای مرتبط ضروری ارزیابی ثانوی در مودل های هر یک از چهار پیشکش کلیدی فهرست شده اند. جزئیات بیشتر در بخش مهارت ها پوشش داده شده است. شیوه استفاده از کتاب کاری اشتراک کنندگان این کتاب تمرین اشتراک کننده با ارایه های کورس CEB OHW مرتبط شده است و برای کمک به شرکت کنندگان در آماده سازی برای هر درس برای به حداکثر رساندن یادگیری طراحی شده است. هر مودل مطالب خواندنی و تمرین هایی را برای تکمیل قبل از درس پیشکش میکند. شرکت کنندگان نباید نگران باشند اگر موضوعات وجود دارد که آنها به تنهایی درک نمی کنند، زیرا تمام محتوای کتاب تمرین در جریان پروگرام آموزشی مورد بحث قرار میگیرند. قبل از هر بخش، شرکت کنندگان باید: تعاریف عبارت های کلیدی مودل های مربوطه را با کپی کردن از لیست در پشت کتاب تمرین، بنویسد. تمام سوالات بررسی کتاب تمرین را در مودل های مربوطه کامل کنید. سوالات چند گزینه ای و سناریوهای مسایل در پایان هر مودل در جلسات گروه کوچک در طول کورس پوشش داده می شود، اما شرکت کنندگان باید قبل از جلسه آنها را مطالعه کنند. پس از اتمام کورس، شرکت کنندگان می توانند از این کتاب به عنوان مرجع استفاده کنند. کارت های سریع مرجع نیز همراه با کتاب است. این کارت ها خلاصه ای از نکات ضروری دوره را ارائه می کنند و به گونه ای طراحی شده اند که در محیط کلینیکی برای رهنمای تمرین روزانه استفاده شوند. شکل مودل این کورس شامل یک مودل در مورد رسیدگی عمومی به همه مریضان عاجل )EDCBA و ELPMAS( است. یک مودل در عملکرد مصدومین )صدمه(؛ سه مودل در مورد سایر تظاهرات کلینیکی خاص )مشکل تنفسی، شاک و تغییر وضعیت ذهنی(. بخش مهارت ها؛ و یک ذخیره اصطلاحات. مودل ها شامل بخش های ذیل هستند: اهداف: فهرستی از کارهایی که شرکت کنندگان باید بتوانند تا پایان دوره انجام دهند. مهارت های ضروری: فهرستی از مهارت های مرتبط با مودل )و بعدا ًدر بخش مهارت ها آموزش داده شد(. اصطلاحات کلیدی: کلمات و عبارات مهم مورد نیاز برای درک مودل. همه تعاریف را می توان در ذخیره اصطلاحات یافت و باید در جا های خالی مشخص شده قبل از شرح هر موضوع نوشته شود. معاینه عمومی: مقدمه ای کوتاه برای ارائه کلینیکی که در مودل مورد بحث قرار می گیرد. اهداف ارزیابی اولیه: هدف اصلی ارزیابی تظاهرات کلینیکی. اهداف مدیریت حاد: نتیجه مطلوب مدیریت شرایط کلینیکی. قمدقم 8 عناصر کلیدی EDCBA: یافته ها و مداخلات EDCBA مربوط به شرایط کلینیکی خاص که در مودل مورد توجه قرار گرفته است. یافته های تاریخچه کلیدی (KSA(: اجزای تاریخچه ELPMAS مربوط به تظاهرات کلینیکی که برای مدیریت حیاتی هستند. یافته های ارزیابی ثانوی )ارزیابی به اساس دیدن، گوش دادن و احساس(: یافته های معاینه ثانوی مربوطه برای بررسی در پیشکش کلینیکی که مودل به آن اشاره می کند. عوامل احتمالی: امراض، ترضیضات یا مریضی های خاصی که میتواند باعث ایجاد شرایط که در مودل به آن اشاره شده ، محسوب گردد )همراه با علایم و نشانه های خاص آن ها(. مدیریت )انجام دادن(: این بخش ها مدیریت حالت های خاص را توضیح می دهند. به یاد داشته باشید که مودل های EDCBA و صدمه فهرست های طولانی تری از شرایط اضطراری احتمالی دارند و بخش های عوامل احتمالی و مدیریت در جداول ارائه شده اند. مودل تروما یک جدول جداگانه برای حالت های خاص سروی ابتدائی دارد. ملاحظات ویژه در کودکان: تفاوت های مهم در اعراض و علایم و نیازهای مدیریتی کودکان. ملاحظات رفتاری: موارد خاصی که هنگام انتقال یا رجعت دهی مریضان باید در نظر گرفته شود. سناریوهای مسایل مبتنی بر تسهیل کننده: این سناریوها توانائی شرکت کنندگان را در استفاده از آموخته هایشان برای مدیریت مریض آزمایش می کند. این سناریوها توسط مربی رهبری می شود. سؤالات چند گزینه ای )QCM(: پنج سؤال چند گزینه ای برای آزمایش دانش شما در پایان هر مودل برای آمادگی برای امتحان کتبی نهایی وجود دارد. مقررات برای شرکت کنند گان شرکت کنندگان باید مقررات کورس آموزشی را با تسهیل کننده خود تأیید کنند. زمانی که کورس مراقبت ابتدایی عاجل به طور کامل اجرا شود، نیاز به تکمیل تمام اجزای فهرست شده در زیر دارد. امتحان قبل از کورس. قبل از دریافت کتاب تمرین کورس مراقبت های ابتدایی عاجل، شرکت کنندگان باید این امتحان را تکمیل کرده باشند، که به اشتراک کننده گان کمک می کند تا سطح دانش فعلی خود را درک کنند. گزارش حاضری. شرکت کنندگان باید هر روز برای هر دو جلسه صبح و بعد از ظهر حاضری امضا کنند. شرکت کنندگان برای گذراندن دوره باید در تمام جلسات شرکت کنند. تکمیل کتاب تمرین. همانطور که در بالا توضیح داده شد، شرکت کنندگان باید تمام اصطلاحات کلیدی و سوالات کتاب تمرین را در مودل مربوطه قبل از هر درس تکمیل کنند. تمام عبارات کلیدی باید تعریف شوند و به تمام سوالات کتاب تمرین پاسخ داده شود تا کتاب تمرین تکمیل شده در نظر گرفته شود. کتابهای کتاب دستور عملیات اشتراک کننده گان 9 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE کار هر روز توسط تسهیل کننده گان بررسی می شود. شرکت کنندگان برای سپری نمودن کورس و یا دوره آموزشی باید کتاب تمرین را تکمیل کنند. مهارت گاه. در طول روز مهارت، اشتراک کننده گان مهارت های خود را در بخش عملی نشان می دهند. شرکت کنندگان این فرصت را خواهند داشت که مهارت را در هر جایگاه چندین بار تمرین کنند. شرکت کنندگان می توانند یک مهارت را هر چند بار که لازم است نظر به زمان بشکل عملی انجام دهند. در طول تمرین، شرکت کنندگان ممکن است از کتاب تمرین و چک لیست مهارت به عنوان مرجع استفاده کنند، و ممکن است در صورت نیاز از تسهیل سؤال بپرسند. در طول ارزیابی، هیچ مواد درسی مجاز نخواهد بود، بنابراین شرکت کنندگان باید بدون مرجع نیز تمرین کنند و از شرکت کننده دیگری بخواهند هر مرحله از دست رفته را مشاهده کند. شرکت کنندگان زمان زیادی برای تمرین و احساس اعتماد به مهارت ها قبل از ارزیابی خواهند داشت، و در صورت آمادگی، باید از مربی درخواست کنند که آنها را در اجرای مهارت ارزیابی کند. تمام مراحل در چک لیست مهارت باید برای سپری نمودن ارزیابی انجام شود. شرکت کنندگان برای گذراندن کورس باید ارزیابی های بخش مهارت را سپری کنند. سناریوهای قضیه. برای کامیابی در کورس آموزشی تمام اشتراک کننده گان باید یک سناریو را موفقانه هدایت و مدیریت کنند . این سناریوها به شرکت کنندگان فرصتی برای تمرین یک عملکرد واحد برای مدیریت در گروه های کوچک 3 تا 4 شرکت کننده می دهد. تسهیل کننده ها با گروه درباره نحوه برخورد با سناریوهای قضیه با استفاده از عملکرد EDCBA بحث خواهند کرد. در مودل های بعدی، هر شرکت کننده از نظر توانائی رهبری و مدیریت یک سناریوی قضیه ارزیابی میشود. رهبری یک سناریوی قضیه شامل شناسایی جنبه های حیاتی ارزیابی و مدیریت، و همچنین ارائه خلاصه ای عملکرد از جریان تمرین )به بخش رجعت دهی در مهارت ها مراجعه کنید(. تسهیل کننده ها چک لیست زیر را تکمیل می کنند تا شرکت کننده ای را که واقعه را هدایت می کند، ارزیابی کنند. به شرکت کنندگانی که در شناسایی و مدیریت شرایط حیاتی در سناریو موفق نباشند، قضیه دوم در همان جلسه یا جلسه بعدی داده می شود. ارزیابی ها بر اساس یک راهنمای استاندارد و جدول ذیل گزارش شده است. تمام شناسائی شده بعضی شناسایی ارزیابی سناریوی قضیه شناسائی نشده شده مداخله حیاتی طرق هوائی مداخله حیاتی تنفس مداخله حیاتی دوران خون مداخله حیاتی ناتوانی مداخله حیاتی در معرض قرار گرفتن ادویه جات حیاتی ) طبق ضرورت( خلاصه تحویل مناسب را در آخر ارائه کرد بلی نخیر شرکت کننده تمام اجزای ضروری را انجام داد بلی نخیر نظرایت )از جمله یادآوری هر عنصر از دست رفته( : قمدقم 01 امتحان نهائی تحریری شرکت کنندگان برای واجد شرایط بودن برای شرکت در امتحان نهایی باید: مرحله قبل از امتحان را تکمیل کند. عبارت های کلیدی و سوالات کتاب تمرین را کامل کند. در تمام جلسات دوره حضور داشته باشد. یک سیناریوی قضیه را رهبری کند. تمام قدمه های مهارت را همانطور که توسط یک مربی بررسی شده است، سپری کند. امتحان نهایی شامل سوالات چند گزینه ای خواهد بود. شرکت کنندگان برای موفق شدن باید حداقل ۵۷ درصد امتیاز کسب کنند. نظرات شما به بهبود کورس های آموزشی آینده کمک خواهد کرد. لطفًا هر گونه نظر، اصلاح یا سؤال را به آدرس tni.ohw@eracycnegreme ارسال کنید. ما همه شرکت کنندگان و داکتران را تشویق می کنیم تا یک نظرسنجی کوتاه قبل و بعد از دوره را در /tni.ohw.www eracycnegreme پر کنند. کتاب دستور عملیات اشتراک کننده گان 11 عملکرد EDCBA و اخذ تاریخچه به اساس ELPMAS قمدقم 21 یادداشت کتاب دستور عملیات اشتراک کننده گان 31 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE مودل 1: عملکرد EDCBA و اخذ تاریخچه به اساس ELPMAS اهداف با تکمیل نمودن این مودل باید بتوانید: خطراتی را که باید هنگام مراجعه به یک فرد مریض یا مجروح در نظر گرفته شود فهرست کنید.. 1 اجزای مداخله مسون به یک مریض یا مجروح را فهرست کنید.2. اجزای مداخلات سیستماتیک EDCBA را برای مریضان عاجل فهرست کنید.. 3 ارزیابی طرق هوایی. 4 توضیح دهید که چه زمانی باید از وسایل برای مدیریت طرق تنفسی استفاده کنید.. 5 توضیح دهید که چه زمانی به مدیریت پیشرفته طرق هوایی نیاز است.. 6 تنفس را ارزیابی کنید. . 7 توضیح دهید که چه زمانی کمک تنفسی را انجام میدهید. . 8 وضعیت مایع )دوران خون( را ارزیابی کنید. . 9 احیای مایع مناسب را توسط مایعات فراهم کنید. . 01 اقدامات حیاتی EDCBA را شرح دهید.. 11 عناصر یک تاریخچه ELPMAS را فهرست کنید.. 21 تاریخچه به اساس ELPMAS اخذ نمایید. . 31 مهارت های ضرورری ارزابی EDCBA بی حرکت ساختن ستون فقرات گردن بی حرکتی کامل ستون فقرات مانور tsurhT waJ /tfil nihC dna tliT daeH سکشن طرق تنفسی مدیریت خفگی وضعیت ریکاوری یا احیا استفاده از وسایل جهت باز نگهداشتن طرق تنفسی ) تیوب انفی بلعومی ویا فمی بلعومی( تهویه ماسک evlav-gaB تجویز آکسیجن تست جلدی ویا tset hcnip nikS ارزیابی UPVA )هشدار، صدا، درد، بی پاسخ(. تنظیم گلوکوز رفع فشار توسط سوزن برای نوموتوراکس تنشی پانسمان سه طرفه برای زخم سینه تطبیق کنول وریدی. احیای مایع وریدی فشار مستقیم برای کنترول خونریزی، از جمله تامپون کردن زخم عمیق تورنیکیت برای کنترول خونریزی اتصال لگن خاصره مدیریت زخم بی حرکت ساختن شکستگی مدیریت مارگزیدگی قلووم1عم:1 لدوم1لدووم م1EDمBل درک مع م1 لدمم1 لدوم 41 اصطلاحات کلیدی اصطلاحات را با استفاده از ذخیره لغات که در عقب کتاب تمرین است، تعریف کنید. EDCBA : استفاده از عضلات اضافی یا جانبی: تغیر وضعیت شعوری )SMA( : حساسیت شدید: UPVA: ) هوش ، صدا ، درد، ، بی پاسخ( ماسک (MVB(: برگشت خون به عروق شعریه )emit llfieR yrallipaC( احیای قلبی ریوی (RPC(: ستون فقرات گردن: تشنج: ترقه یا (snoitatiperc( : کریپیتوس: بسته بندی زخم عمیق: دستگاه شاک یا دیفیبریلاتور: siserohpaiD یا عرقریزی زیاد: مشکلات تنفسی: بیجاشدن )noitisopsiD( کتاب دستور عملیات اشتراک کننده گان 51 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE جسم اجنبی: مقیاس کومای wocsolG )SCG( : لکه های جلدی )seviH(: amotameaH خونریزی: xarohtomeaH یا تجمع خون در ریه ها: ecnanoserrepyH یا صدای طبلیت: aimrehtrepyH یا حرارت بلند: aimeacylgopyH یا شکر پایین خون: aimrehtopyH یا حرارت پایین بدن: noisnetopyH یا فشار پایین خون: aixopyH یا کاهش اکسیجن: yrujni noitalahnI یا آسیب ناشی از انشقاق: noitabutnI یا تیوب گذاری: کنول وریدی با قطر بزرگ: گشاد شدن بینی: تیوب انفی بلعومی: رفع فشار با سوزن: amedeO یا اذیما )پندیدگی( : قلووم1عم:1 لدوم1لدووم م1EDمBل درک مع م1 لدمم1 لدوم 61 تیوب فمی بلعومی (APO( اشباع اکسیجن (2O tas(: noissucreP یا قرع: noisufreP : جریان مایعات داخل رگ ها : edanopmat laidracireP یا تیمپوناد قلبی: وسایل محفاظت فردی/شخصی (EPP(: noisuffe laruelP یا انصباب پلورا: xarohtomuenP یا تجمع هوا در جوف پلورای ریه: retemixo esluP نبض سنج: snoitcarteR یا فرورفتن عضلات صدری: yrotsih ELPMAS یا تاریخچه سمپل: eruzieS یا تشنج: شاک: rodirtS یا تنفس صدادار: جروحات مکنده صدری: aenpyhcaT یا تنفس سریع: xarohtomuenp noisneT: gnizeehW: کتاب دستور عملیات اشتراک کننده گان 71 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE مرور اجمالی عملکرد با هر مریض به روش سیستماتیک تضمین می کند که شرایط تهدید کننده زندگی به سرعت شناسایی شده و حیاتی ترین مداخلات در اوئل انجام می شود. در یک مریض باثبات از نظر علایم حیاتی، عملکرد اولیه EDCBA ممکن است تنها چند ثانیه تا چند دقیقه طول بکشد. EDCBA باید با یک شرح حال سریع با استفاده از روش ELPMAS )علایم و نشانه ها، الرژی ها، ادویه ها، ستاریخچه طبی گذشته، آخرین مصرف خوراکی و رویدادها( تعقیب شود. مقوله های تاریخچه ELPMAS به طور کلی در زیر توضیح داده شده اند و سؤالات ضروری برای یک ارائه خاص در مودل مربوطه فهرست شده اند. استفاده از روش استاندارد ELPMAS و EDCBA با هم تضمین می کند که ارائه دهندگان مختلف می توانند به راحتی در مورد مریضان مبتلا به مریضی حاد ارتباط برقرار کنند. هدف از عملکرد EDCBA شناسایی سریع شرایط تهدید کننده زندگی است. اطمینان حاصل کنید که طرق تنفسی باز می ماند. و اطمینان حاصل کنید که تنفس و دوران خون برای رساندن اکسیجن به بدن کافی است. هدف اخذ ELPMAS جمع آوری سریع تاریخچه مطابق آن است که برای مدیریت مریضان حاد ضروری است. این مودل به موارد ذیل خواهد پرداخت: ملاحظات محافظتی عناصر عملکرد EDCBA بطور مشرح: شرایط حاد تهدید کننده زندگی )اعراض، علایم و مدیریت( ملاحظات اطفال در عملکرد EDCBA عناصر تاریخچه ELPMAS ملاحظات وضعیت مصئونیت بخش مهمی از عملکرد حفاظت مریضان و مصدومین و ارایه کنندگان خدمات عاجل میباشد.. یک کمک کننده مریض یا مجروح نمیتواند به کسی دیگر کمک کند، و در عوض به یک مریض اضافی برای سایر کمک دهندگان تبدیل می شود. ملاحظات محافظتی شامل بررسی موارد ذیل است: خطرات صحنه. آیا آتش سوزی، سیم برق یا نشات مواد کیمیاوی وجود دارد که میتواند به کمک قلووم1عم:1 لدوم1لدووم م1EDمBل درک مع م1 لدمم1 لدوم 81 کنندگان یا اطرافیان آسیب برساند؟ در حادثات جاده ای، آیا صحنه برای ترافیک روبرو بسته است؟ اگر ساختمانی فروریخته باشد، آیا ورود آن امن است؟ در صحنه انفجار، همیشه احتمال انفجارهای بعدی را در نظر بگیرید. به یاد داشته باشید که فروریختن تاخیری ساختمان ممکن است به تعقیب انفجار، آتش سوزی و زلزله باشد. خشونت. آیا احتمال آسیب رساندن به ارائه دهندگان توسط مریض یا دیگران وجود دارد؟ برای مریضانی که پرخاشگر یا آشفته هستند، قبل از شروع ارزیابی، در صورت نیاز از پرسنل امنیتی یا پولیس درخواست کمک کنید. خطر مبتلا شدن به انتان. آیا احتمال قرار گرفتن در معرض انتانات )مانند آنفولانزا یا تب خونریزی دهنده( وجود دارد؟ استفاده از وسایل محافظت شخصی ممکن است وقتی برای اولین بار به مریض نزدیک می شوید علت مریضی یا آسیب را ندانید و بدون وسایل حفاظتی شخصی )EPP( مناسب ، ممکن است خود را در معرض انتانات، مواد کیمیاوی یا سموم قرار دهید. هر بار که به مریض نزدیک می شوید باید از وسایل حفاظتی شخصی مناسب استفاده کنید. همیشه از خود در برابر هرگونه قرار گرفتن در معرض مایعات بدن محافظت کنید. این تقریبا ًهمیشه به دستکش و محافظ چشم نیاز دارد و ممکن است نیاز به روپوش و ماسک داشته باشد. بعضی شرایط، مانند شیوع تب خونریزی دهنده مشکوک یا تایید شده، نیاز به اقدامات حفاظتی خاصی دارد. همیشه مطمئن باشید که در مورد توصیه های فعلی طبق روز هستید. پاک نمودن و ضد عفونی کردن مواجع شدن به واقعات انتانی یک خطر قابل توجه است. از وسایل مخفاظتی شخصی استفاده کنید و دست های خود را قبل و بعد از هر تماس با مریض بشویید. در صحنه، شستن دست ها ممکن است فورا امکان پذیر نباشد. در صورت امکان یک پاک کننده ژل الکولی همراه داشته باشید. بین مریضان، تمام سطوح تاسیسات و وسایل نقلیه و تمام تجهیزات قابل استفاده مجدد را پاک و ضد عفونی کنید. ممکن است پس از قرار گرفتن در معرض ضد عفونی یا سایر مواد کیمیاوی )خشک یا مرطوب( ضدعفونی لازم باشد و وابسته به ماده کیمیاوی، ممکن است شامل شستشو یا برس کردن برای حذف ماده باشد. همه مواد کیمیاوی را نمی توان به طور محفوظ شست و شو داد، و بعضی باید به روش های خاصی پاک شوند تا از آسیب بیشتر جلوگیری شود. برای این کار باید از وسایل محافظتی شخصی EPP مناسب استفاده کنید. به پروتوکول های ضدعفونی محلی برای افراد و تجهیزات مراجعه کنید. در صورت نیاز کمک بیشتر بخواهید اگر چند نفر مجروح یا مریض هستند، برای کمک تماس بگیرید یا کسی را برای تماس بفرستید. در صورت نیاز به مراقبت پیشرفته، هر چه زودتر مقدمات مشوره یا انتقال را آغاز کنید. سازمان های محلی مربوطه را بشناسید تا برای شیوع های مشکوک یا قرار گرفتن در معرض خطر، مانند نشات مواد کیمیاوی یا تشعشعات، با آنها تماس بگیرید. اغلب پشتیبانی و راهنمایی برای مهار و رفع آلودگی وجود دارد. کتاب دستور عملیات اشتراک کننده گان 91 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE سوال شماره 1 کتاب تمرین: محافظت فردی با استفراغ، خونریزی از دهن و شکایت از درد شکم وارد مرکز صحی شما میشود. با استفاده از بخش کتاب تمرین بالا، آنچه برای مراجعه مصئون با این شخص لازم است را شرح دهید: عناصر عملکرد EDCBA عملکرد EDCBA عملکرد EDCBA چارچوبی را برای ارزیابی سیستماتیک و سازماندهی شده مریضان حاد به منظور شناسایی سریع و مداخله در شرایط تهدید کننده زندگی فراهم می کند: A - طرق تنفسی: هرگونه انسداد )بندش( در حرکت هوا به داخل ریه ها را بررسی و اصلاح کنید B - تنفس: از حرکت کافی هوا به داخل ریه ها اطمینان حاصل کنید. C - دوران خون: بررسی کنید که آیا، جریان خون کافی برای رساندن آکسیجن به انساج وجود دارد یا خیر. علایم خونریزی تهدید کننده زندگی را بررسی کنید. D - ناتوانی: عملکرد مغز و ستون فقرات را ارزیابی و محافظت کنید C - در معرض قرار گرفتن: همه صدمات و هرگونه تهدید محیطی را شناسایی کنید و از درجه پایین حرارت اجتناب کنید. این عملکرد گام به گام طراحی شده است تا اطمینان حاصل شود که شرایط تهدید کننده زندگی را می توان به ترتیب اولویت شناسایی و تداوی کرد. اگر مشکلی در هر یک از این مراحل کشف شد، باید بلافاصله قبل از رفتن به مرحله بعدی به آن رسیدگی شود. روش EDCBA باید در ۵ دقیقه اول انجام شود و هر زمان که وضعیت مریض تغییر کرد یا بدتر شد، تکرار شود. قلووم1عم:1 لدوم1لدووم م1EDمBل درک مع م1 لدمم1 لدوم 02 ارزیابی و مدیریت EDCBA به یاد داشته باشید.... همیشه نشانه های صدمه را در هر یک از بخش های EDCBA بررسی کنید و در صورت نیاز به مودل صدمه مراجعه کنید. [به صدمه مراجعه کنید] ارزیابی مدیریت فوری اگر مریض بیهوش است و به طور طبیعی نفس نمی کشد و: بدون صدمه: طرق هوایی را باز کنید با استفاده از مانور tfil nihc tliT daeH. [به مهارت ها مراجعه کنید] نگرانی برای صدمه: حفظ بی حرکتی ستون فقرات گردنی و باز کردن طرق هوایی با استفاده از مانور بلند tsurht waJ. [به مهارت ها مراجعه کنید] یک APO و یا تیوب فمی بلعومی برای حفظ طرق هوایی قرار دهید. [به مهارت ها مراجعه کنید] در صورت مشکوک بودن به جسم خارجی: اگر جسم قابل مشاهده است، آن را بردارید - مراقب باشید که جسم را به عمق بیشتری فشار ندهید. اگر مریض قادر به سرفه کردن یا ایجاد صدا است، مریض را آرام نگه دارید و سرفه را تشویق کنید. اگر مریض در حال خفگی است )نمی تواند سرفه کند، صدا تولید نمی کند( از فشار های سینه / ضربه های بطنی/ ضربه های پشت بدن مناسب سن استفاده کنید.[به مهارت ها مراجعه کنید] اگر مریض هنگام خفگی بیهوش شد، پروتوکول های RPC مربوطه را تعقیب کنید. اگر ترشحات یا استفراغ وجود دارد، در صورت وجود سکشن کنید یا پاک کنید. اگر بقیه EDCBA طبیعی است و مشکوک به صدمه نیست، مریض را در وضعیت بهبودی قرار دهید. [به مهارت ها مراجعه کنید] اگر مریض پندیدگی، کهیر یا rodirts دارد، عکس العمل حساسیتی شدید )عکس العمل شدید( را در نظر بگیرید و ادرینالین عضلی بدهید. [به مهارت ها مراجعه کنید] به مریض اجازه دهید تا در موقعیت راحتی بماند و در صورت نیاز برای انتقال/رجعت دهی سریع به مرکزی که قادر به مدیریت پیشرفته طرق هوایی است، آماده شود. آیا مریض میتواند بوطور نارمل صحبت کند؟ اگر بلی پس طرق تنفسی باز است. اگر مریض نمیتواند نارمل صحبت کند پس: نگاه کنید تا ببینید آیا دیوار قفس سینه در حال حرکت است یا خیر و گوش دهید تا ببینید آیا حرکت هوا از دهان یا بینی وجود دارد یا خیر. به صداهای غیرعادی )مانند استریدور، وصف جوشیدن آب، یا خروپف( یا صدای خشن یا خشن که نشان دهنده انسداد )بندش( جزئی طرق هوایی است گوش دهید. استریدور به همراه پندیدگی نشان دهنده یک عکس العمل حساسیتی شدید )عکس العمل شدید( است. به وجود مایعات )مانند خون، استفراغ( در طرق هوایی نگاه کنید و گوش دهید. به تعقیب پندیدگی غیر نارمل جسم خارجی در اطراف طرق هوایی و تغییر وضعیت ذهنی باشید. بررسی کنید که آیا مریض قادر به بلعیدن بزاق است یا آب دهان می ریزد. طرق هوایی اگر طرق هوایی ( تنفسی ) باز است پس به تنفس توجه کنید. کتاب دستور عملیات اشتراک کننده گان 12 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE ارزیابی مدیریت فوری در صورت بیهوشی همراه با تنفس غیرطبیعی، تهویه ماسک evlav-gaB را شروع کنید و پروتوکول های RPC مربوطه را تعقیب کنید. اگر به اندازه کافی نفس نمی کشید )به دلیل سن خیلی کم یا خیلی کم عمق(، تهویه ماسک evlav-gaB را با آکسیجن شروع کنید [به مهارت ها مراجعه کنید]. اگر آکسیجن فورا ً در دسترس نیست، تهویه را به تاخیر نیندازید. در حالی که آکسیجن در حال آماده شدن است، تهویه را شروع کنید. برای رجعت دهی / انتقال سریع برنامه ریزی کنید. در صورت تنفس سریع یا کمبود آکسیجن، آکسیجن بدهید [به مهارت ها مراجعه کنید] در صورت ویزینگ، سالبوتامول بدهید. [به مهارت ها مراجعه کنید] سالبوتامول را در صورت نیاز تکرار کنید. اگر نگران عکس العمل شدید حساسیتی )عکس العمل شدید( هستید، ادرینالین عضلی بدهید. [به مهارت ها مراجعه کنید] اگر نگران نوموتوراکس تنشی هستید، فورا ً رفع فشار با سوزن را انجام دهید و مایعات وریدی و آکسیجن بدهید. [به مهارت ها مراجعه کنید] برای رجعت دهی/انتقال سریع برنامه ریزی کنید. اگر نگران پلورال افیوژن بزرگ یا هموتوراکس هستید، آکسیجن بدهید و برای انتقال/ انتقال سریع برنامه ریزی کنید. اگر علت ناشناخته است، احتمال صدمه را به خاطر بسپارید [به صدمه مراجعه کنید] بیبینید. گوش کنید. حس کنید که آیا مریض نفس می کشد یا خیر. ارزیابی کنید که آیا تنفس بسیار سریع، بسیار کند یا بسیار کم عمق است. به تعقیب علایم افزایش تنفس )مانند استفاده از عضلاتی جانبی، عقب کشیدن/ کشیدن قفس سینه، گشاد شدن بینی( یا حرکت غیر نارمل دیوار قفس سینه باشید. به صداهای غیرعادی نفس مانند ویزینگ یا غژغژ گوش دهید. [مشکل در تنفس را ببینید] با ویزینگ شدید، ممکن است در معاینه صداهای تنفسی محدود یا بدون صدا وجود داشته باشد، زیرا باریک شدن راه های هوایی ممکن است آنقدر شدید باشد که تنفس شنیده نشود. گوش کنید تا ببینید آیا صدای نفس در هر دو طرف برابر است یا خیر. عدم وجود صداهای تنفسی و صداهای مبهم را با قرع در یک طرف بررسی کنید )پلورال افیوژن بزرگ یا هموتوراکس(. [به مهارت ها مراجعه کنید] اگر صدای تنفس در یک طرف وجود ندارد و فشار خون پاین است، وریدهای گردن متوسع یا شزن بیجا شده )نوموتوراکس تنشی( را بررسی کنید. در صورت وجود، اشباع آکسیجن را با پالس اکسیمتر بررسی کنید تنفس اگر تنفس کافی است پس به دوران خورن بروید. برای توقف قلبی ریوی، پروتوکول های RPC مربوطه را تعقیب کنید. در صورت علایم اروا ضعیف، مایعات و اکسیجن وریدی بدهید [به مهارت ها مراجعه کنید] و: برای خونریزی خارجی، فشار مستقیم وارد کنید یا از روش های دیگر برای کنترول استفاده کنید. [به مهارت ها مراجعه کنید] در صورت مشکوک بودن به خونریزی داخلی یا تامپوناد پریکارد قلب، سریعا ً به مرکز صحی دارای قابلیت جراحی مراجعه کنید. اگر علت ناشناخته است، احتمال صدمه را به خاطر بسپارید: شکستگی های لگن خاصره و شکستگی استخوان ران، یا هر شکستگی با دوران خون به خطر افتاده را ببندید. [به صدمه و مهارت ها مراجعه کنید] علایم اروا ضعیف )سرد و مرطوب بودن اندام ها، تاخیر در پر شدن مجدد مویرگ ها بیش از 3 ثانیه، فشار خون پایین، تنفس سریع، ضربان سریع، نبود نبض( را مشاهده و احساس کنید. به تعقیب خونریزی داخلی و خارجی باشید، از جمله خونریزی: به صدر داخل بطن از معده یا امعا از شکستگی لگن خاصره یا استخوان ران از زخم ها به تعقیب فشار خون پایین، توسع وریدهای گردن و صداهای معدوم شدن صدای قلب باشید که ممکن است نشان دهنده تامپوناد پریکارد باشد. دوران خون اگر جریان دوران خون کافی است پس به «ناتوانی» بروید. قلووم1عم:1 لدوم1لدووم م1EDمBل درک مع م1 لدمم1 لدوم 22 ارزیابی مدیریت فوری در صورت تغییر وضعیت شعوری و عدم وجود شواهدی از ضربه، در وضعیت بهبودی قرار دهید. [به مهارت ها مراجعه کنید] اگر گلوکوز پایین )5.3 L/lomm( یا آزمایش گلوکوز در دسترس نیست و وضعیت ذهنی مریض تغییر کرده است، گلوکوز بدهید. [به مهارت ها مراجعه کنید] برای تشنج فعال، بنزودیازپین بدهید. [به مهارت ها مراجعه کنید] در صورت حمل و تشنج، muisengaM etafluS بدهید. [به مهارت ها مراجعه کنید] اگر حدقه ها کوچک هستند و تنفس کاهش است، مصرف بیش از حد مواد افیونی را در نظر بگیرید و نالوگزان بدهید. [به مهارت ها مراجعه کنید] اگر حدقه ها با هم برابر نیستند، فشار بیشتری را روی مغز در نظر بگیرید و در صورت عدم نگرانی برای آسیب نخاعی، سر تخت را 03 درجه بالا بیاورید. برای انتقال سریع به یک مرکز پیشرفته با مراقبت های جراحی مغز و اعصاب ، برنامه ریزی کنید. اگر علت ناشناخته است، احتمال ضربه را به خاطر بسپارید: در صورت نگرانی از صدمه، ستون فقرات حسیت را بی حرکت کنید. [به صدمه و مهارت ها مراجعه کنید] سطح شعور را با مقیاس UPVA )هوشیار، جواب در مقابل صدا، جواب در مقابل تنبه درد، بی پاسخ( یا در موارد صدمه، مقیاس کوما گلاسکو (SCG( ارزیابی کنید. [به مهارت ها مراجعه کنید] همیشه سطح گلوکوز را در مریض گیج یا بیهوش بررسی کنید. اندازه حدقه چشم، برابر بودن حدقه های چشم و عکس العمل حدقه ها به نور را بررسی کنید. حرکت و حسیت را در هر چهار اندام بررسی کنید. به تعقیب حرکات تکراری غیر نارمل یا تکان دادن در یک یا هر دو طرف بدن )تشنج/اختلاج( باشید. ناتوانی/ معلولیت اگر مشکوک به مارگزیدگی هستید، اندام را بی حرکت کنید. [به مهارت ها مراجعه کنید]. در صورت امکان از راه دور از مار عکس بگیرید و با مریض ارسال کنید. خطر نیش های اضافی برای گرفتن/ازبین بردن مار را نداشته باشید. لباس های تنگ و تمام جواهرات را بردارید برای جلوگیری از هیپوترمی یا حرارت پایین بدن مریض را در اسرع وقت بپوشانید. مریضان مبتلا به مریضی حاد در تنظیم حرارت بدن مشکل دارند. هر گونه لباس خیس یا تر را خارج کرده و مریض را کاملا خشک کنید. به مریض احترام بگذارید و از حیا در هنگام مواجهه محافظت کنید. اگر علت ناشناخته است، احتمال تروما را به خاطر بسپارید: در صورت مشکوک شدن به ترضیض ستون فقرات، لاگ رول کنید )به تروما و مهارت ها مراجعه کنید( تمام بدن را از نظر صدمات پنهان، دانه ها، گزیدن یا سایر لکه های جلدی بررسی کنید. دانه های جلدی، مانند اندفاعات حساسیتی )پت(، میتواند نشان دهنده عکس العمل حساسیتی باشد، و دانه های جلدی دیگر میتواند نشان دهنده انتان جدی باشد. برهنه ساختن مریض کتاب دستور عملیات اشتراک کننده گان 32 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE EDCBA با جزئیات بیشتر: شرایط حاد، تحدید کننده زندگی این بخش نگاهی عمیق تر به شرایطی دارد که باید در طول عملکرد EDCBA مدیریت شوند. شرایط طرق تنفسی توصیف عمق و مدیریتاعراض و علایم حالت انسداد طرق تنفسی ناشی از جسم اجنبی ترشحات قابل مشاهده، استفراغ اجسام اجنبی در طرق تنفسی صداهای غیر نارمل از طرق تنفسی )مانند استریدور، خروپف، وصف جوشیدن آب کردن( تغییر وضعیت ذهنی که منجر به انسداد )بندش( طرق هوایی از زبان می شود بلند شدن ضعیف قفس سینه طرق تنفسی ممکن است توسط ترشحات، استفراغ یا اجسام خارجی مسدود شود. در صورت امکان جسم اجنبی را خارج کنید و مایع را سکشن کنید. مراقب باشید جسم خارجی را بیشتر به داخل طرق هوایی فشار ندهید. سعی نکنید جسم خارجی را بردارید مگر اینکه به وضوح قابل مشاهده باشد. اگر مجرای تنفسی به طور کامل مسدود شده است، از ضربه های قفس سینه / ضربه های شکمی / پشت مناسب سن استفاده کنید. [به مهارت ها مراجعه کنید] در مریضانی که سطح شعوری آنها کاهش یافته است، زبان ممکن است طرق تنفسی را مسدود کند. طرق تنفسی را با استفاده از مانورnihc dna tlit daeH tsurht waJ /tfel استفاده کنید )اگر نگرانی از ضربه وجود دارد(. و در صورت نیاز یک تبوب فمی بلعومی یا نازوفارنکس قرار دهید. [به مهارت ها مراجعه کنید] این مریضان همچنین ممکن است نتوانند از طرق تنفسی خود محافظت کنند و باید از نظر استفراغ و اسپایریشن یا داخل شدن مواد استفارغ در طرق تنفسی تحت نظر باشند. در صورت عدم رفع انسداد، برای رجعت دهی/انتقال سریع به مرکز پیشرفته ای که قادر به مدیریت پیشرفته طرق تنفسی است، برنامه ریزی کنید. انسداد (بندش) ناشی از سوختگی سوختگی سر و گردن سوختگی موهای بینی یا دوده اطراف بینی یا دهان صداهای غیر نارمل از طرق هوایی )مانند استریدور( تغییر در صدا بلند شدن ضعیف قفس سینه سوختگی میتواند باعث پندیدگی طرق تنفسی به دلیل آسیب های استنشاقی شود. به همه مریضان مشکوک به سوختگی طرق تنفسی، حتی اگر علایم کمبود آکسیجن را نشان نمی دهند، آکسیجن بدهید. [به مهارت ها مراجعه کنید] طرق هوایی را با استفاده از مانور مناسب باز کنید و در صورت نیاز یک تیوب فمی بلعومی یا نازوفارنکس قرار دهید. [به مهارت ها مراجعه کنید] در صورت وجود شواهدی از صدمه، بی حرکتی ستون فقرات رقبی را حفظ کنید. [به مهارت ها مراجعه کنید] طرق تنفسی در مریضان سوختگی میتواند خیلی سریع پندیده و یا تورم بسته شود. برنامه ریزی برای رجعت دهی/ انتقال سریع به ارائه دهنده ای که قادر به مدیریت پیشرفته طرق تنفسی باشد. قلووم1عم:1 لدوم1لدووم م1EDمBل درک مع م1 لدمم1 لدوم 42 خدمات و یا مدیریت عاجلاعراض و علایمحالت انسداد طرق تنفسی ناشی از عکس العمل حساسیتی شدید (عکس العمل شدید) پندیدگی دهان، لب و زبان مشکلات تنفسی همراه با استریدور و/یا ویزینگ دانه های جلدی یا کهیر )لکه های رنگ پریده یا سرخ، خارش دار، گرم و پندیدگی جلد( ضربان سریع )aidracyhcaT( و هیپوتانسیون صداهای غیر نارمل از طرق هوایی )مانند استریدور، خروپف، وصدای مثل جوشیدن آب کردن( بلند شدن ضعیف قفس سینه عکس العمل های حساسیتی شدید میتواند باعث پندیدگی طرق تنفسی شود که میتواند منجر به انسداد شود. برای انسداد طرق تنفسی، ویزینگ شدید یا شاک، ادرینالین عضلی بدهید. [به مهارت ها مراجعه کنید] ادرینالین میتواند در عرض چند دقیقه از بین برود، بنابراین برای دادن دوزهای اضافی آماده باشید. یک ورید را بازکنید و مایعات وریدی بدهید. [به مهارت ها مراجعه کنید] در صورت نیاز طرق تنفسی را تغییر دهید )مریض را در حالت ایستاده بنشینید، اگر ضربه ای وارد نشده باشد( و آکسیجن بدهید. [به مهارت ها مراجعه کنید] در صورت شدید بودن یا عدم بهبود، برای رجعت دهی سریع/انتقال برای مدیریت پیشرفته طرق تنفسی آماده شوید. انسداد طرق تنفسی ناشی از صدمه هماتوم گردن یا ترضیض سر و گردن صداهای غیر نارمل ازطرق تنفسی )مانند استریدور، خروپف، وصف جوشیدن آب کردن( تغییر در صدا بلند شدن ضعیف قفس سینه انسداد )بندش( طرق تنفسی ممکن است در اثر ترضیض به سر یا گردن ایجاد شود. خون، استخوان یا انساج آسیب دیده ممکن است مجرای تنفسی را مسدود کند. زخم های نافذ به گردن نیز ممکن است به دلیل پندیدگی یا گسترش هماتوم باعث انسداد )بندش( شود. برای برداشتن خونی که ممکن است طرق تنفسی را مسدود کند، سکشن کنید. طرق تنفسی را فقط با استفاده از tsurhT waJ باز کنید )tfil nihc dna tlit daeH استفاده نکنید(. و apo/ در صورت نیاز تیوب فمی بلعومی قرار دهید )در صورت وجود ضربه به صورت از تیوب انفی بلعومی استفاده نکنید(. [به مهارت ها مراجعه کنید] در صورت وجود شواهدی از صدمه، بی حرکتی ستون فقرات گردنی را حفظ کنید. [به مهارت ها مراجعه کنید] برای رجعت دهی/انتقال سریع به یک مرکز صحی پیشرفته که قادر به مدیریت پیشرفته طرق مرکز صحی یا مداخله جراحی است، برنامه ریزی کنید. برای هر گونه صدای غیر نارمل طرق تنفسی، طرق تنفسی را مرتبًا ارزیابی کنید زیرا انسداد جزئی ممکن است به سرعت بدتر شود و طرق هوایی را مسدود کند. کتاب دستور عملیات اشتراک کننده گان 52 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE حالات تنفس خدمات ویا مدیریت عاجلاعراض و علایم حالت نیوموتوراکس تنشی noisneT xarohtomuenp فشار خون پایین با مشکلات تنفسی و هر یک از موارد زیر: توسع ورید های عنق عدم وجود صداهای تنفس در سمت آسیب دیده تشدید صدا های تنفسی بیش از حد با قرع در سمت آسیب دیده [به مهارت ها مراجعه کنید] بیجاشدن شزن از سمت آسیب دیده هر نوموتوراکس میتواند به نوموتوراکس تنشی تبدیل شود. تجمع هوا در جوف صدر ویا پلورا میتواند بالای ریه ها فشار وارد کند )نوموتوراکس ساده(. افزایش فشار )تنش( از یک نوموتوراکس بزرگ میتواند باعث مانع و یا و مسدود شدن جریان از عروق اصلی به قلب شود و باعث ایجاد شاک )نوموتوراکس تنشی( شود. در صورت مشکوک بودن به نوموتوراکس تنشی، رفع فشار با سوزن عاجل انجام دهید. [به مهارت ها مراجعه کنید] آکسیجن بدهید. [به مهارت ها مراجعه کنید] مایعات وریدی بدهید. [به مهارت ها مراجعه کنید] برای رجعت دهی/انتقال سریع به مرکز صحی امکانات پیشرفته که قادر به قرار دادن تیوب صدری است، تنظیم کنید. مشکوک به مصرف بیش از حد مواد افیونی سرعت تنفس کند کمبود آکسیجن حدقه های بسیار کوچک اوپیاد )مانند مورفین، پتیدین و هروئین( می توانند انگیزه تنفسی بدن را کاهش دهند. برای معکوس کردن اثرات اوپیاد ها نالوگزان بدهید. [به مهارت ها مراجعه کنید] به دقت نظارت کنید زیرا تاثیرات نالوگزان از بین می رود و ممکن است به دوزهای اضافی نیاز باشد. آکسیجن بدهید. [به مهارت ها مراجعه کنید] استما / DPOC (مریضی مزمن انسدادی ریه) ویزینگ )خس خس سینه( سرفه استفاده از عضلات اضافی ممکن است سابقه استما /DPOC داشته باشد تشخیص، الرژی یا کشیدن سگرت استما )نفس تنگی( و DPOC شرایطی هستند که باعثمنقبض شدن عضلات شزن میشود و در نتیجه باریک می شوند که باعث مشکل در تنفس و ویزینگ میشود. در اسرع وقت سالبوتامول را تجویز کنید. )سالبوتامول به از بین بردن شخی یا سپزم در مجرای تنفسی کمک می کند( [به مهارت ها مراجعه کنید] در صورت لزوم اکسیجن بدهید. [به مهارت ها مراجعه کنید] انصباب پلورا (تجمع مایعات در ریه) بزرگ/ هموتوراکس (تجمع خون در ریه ها) کاهش صدای تنفس در سمت آسیب دیده صداهای ُکند همراه با قرع در سمت آسیب دیده [به مهارت ها مراجعه کنید] موجودیت مقدار زیاد مایع درجوف پلورا سبب شاک میشود پلورال افیوژن زمانی رخ می دهد که مایع در جوف پلورا جمع شود. همانطور که مایع جمع می شود، انبساط ریه ها را محدود می کند. آکسیجن بدهید. [به مهارت ها مراجعه کنید] فورا ًرجعت دهی / انتقال را ترتیب دهید )مریضان به تخلیه مایع از جوف پلورا نیاز دارند(. اگر علت ناشناخته است، احتمال صدمه را به خاطر بسپارید [به صدمه مراجعه کنید] قلووم1عم:1 لدوم1لدووم م1EDمBل درک مع م1 لدمم1 لدوم 62 حالات دوران خون خدمات عاجلاعراض و علایم حالت/ شرایط عدم موجودیت نبض معدوم شدن نبض بی هوش معدم شدن تنفس پروتوکول های مربوط به احیای قلبی ریوی (RPC( را تعقیب کنید. ضربان قلب سریع )تاکی کاردی( شاک تنفس سریع و پی در پی تنفس سریع )aenpyhcaT( جلد خاسف و سرد برگشت خون در عروق شرعیه 3 ثانیه تعرق )دیافوریزیس( ممکن است سرچرخی، گیجی، تغییر وضعیت ذهنی داشته باشد ممکن است فشار خون پایین داشته باشد اروا ضعیف، زمانی اتفاق می افتد که خون اکسیجن کافی را به اعضای حیاتی حمل نتواند واین ازوا ضعیف در صورتیکه ادامه میابد سبب تمام اعضای حیاتی متاثر شده که این حالت شاک نامیده میشود. تداوی اولیه شاک شامل خواباندن مریض به صورت هموار )در صورت تحمل( است. آکسیجن بدهید. [به مهارت ها مراجعه کنید] خونریزی را کنترول کنید. [به مهارت ها مراجعه کنید] ورید مریض را باز کنید و مایعات وریدی بدهید. [به مهارت ها مراجعه کنید] در صورت وجود علایم انتان، انتی بیوتیک بدهید اگر قابل دسترس است. برای رجعت دهی/انتقال سریع آماده شوید. خونریزی شدید (خونریزی) زخم های خونده کبودی اطراف ناف )ناف( یا روی پهلوها میتواند نشانه خونریزی داخلی باشد. خونریزی محبلی یا رکتوم یا خون در استفراغ شکستگی لگن خاصره شکستگی استخوان ران کاهش صدای تنفس در یک طرف قفس سینه ) هموتوراکس( علایم اروا ضعیف )مانند فشار خون پایین، ضربان سریع )aidracyhcaT(، جلد خاسف، عرق سرد خونریزی خارجی که کنترول نمی شود میتواند به سرعت منجر به شاک شود. در خون ریزی داخلی، مقدار زیادی خون نیز میتواند در قفس سینه، لگن خاصره، ران و شکم از ضایع شود. خونریزی را متوقف کنید. نظربه منابع دست داشته، از موارد ذیل استفاده کنید: فشار مستقیم [به مهارت ها مراجعه کنید] بسته بندی زخم عمیق [به مهارت ها مراجعه کنید] بستن یک تورنیکت [به مهارت ها مراجعه کنید] بستن لگن خاصره یا اسپلینت ران. [به مهارت ها مراجعه کنید] تطبیق مایعات وریدی. [به مهارت ها مراجعه کنید] در صورت نیاز برای تطبیق خون و مدیریت جراحی مورد نیاز مریض را در به مرجع پیشرفته انتقال دهید. تورنیکیت فقط برای خونریزی های تهدید کننده حیات باید استفاده شود. علایم اروا ضعیف )ضربان سریع تامپوناد قلبی )aidracyhcaT(، تنفس سریع ، افت فشار خون، جلد رنگ پریده و سرد، سردی اندام ها، برگشت خون به عروق شرعیه > 3 ثانیه وریدهای گردن متوسع شده صدای قلب خفه شده است ممکن است سرچرخی، گیجی، تغییر وضعیت ذهنی داشته باشد تامپوناد پریکارد زمانی اتفاق می افتد که مایع در جوف پریکارد جمع شود. فشار ناشی از این مایع می تواند حفره های قلب را فرو بپاشد و از پر شدن مناسب آن ها جلوگیری کند، دوران خون را به انساج محدود کرده و باعث شاک شود. تداوی آن کشیدن مایع توسط سوزن یا پریکاردیوسنتز است. به منظور زنده نگهداشتن مریض تا زمانی که مایع اطراف قلب تخلیه شود، مایعات وریدی داده شود تا اطمینان حاصل شود که تا حد ممکن حجم خون وارد قلب می شود. [به مهارت ها مراجعه کنید] به سرعت برای مدیریت جراحی مراجعه کنید. اگر علت ناشناخته است، احتمال صدمه را به خاطر بسپارید (به صدمه مراجعه کنید) کتاب دستور عملیات اشتراک کننده گان 72 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE حالات ناتوانی /معلولیت مدیریت فوریاعراض و علایم حالت/ شرایط شکر پایین (هایپوگلایسیمی) تعرق تغیر وضعیت شعوری ) از گیچی تا از دست دادن شعور( اختلاج / تشنج گلوکوز یا شکر خون <5.3 L/lomm سابقه دیابت، ملاریا یا انتان شدید به سرعت به گلوکوز پاسخ میدهد مریضان مبتلا به رهایپوگلایسیمی )شکر خون پایین( نیاز فوری به گلوکوز دارند. [به مهارت ها مراجعه کنید] اگر فرد میتواند صحبت کند وبلع کند ، گلوکوز خوراکی بدهید. اگر فرد نمیتواند صحبت کند یا بیهوش است، در صورت امکان گلوکوز وریدی بدهید. اگر گلوکوز وریدی امکان پذیر نیست یا در دسترس نیست، گلوکوز بوکال )داخل دهن( بدهید. [به مهارت ها مراجعه کنید] افزایش فشار روی مغز سردرد تشنج/اختلاج دلبدی، استفراغ تغییر وضعیت ذهنی حدقه های نابرابر ضعف در یک طرف بدن افزایش فشار دهن مغز میتواند در اثر ضربه، تومور، افزایش مایعات، خونریزی یا انتان رخ دهد. از آنجایی که جمجمه سخت است، هر پندیدگی، مایع یا دهن ای فشار اطراف مغز را افزایش می دهد و دوران خون را محدود می کند و احتمالا ًنسج مغز را بی جا می کند که باعث مرگ می شود. در صورت عدم نگرانی از ضربه و عدم وجود فشار پایین، سر تخت بستر را تا 03 درجه بالا ببرید. گلوکوز را چک کنید. [به مهارت ها مراجعه کنید] اگر اختلاج/تشنج وجود دارد، آبنزودیازپین بدهید. [به مهارت ها مراجعه کنید] فشار باید تا حد امکان کاهش یابد. برای رجعت دهی سریع / انتقال به یک مرکز جراحی اعصاب ترتیبات بگیرید. علایم و نشانه های تشنج فعال:اختلاج/تشنج حرکات تکراری، نگاه ثابت به یک طرف یا متناوب به صورت ریتمیک و عدم پاسخگو علایم و نشانه های تشنج اخیر: جویدن زبان ادرار کردن بر خود سابقه شناخته شده اختلاج / تشنج گنسیت که به صورت تدریجی بهبود میابد هدف از مدیریت اختلاج/تشنج جلوگیری از کمبود آکسیجن و آسیب است. از فرد مبتلا در برابر افتیدن و هر گونه اجسام سخت یا تیز نزدیک شخص محافظت کنید. در دهان فردی که تشنج فعال دارد چیزی جز سکشن طرق تنفسی قرار ندهید. [به مهارت ها مراجعه کنید]. آکسیجن بدهید. [به مهارت ها مراجعه کنید] شکر خون را چک کنید. اگر کمتر از L/lomm5.3 باشد، گلوکوز بدهید. [به مهارت ها مراجعه کنید] بنزودیازپین تطبیق کنید [به مهارت ها مراجعه کنید] نوع. اگر مشکوک به صدمه نیست، مریض را در وضعیت بهبودی قرار دهید [به مهارت ها مراجعه کنید]. اگر مریض حامله است یا به تازگی ولادت کرده است، etafluS muisengaM بدهید. [به مهارت ها مراجعه کنید] اگر علت ناشناخته است، احتمال صدمه را به خاطر بسپارید [به صدمه مراجعه کنید] قلووم1عم:1 لدوم1لدووم م1EDمBل درک مع م1 لدمم1 لدوم 82 برهنه ساختن مریض توصیف عمق و مدیریتاعراض و علایم حالت تاریخچه مارگزیدگی مارگزیدگی ممکن است آثار گزش دیده شود اذیما )پندیدگی( آبله زدن جلد کبودی فشار خون پایین فلج تشنج خونریزی از زخم هدف از مدیریت مارگزیدگی محدود کردن انتشار سم و اثرات زهر بر بدن است. عضو را بی حرکت کنید. [به مهارت ها مراجعه کنید] در صورت امکان از مار عکس بگیرید و با مریض ارسال کنید )مثًلا با تلفن همراه مریض(. در صورت شواهد شاک مایعات وریدی بدهید. [به مهارت ها مراجعه کنید] این مریضان ممکن است شاک تاخیری یا مشکلات طرق تنفسی داشته باشند. نظارت دقیق و اولیه را انجام داده و برای رجعت دهی / انتقال سریع برنامه ریزی کنید. علایم حیاتی باید در پایان EDCBA بررسی شود مجموعه کاملی از علایم حیاتی )فشار خون، ضربان قلب، تعداد تنفس و اشباع آکسیجن در صورت امکان( باید پس از عملکرد EDCBA انجام شود. مداخلات EDCBA را برای علایم حیاتی به تاخیر نیندازی EDCBA باید به طور مکرر تکرار شود عملکرد EDCBA برای شناسایی سریع شرایط قابل برگشت و تهدید کننده زندگی طراحی شده است. در حقیقت، عملکرد EDCBA باید حداقل هر 51 دقیقه یا با هر تغییری در حالت مریض تکرار شود. سوال کتاب تمرین 2 : عملکرد EDCBA با استفاده از بخش کتاب تمرین بالا، مدیریت بندش طرق تنفسی توسط جسم خارجی را فهرست کنید. کتاب دستور عملیات اشتراک کننده گان 92 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE ملاحظات EDCBA در اطفال در حالی که عملکرد EDCBA هم در بزرگسالان و هم در کودکان استفاده می شود، جنبه هایی از ارزیابی و مدیریت کودکان وجود دارد که با بزرگسالان متفاوت است. بخش های «ملاحظات اطفال» در سراسر کتاب تمرین این تفاوت ها را برجسته می کند. ملاحظات اطفال مشکلات طرق تنفسی در اطفال ترشح بیش از حد لعاب دهن ، استریدور، پندیدگی طرق هوایی و عدم تمایل به حرکت دادن گردن همه از علایم خطرات جدی در کودکان هستند. به دقت مراقب انسداد مجرای تنفسی ناشی از اجسام اجنبی و سوختگی باشید. به کودک اجازه دهید در یک موقعیت راحت بماند. طرق هوایی را بر حسب نیاز در زیر قرار دهید. در صورت نیاز جهت باز نگهداستن مجرای تنفسی وضعیت دهید. پس آنچه را شما باید انجام دهید: در مقایسه با بزرگسالان، کودکان دارای: کودک را در وضعیت خنثی قرار دهید )nihc dna tliT daeH tfil – مانند کج شدن جزئی سر به سمت بالا و جلو هنگام استشمام گل( زبان های بزرگ گردن های کوتاه تر با راه مجرای تنفسی که نرم تر و به آسانی از دراز کردن یا خم کردن بیش از حد گردن خودداری کنید. مسدود می شوند. به دقت مراقب انسداد )بندش( طرق تنفسی باشید. اگر طرق تنفسی باز نیست از tsurht waJ استفاده کنید. [به مهارت ها مراجعه کنید] موقعیت دادن سر )با استفاده از بالشتک زیر شانه برای کودکان بسیار کوچک برای باز کردن طرق هوایی در صورت عدم ضربه [به مهارت ها مراجعه کنید] سر بزرگتر نسبت به بقیه بدن برای خفگی، از فشارهای سینه / ضربه های شکمی / ضربه های پشت مناسب سن استفاده کنید. [به مهارت ها مراجعه کنید] stnafni ni noitisop lartueN 2 egap قلووم1عم:1 لدوم1لدووم م1EDمBل درک مع م1 لدمم1 لدوم 03 مشکلات تنفسی در اطفال گشاد شدن بینی، کوبیدن سر، وصف جوشیدن آب کردن و بیرون آمدن قفس سینه یا پس رفتن، از علایم اختلاط تنفسی در کودکان است. سیانوزیس – تغییر رنگ آبی/خاکستری در اطراف لب ها، دهان یا نوک انگشتان – نتیجه کمبود اکسیجن است و یک علامت خطر است. فرورفتن عضلات صدری ویا gniwradni tehc یک تظاهرات رایج استفاده از عضلات اضافی در کودکان است. در قسمت پایین صدر نگاه کنید. اگر وقتی کودک به داخل نفس می کشد، دیوار پایین قفس سینه به داخل کشیده میشود. در تنفس طبیعی، تمام دیوار قفس سینه )بالا و پایین( و شکم هنگام تنفس کودک به بیرون حرکت می کنند. صدر خاموش )هنگامی که به صدای تنفسی گوش می دهید صدای تنفس نمی آید( نشانه ای از مشکلات شدید تنفسی در کودک است. با شخی یا سپزم شدید و باریک شدن مجرای تنفسی، ممکن است حرکت هوا محدود و صدای تنفس کمی در معاینه وجود داشته باشد. سالبوتامول و آکسیجن بدهید و مرتبا ارزیابی کنید. [به مهارت ها مراجعه کنید] RODIRTS نشان دهنده اختلال شدید طرق تنفسی است و دلایل احتمالی زیادی وجود دارد. کودکان که استرایدور دارند یک وضعیت راحت دهید و کودک را به یک مرکز صحی پیشرفته منتقل کنید. تداوی آن شامل ادرینالین در نبولیزر است. اگر انتقال فوری امکان پذیر نیست، ادرینالین عضلی را طبق تداوی عکس العمل حساسیتی شدید در نظر بگیرید. [به مهارت ها مراجعه کنید] مشکلات دوران خون در اطفال مدیریت اروا ضعیف در کودکان ممکن است بر اساس علت و وضعیت کودک تغییر کند. )به مودل های شاک و مهارت ها مراجعه کنید( فشار خون پایین در کودک نشانه شاک شدید است. کودکان در زمان شاک می توانند فشار خون طبیعی را برای مدت طولانی تری در اطفال نسبت به بزرگسالان حفظ کنند. سایر علایم اروا ضعیف مانند کاهش تولید ادرار = و تغییر وضعیت ذهنی را به دقت کنترول کنید. مقدار مایعات داخل وریدی که به کودکان داده می شود با بزرگسالان متفاوت است. [به مهارت ها مراجعه کنید] در کودکان مبتلا به سوء تغذی، هم میزان مصرف مایعات و هم نوع مایعات متفاوت است. [به مهارت ها مراجعه کنید] علایم شدید: فونتانل فرورفته، تست جلدی جهت دانستن سطح مایعات بدن گرفتن ضعیف جلد [به مهارت ها مراجعه کنید]، بی حالی، تغییر وضعیت ذهنی. gniwardni tsehC 33 egap کشیدن قفس یا چست اندراونگ کتاب دستور عملیات اشتراک کننده گان 13 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE حالات نا توانی در اطفال کمبود گلوکوز خون یک علت بسیار شایع تغییر وضعیت شعوری در کودکان مریض است. - در صورت امکان، شکر خون کودکان با اختلال شعوری را بررسی کنید. در مواقعی که امکان بررسی سطح گلوکوز خون وجود ندارد، گلوکوز تجویز کنید. همیشه اختلاج / تشنج را بررسی کنید. گاهی اوقات تشخیص اینکه آیا نوزادان به طور طبیعی عمل می کنند دشوار است. همیشه از شخصی که از کودک مراقبت می کند بپرسید. برهنه ساختن مریض نوزادان و کودکان در حفظ تعادل درجه حرارت بدن مشکل دارند و خیلی سریع میتوانند cimrehtopyH )درجه پایین حرارت( یا حرارت بلند بدن )aimrehtrepyH(ک )درجه حرارت بلند( شوند. لباس های تر را بطور کامل دور کنید و بدن را خشک نمائید. در صورت امکان نوزادان را جلد به جلد قرار دهید. برای حرارت پایین بدن )aimrehtopyH( حتمن سر نوزاد را بپوشانید )اما صورت را نپوشانید.( برای حرارت بلند بدن )aimrehtrepyH( نوزادان را که محکم بسته نموده اند، باز کنید. علایم خطر در اطفال در عملکرد EDCBA علاوه بر انجام یک عملکرد کامل EDCBA، همه کودکان مریض باید از نظر وجود علایم خطر ارزیابی شوند. کودکان که دارای علایم خطر هستند نیاز به توجه فوری و رجعت دهی به مرجع را دارند که بتواند مراقبت های پیشرفته اطفال را فراهم کند. علایم خطر در اطفال شامل ذیل اند: علایم انسداد )بندش( طرق هوایی )استریدور یا ترشح آب دهان/ناتوانی در بلع لعاب دهن( افزایش تلاش تنفسی )تنفس سریع، گشاد شدن بینی، صدای نالش ؛استفاده از عضلات اضافی صدری( سیانوز )رنگ آبی جلد، به ویژه در لب ها و نوک انگشتان( تغییر وضعیت ذهنی )از جمله بی حالی یا خواب آلودگی غیر معمول، گیجی، نآ آگاهی( یعنی بیداری کامل دیگران در اطفال علامه خطر در مقیاس UPVA به جز از A عدم توانایی طفل در خوردن و آشامیدن همه چیز را استفراغ می کند اختلاج / تشنج درجه حرارت بدن پایین ))aimrehtrepyH(( قلووم1عم:1 لدوم1لدووم م1EDمBل درک مع م1 لدمم1 لدوم 23 سوال کتاب تمرین 3: عملکرد EDCBA با استفاده از بخش کتاب تمرین بالا، یکی از هر یک از موارد زیر را فهرست کنید: ملاحضات راجع به طرق هوایی یا تنفسی کودکان ملاحضات راجع به تنفس کودکان ملاحضات راجع به دوران خون در کودکان ملاحضات راجع به ناتوانی کودکان ملاحضات راجع به در معرض قرار گرفتن کودکان اجزای تاریخچه ELPMAS اختصار ELPMAS یک روش استاندارد برای جمع آوری تاریخچه معلومات کلیدی مربوط به یک مریضی یا مصدوم است. منبع معلومات میتواند: فرد مریض/مصدوم، اعضای خانواده، دوستان، اطرافیان یا ارائه دهندگان قبلی باشند. ELPMAS مخفف: S: اعراض و علایم (smotpmys dna sngiS) گزارش مریض/خانواده از علایم و نشانه ها برای ارزیابی و مدیریت ضروری است. A: الرژی یا حساسیت مهم است که از با ادویه ها آگاه باشید تا تداوی ها باعث آسیب نشوند. الرژی همچنین ممکن است عکس العمل شدید را به عنوان علت علایم حاد نشان دهد. کتاب دستور عملیات اشتراک کننده گان 33 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE M: ادویه فهرست کاملی از ادویه جاتیی را که فرد در حال حاضر مصرف می کند به دست آورید و در مورد ادویه جات یا تغییرات دوز اخیر بپرسید. اینها ممکن است بر تصمیمات تداویی تأثیر بگذارند و برای درک مرض مزمن فرد مهم هستند. P: تاریخچه سوابق طبی دانستنامراض سابقه درک مرض فعلی را تسهیل بخشیده و همچنان به تداوی مریض کمک کند. L: آخرین مصرف خوراکی زمان آخرین مصرف خوراکی و یا وعده غذایی را یادداشت کنید. معده پر، خطر استفراغ و خفگی متعاقب آن را افزایش می دهد، به خصوص با تطبیق ادویه انستیزی جهت انتوبیشن و عملیه جراحی. E: رویداد های مروبط به آسیب یا مریضی دانستن شرایط پیرامون آسیب یا مریضی ممکن است برای درک علت، پیشرفت و شدت آن مفید باشد. سوال کتاب تمرین 4: عملکرد ELPMAS با استفاده از بخش کتاب تمرین بالا، حروف در ELPMAS را فهرست کنید که چی معنی میدهد: S: A: M: P: L: E: قلووم1عم:1 لدوم1لدووم م1EDمBل درک مع م1 لدمم1 لدوم 43 ملاحظات انتقال مریض جهت اگر مجبور به مداخله در هر یک از بخش های EDCBA هستید، فورا ًبرای رجعت دهی/انتقال به سطح بالاتر مراقبت صحی برنامه ریزی کنید. پس از تکمیل روش EDCBA، تاریخچه ELPMAS را بگیرید و معاینه فیزیکی را بر اساس شرایط خاص )معاینه ثانوی( تکمیل کنید. یک خلاصه رجعت دهی خوب [به مهارت ها مراجعه کنید] به فراهم کننده خدمات طبی بعدی نیازمند موارد ذیل است: شناسایی مختصر مریض؛ عناصر مرتبط تاریخچه ELPMAS ؛ یافته های معاینه فیزیکی؛ درج مداخلات طبی ارایه شده به مریض در صورت نیاز به مراقبت های بعدی و شاکی بودن به نگرانی های دیگر انتقال مریض را برنامه ریزی کنید. علایم حیاتی نورمال علایم حیاتی نورمال در بزرگسالان تعداد نبض: 06 تا 001 ضربه در دقیقه تعداد تنفس: 01-02 تنفس در دقیقه تعداد تنفس کمتر از هشت نفس در دقیقه یک علامت خطر است و ممکن است نیاز به مداخله داشته باشد. فشار خون سیستولیک> 09 میلی متر ستون سیماب اشباع آکسیجن > 29% اگر نمی توانید فشار خون را اندازه گیری کنید، می توانید از نبض برای تخمین فشار خون سیستولیک استفاده کنید. احساس نبض در مکان های زیر می تواند تخمینی از فشار خون سیستولیک در بزرگسالان ارائه دهد )اگرچه این روش ممکن است در افراد مسن کارایی خوبی نداشته باشد(: نبض کاروتید )گردن( ≥ 06 میلی متر ستون سیماب نبض laromeF )کشاله ران( ≥ 07 میلی متر ستون سیماب نبض laidaR )مچ دست( ≥ 08 میلی متر ستون سیماب علایم حیاتی نورمال در اطفال علایم حیاتی در کودکان به سن بستگی دارد. ضربان قلب طبیعی و تعداد تنفس در کودکان کوچکتر بیشتر است و فشار خون طبیعی کمتر است. شریان laihcarB )وسط بازو( باید برای بررسی نبض در نوزادان و کودکان کوچک استفاده شود. کتاب دستور عملیات اشتراک کننده گان 53 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE sngiS latiV cirtaideaP lamroN ضربان طبیعی قلب (ضربان سن(در سال ها) در دقیقه) 001-0611≥ 09-0511-3 08-0414-5 تعداد تنفس (نفس در سن دقیقه) 04-06≤2 ماه ها 52-052-21 ماه ها 02-041-5 سال ها * برای تخمین کردن وزن کودک )از 1 تا 01 ساله( به کیلوگرام از فرمول ذیل استفاده کندی: [سن به سال+4]×2 یا از ابزارهای تخمین وزن مانند REPWAP، EPAT ycreM یا epat wolesorB استفاده کنید. کودکان زمانی که در شاک هستند می توانند فشار خون طبیعی را برای مدت طولانی تری نسبت به کاهلان حفظ کنند. باید از مراقب برسی علایم اروا ضعیف باشید. مقدار مایع وریدی مناسب برای کودکان با بزرگسالان متفاوت است. [به مهارت ها مراجعه کنید] سناریوی قضایا به رهبری داکتر یا تسهیل کننده این سناریوهای قضیه در گروپ های کوچک مورد بحث قرار خواهند گرفت. این موارد در این مودل ارزیابی نخواهند شد و فقط برای تمرین هستند. مهم است که با این سناریوها تمرین کنید زیرا در مودل های بعدی شما در مورد نحوه رهبری پرونده مورد ارزیابی قرار خواهید گرفت. برای تکمیل یک سناریوی قضیه، گروپ باید یافته های حیاتی و مدیریت مورد نیاز را شناسایی کند و خلاصه ای از رجعت دهی 1 تا 2 خطی را که شامل یافته ها و مداخلات ارزیابی است، تدوین کند. برای مدیریت این سناریوها باید از کارت های سریع استفاده کنید. قضیه شماره 1 : EDCBA بزرگسال/ کاهل پیرمرد 07 ساله ای را با تاکسی می آورند. راننده می گوید که مریض هنگام صحبت با دخترش از هوش رفت. هیچ واقعه صدمه در بین نیست، اما دخترش بروی او آب ریخت تا سعی کند تا را بیدارش کند. در ابتدا پدرش گیچ بوده گیج بود و استفراغ می کرد. اکنون او با تعداد تنفس 3 در دقیقه بیهوش است. در عملکرد اولیه خود چه کاری باید انجام دهید؟. 1 dlihc a ni eslup laihcarb fo noitacoL 53 egap موقعیت نبض براخیل در اطفال قلووم1عم:1 لدوم1لدووم م1EDمBل درک مع م1 لدمم1 لدوم 63 برای ارزیابی و مدیریت این مریض از روش EDCBA استفاده کنید. از تسهیل کننده در مورد . 2 یافته ها، به اساس گوش دادن و احساس کردن بپرسید. در صورت لزوم از کارت های سریع برای مرجع استفاده کنید. مداخلات برای انجام: آیا نیاز مداخله است؟یافته ها ارزیابی نخیر بلی طرق تنفسی نخیربلیتنفس نخیربلیدوران خون نخیربلیناتوانی نخیربلیدر معرض قرار گرفتن 1 – 2 جمله را برای خلاصه کردن این مریض برای رجعت دهی پیشرفته. . 3 واقعه شماره 2 : به اساس EDCBA در اطفال مادری پسر 2 ساله خود را به دلیل مشکلات تنفسی نزد شما میاورد. او حکایت میکند که طفل اش از مدت 3 روز تب داشته و مشکلات تنفسی او شدید تر شده است. او خیلی سرفه می کرد و امروز نه می خورد و نه می نوشد. عملکرد اولیه شما به این مریض چیست؟. 1 برای ارزیابی و مدیریت این مریض از روش EDCBA استفاده کنید. از تسهیل کننده در مورد . 2 یافته ها به اساس گوش دادن و احساس کردن بپرسید. در صورت لزوم از کارت های سریع برای مرجع استفاده کنید. مداخلات برای انجام: آیا نیاز مداخله است؟یافته ها ارزیابی نخیر بلی طرق تنفسی نخیربلیتنفس نخیربلیدوران خون نخیربلیناتوانی نخیربلیدر معرض قرار گرفتن 1 – 2 جمله را برای خلاصه کردن این مریض برای رجعت دهی دادن ترتیب کنید.. 3 سوالات چند گزینه یی به سوالات زیر پاسخ دهید. پرسش و پاسخ در طی جلسه یی مورد بحث قرار خواهد گرفت. مادری فرزند 3 ساله خود را به دلیل مشکلات تنفسی می آورد. در ارزیابی، هنگامی که کودک نفس . 1 می کشد، صداهای با تون بالا می شنوید. فوری ترین نگرانی چیست؟ A. انتان شدید کتاب دستور عملیات اشتراک کننده گان 73 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE B. شاک C. حمله استما D. اسنداد طرق تنفسی علوی زن محسن در خانه افتاد. او علایم حیاتی طبیعی داشته، اما قبل از انتقال از درد گردن و زانو شکایت داشته. . 2 درجریان انتقال تنفس او وخیم شده که وصف غرغر و ُخر و پف را دارد. مناسب ترین روش برای مدیریت فوری این مشکل چیست؟ A. قرار دادن وی در وضعیت بهبودی یا ریکوری B. تجویز سالبیوتامول C. بلند کردن الاشه )tsurht waJ( D. tfil nihc dna tlit daeH مردی 05 ساله در یک فروشگاه به زمین می افتد و از شما خواسته می شود تا به او کمک کنید. او بیهوش . 3 است، تعداد تنفسش 4 بار در دقیقه و نبضش 001 ضربه در دقیقه است. افتادن او مشاهده شده اما هیچ علامه ضربه ای وجود ندارد. بهترین قدم بعدی چیست؟ A. شروع کردن به فشردن صدر B. باز کردن طرق تنفسی C. شروع کردن تهویه با ماسک و امبو بک D. چک کردن حدقه های چشم یک پسر 2 ساله را به خاطر خواب آلودگی بیشتر از حد معمول نزد شما آورده اند. او بیهوش است. طرق . 4 تنفسی او را بوسیله تیوب فمی بلعومی باز می کنید. قدم بعدی شما چیست؟ A. چک کردن فشار خون B. بررسی کردن سطح UPVA C. چک کردن سویه گلوکوز D. چک کردن تنفس در حال گوش دادن به ریه های یک مرد 62 ساله هستید که دچار درد ناگهانی صدری شده و 03 تنفس . 5 در دقیقه می کشد. کدام یافته از صدای ریه بیشتر نشان دهنده نوموتوراکس است؟ A. کریکلز در هر دو طرف صدر B. عدم موجودیت صدا های ریه در یک طرف C. سترایدور D. ویزینگ در هر دو طرف قلووم1عم:1 لدوم1لدووم م1EDمBل درک مع م1 لدمم1 لدوم 83 یادداشت کتاب دستور عملیات اشتراک کننده گان 93 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE مودل دوم : رسیدگی به صدمه یا ضربه اهداف با تکمیل نمودن این مودل شما باید بتوانید تا: شناسایی دریافت نکات کلیدی تاریخچه که نشان دهنده خطرات جدی هستند... 1 دانستن نکات کلیدی در معاینه فزیکی با خطرات بلقوه. 2. بررسی اولیه صدمه )روش EDCBA برای مریضان صدمه( را انجام دهید. . 3 ارزیابی ثانوی صدمه )بشکل کلی از سرتا پا( را انجام دهید. 4. خطرات تهدید کننده حیات را شناسایی کنید. 5. مداخلات حیاتی را به واقعات که خطر تهدید کننده حیات وجود دارد را فراهم کنید.. . 6 مهارت های ضروری بی حرکت ساختن ستون فقرات رقبی بی حرکت ساختن ستون فقرات و مانور llor-gol tsurht waJ سکشن یا پاک کردن طرق تنفسی تطبیق تیوب فمی بلعومی وضعیت ریکوری یا احیا تطبیق آکسیجن تهویه توسط ماسک evlav-gaB رفع فشار توسط سوزن برای نوموتوراکس فشاری پانسمان سه طرفه برای زخم صدر )مکنده( فشار مستقیم برای کنترول خونریزی، از جمله بسته شدن زخم عمیق تورنیکیت برای کنترول خونریزی درج خط مایعات وریدی احیای مایع وریدی ارزیابی UPVA و SCG اتصال لگن خاصره بی حرکت ساختن اساسی شکستگی ارزیابی ثانوی تروما مدیریت اولیه زخم از جمله شستشو مدیریت سوختگی اصطلاحات کلیدی تعریف را با استفاده از واژه نامه که عقب کتاب تمرین است، بنویسید. UPVA: برادی کاردیا )aidracydarB(: قلوومو معم ددگدمع م:دقودلمدعم 04 سوختگی درویی )nrub laitnerefmucriC( : کریپتوس )sutiperC(: سندروم کمپارتمنت: سیانوزس: رفع آلودگی noitanimatnoceD: بسته بندی زخم عمیق: عرق siserohpaiD: فشار مستقیم: انتقال )noitisopsiD( : اسکاروتومی )ymotoracsE(: صدر LIALF: کسر: جدول کومای گلاسکو elacs amoc wogsalG: محافظت: خونریزی egahrromeaH: kcohS cigahrromeaH: هیماتوما amotomeaH: هیموتوراکس xarohtomeaH: طبلیت )ecnanoserrepyH(: aimrehtopyH: شاک هایپوولمیک: کمبود اکسیجن aixopyH: پارگی noitarecaL: کتاب دستور عملیات اشتراک کننده گان 14 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE کنول وریدی با قطربزرگ: مانور llor-goL: noisserpmoceD eldeeN: فرمول پارکلند dnalkraP: قرع noissucreP: تیمپوناد قلبی danopmet laidacerP: نوموتوراکس xarohtomenP: پریاپیسم یا انتعاز طولانی: تندرنیس برگشتی ssenrednet dnuobeR: تاریخچه ELPMAS: شاک: پیچ خوردن niarpS: dnuow tsehc gnikcuS: نوموتوراکس فشاری )xarohtomuenp noisneT(: بررسی اولیه صدمه: بررسی ثانوی صدمه: قلوومو معم ددگدمع م:دقودلمدعم 24 مرور اجمالی اصول کلی مراقبت از صدمه اولویت های اولیه برای یک فرد آسیب دیده شامل مدیریت طرق تنفسی و رسیدگی عاجل تنفسی، کنترول خونریزی، تداوی شاک و بی حرکت کردن ستون فقرات در صورت نیاز است. هدف از ارزیابی اولیه شناسایی خطرات های تهدید کننده زندگی است. هدف مدیریت حاد اطمینان از اکسیجن رسانی و اروا، کنترول درد و برنامه ریزی برای مراقبت مداوم است. این مودل شما را از طریق موارد ذیل رهنمایی میکند: عملکرد باصدمه EDCBA : بررسی اولیه صدمه انجام دان: شرایط مهم برای تشخیص و مدیریت در سروی ابتدایی)اعراض، علایم و مدیریت( بپرسید: یافته های تاریخچه کلیدی )تاریخچه ELPMAS( بررسی: بررسی ثانوی صدمه انجام دادن: شرایط مهم برای شناسایی و مدیریت بر اساس تاریخچه و بررسی ثانوی )اعراض، علایم و مدیریت( گروپ های خاص صدمه در حمل ملاحظات خاص در اطفال ملاحظات انتقال رسیدگی به صدمات عملکرد با مصدومین دارای سه مرحله است: بررسی اولیه صدمه: عملکرد EDCBA برای مصدومین و مجروحین تاریخچه ELPMAS: اعراض و علایم، الرژی یا حساسیت، ادویه جات، تاریخچه سابقه طبی، آخرین مصرف خوراکی، و رویدادهای مربوط به صدمه. بررسی ثانوی صدمه: یک معاینه کامل سر تا پا برای بررسی خطرات که توسط بررسی اولیه شناسایی نشده اند. در طی بررسی های اولیه و ثانوی، اگر مشکلات تهدید کننده زندگی شناسایی شد، آنها را متوقف و مدیریت کنید. کتاب دستور عملیات اشتراک کننده گان 34 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE EDCBA : بررسی اولیه صدمه روش EDCBA در مصدومین اغلب ارزیابی اولیه صدمه نیز نامیده میشود. همانطور که برای همه مریضان، این باید در 5 دقیقه اول انجام شود و هر زمان که وضعیت مریض بدتر شد، تکرار شود. این روش EDCBA ویژه صدمه شامل ارزیابی اولیه و مدیریت برای تمام خطرات بلقوه تهدید کننده خطرات بلقوه است. همیشه به آسیب سر و ستون فقرات در یک مریض صدمهیی با تغیر وضعیت شعوری یافته مشکوک باشید. ارزیابی مدیریت فوری ستون فقرات رقبی را تثبیت کنید. )به مهارت ها مراجعه کندی.( طرق هوایی را با استفاده از tsurhT waJ باز کنید، در صورت مشکوک شدن به آسیب ستون فقرات، tfil nihC dna tliT daeH نکنید. [به مهارت ها مراجعه کنید] ترشحات طرق هوایی، خون و/یا استفراغ را سکشن یا پاک کنید. هر گونه جسم خارجی قابل مشاهده را از طرق تنفسی خارج کنید. [به مهارت ها مراجعه کنید] وسیله تیوب فمی بلعومی را قرار دهید )در صورت ضربه به صورت از طرق تنفسی بینی خودداری کنید(. [به مهارت ها مراجعه کنید] اگر مریض دارای هماتوم در حال گسترش گردن یا شواهدی از سوختگی یا صدمه در طرق تنفسی است، برای رجعت دهی/انتقال سریع به یک مرکز طبی قادر به مدیریت پیشرفته طرق هوایی برنامه ریزی کنید. اگر طرق هوایی باز است، به «تنفس» بروید. مشاهده کنید: خون، استفراغ، زبان یا اشیایی که طرق هوایی را مسدود می کنند موهای بینی سوخته یا دور بینی یا دهان صدمه به سر و گردن هماتوم گردن )خونریزی زیر جلد( تغییر وضعیت ذهنی، زیرا میتواند بر توانائی محافظت از طرق تنفسی تأثیر بگذارد به صداهای غیرعادی طرق هوایی )مانند وصف جوشیدن آب، خروپف، استریدور، تنفس پر سر و صدا( گوش دهید. طرق تنفسی با بی حرکتی ستون فقرات رقبی اکسیجن بدهید [به مهارت ها مراجعه کنید] فورا ًرفع فشار توسط سوزن را انجام دهید و برای نوموتوراکس تنش اکسیجن و مایعات وریدی بدهید. [به مهارت ها مراجعه کنید] برای مکنده پانسمان سه طرفه قرار دهید. [به مهارت ها مراجعه کنید] درصورت عدم داشتن تنفس کافی و موجودیت سیانوز، با تهویه ماسک evlav-gab به تنفس کمک کنید. [به مهارت ها مراجعه کنید] برای سوختگی قفس سینه یا شکم که تنفس را محدود می کند، مریض را برای اسکاروتومی )روشی جراحی برای بریدن و رهاسازی نسج سوخته که ممکن است تنفس یا خون رسانی به اندام را محدود کند( انتقال دهید. اگر تنفس کافی است، به «دوران خون» مراجعه کنید. مراقب باشید به: افزایش کار تنفس حرکت غیرطبیعی جدار صدری که ممکن است نشان دهنده شکستن اضلاع صدر باشد بی جا شدن شزن یا تراخیا نوموتوراکس ) تجمع هوا در صدر( سیانوز )رنگ خاکستری آبی جلد( در اطراف لب ها و نوک انگشتان سایش، کبودی یا سایر علایم آسیب به قفس سینه سوختگی های جدار صدری )سوختگی هایی که در تمام قسمت های بدن ایجاد می شود( به سینه یا شکم وجود یا کاهش صداهای تنفسی به صداهای جدار صدری یا تشدید بیش از حد با قرع گوش دهید. احساس کرپیتوس )ترک خوردن در هنگام فشار دادن روی جلد(. نفس گرفتن قلوومو معم ددگدمع م:دقودلمدعم 44 ارزیابی مدیریت فوری برای کنترول خونریزی فعال یا تامپون زخم عمیق در صورت بزرگ یا خالی بودن فشار مستقیم وارد کنید. [به مهارت ها مراجعه کنید] اگر تامپون قطع شده یا هر منبع دیگری از خونریزی کنترول نشود، تورنیکیت را تطبیق کنید و زمان تطبیق آنرا درج کنید. مایعات وریدی را شروع کنید و برای انتقال فوری به بخش جراحی برنامه ریزی کنید. [به مهارت ها مراجعه کنید] در صورت از دست دادن خون یا شواهدی از اروا ضعیف، دو کنول وریدی با قطر بزرگ تطبیق کنید. بعد از تطبیق مایعات مجددا ارزیابی کنید. [به مهارت ها مراجعه کنید] در صورت سوختگی، مایعاتوریدی را با توجه به اندازه سوختگی شروع کنید. اتل بگذارید در صورت مشکوک به شکستگی استخوان ران. [به مهارت ها مراجعه کنید] شکستگی لگن خاصره را ببندید. [به مهارت ها مراجعه کنید] هر گونه اجسام نافذ را دور نکنید و در جای خودش تثبیت کنید. مریضان حامله را با با بی حرکت کردن ستون فقرات در سمت چپ قرار دهید. بیبینید: برگشت خون به عروق شعرعیه بیشتر تر از 3 ثانیه خاسف شدن اطراف متوسیع شدن ورید های عنق خونریزی خارجی و داخلی منابع شایع خونریزی شدید عبارتند از: صدمات صدری صدمات بطنی کسر لگن خاصره کسور عظام فخذ قطع عضو یا زخم های خارجی بزرگ سوختگی، توجه به اندازه و عمق احساس کنید: اطراف و یا نهایات سرد نبض ضعیف و سریع )aidracyhcaT( دوران خون اگر SCG کمتر از 9 )یا برای کودکان، UPVA امتیاز P یا U(، برای رجعت دهی/انتقال سریع به یک سهولتی که قادر به مدیریت پیشرفته طرق تنفسی باشد برنامه ریزی کنید. اگر مصدوم بی حال یا بیهوش است، طرق هوایی را مرتبا ًمطابق بالا ارزیابی کنید. به ترضیض ستون فقرات یا ترضیض بسته قحف با هر نوع صدمات دیگر و تغییر وضعیت شعوری مشکوک باشید . اگر نگرانی از کمبود آکسیجن دلیل تغییر وضعیت ذهنی است، به او اکسیجن بدهید. ] به مهارت ها مراجعه کنید[ در صورت تغییر وضعیت شعوری، گلوکوز بدهید و در صورتیکه شما قادر نباشید که سویه شکر را چک کنید. [به مهارت ها مراجعه کنید] در صورت تشنج، بنزودیازپین بدهید. [به مهارت ها مراجعه کنید] مراقب موارد ذیل باشید: گیجی، بی حالی با بی حرکت کردن تشنج/اختلاج عدم تناظر حدقه ها با عکس العمل ضعیف سو شکل های جمجمه خون یا مایع از گوش یا بینی بررسی کنید: UPVA یا SCG حرکت و احساس در تمام اطراف تعین سطح گلوکوز خون در صورت گیجی یا بیهوشی ناتوانی کتاب دستور عملیات اشتراک کننده گان 54 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE ارزیابی مدیریت فوری اگر مشکوک به آسیب ستون فقرات هستید، مانور llor-gol را برای معاینه پشت انجام دهید. [به مهارت ها مراجعه کنید] لباس های محدود کننده و تمام جواهرات را بردارید. هر گونه لباس صدمات را خارج کرده و مریض را کاملا خشک کنید. در اسرع وقت مریض را بپوشانید تا از )aimrehtopyH( حرارت پایین بدن جلوگیری شود. مریضانی که به شدت آسیب دیده اند در تنظیم حرارت بدن مشکل دارند. به مریض احترام بگذارید و از حریم مصدوم در هنگام معاینه محافظت کنید. تمام لباس ها را دور کنید. با استفاده از مانور llor-gol کل بدن را برای شواهد صدمات )از جمله پشت، ستون فقرات، کشاله ران و زیر بغل( بررسی کنید. مشاهده مریض سوال 1 کتاب تمرین: عملکرد باصدمه مردی میانسال را پس از متقبل شده صدمه با موتر به داخل می آورند. با استفاده از بخش کتاب تمرین بالا، مدیریت فوری یافته های ارزیابی را در زیر فهرست کنید. مدیریت فورییافته های بررسی اولیه در ارزیابی طرق تنفسی: صدای غر غر طرق هوایی صدمهی آشکار در سر 1. 2. 3. 4. در ارزیابی دوران خون: نبضان ضعیف برگشت خون به عروق شعرعیه در >3 ثانیه لگن خاصره غیرثابت در معاینه 1. 2. 3. قلوومو معم ددگدمع م:دقودلمدعم 64 انجام دهید: شرایط مهم برای شناخت و مدیریت در نظر سنجی اولیه طرق تنفسی حالت اعراض و علایم مدیریت عمیق صدمات به سر و گردن ممکن است منجر به انسداد )بندش( طرق تنفسی توسط خون، ترشحات، استفراغ، اجسام خارجی یا پندیدگی شود. زخم های نافذ به گردن میتواند باعث گسترش هماتوم شود. صدمات استنشاقی ناشی از سوختگی میتواند باعث پندیدگی شود. مریضانی که سطح شعوری آنها کاهش یافته است ممکن است نتوانند از مجاری تنفسی خود محافظت کنند و باید از نظر استفراغ و آسپایریشن تحت نظر باشند. طرق تنفسی را پاک کنید و اجسام اجنبی را خارج کنید. طرق هوایی را با استفاده از مانور بلندکردن الاشه باز کنید )نه با شیب سر/ بالابر چانه( و در صورت نیاز تیوب فمی بلعومی قرار دهید. )به مهارت ها مراجعه کنید(. در صورت نیاز، ستون فقرات رقبی و تمام ستون فقرات را بی حرکت بسازید. برای رجعت دهی/انتقال سریع به یک مرجع پیشرفته طبی که قادر به مدیریت پیشرفته طرق تنفسی برنامه ریزی کنید. خون قابل مشاهده، ترشحات، استفراغ، زبان یا اجسام خارجی در طرق هوایی تغییرات در صدا صداهای غیر نارمل از طرق هوایی )مانند استریدور، خروپف، وصف جوشیدن آب کردن( هماتوم گردن یا سوختن سر و گردن تغییر وضعیت روانی که منجر به انسداد )بندش( طرق هوایی می شود ضعف حرکات صدری آسیبی که باعث پندیدگی مجرای تنفسی می شود )مانند عکس العمل شدید یا سوختگی طرق تنفسی( انسداد طرق تنفسی حالات تنفس حالات اعراض و علایم مدیریت عمیق هر نوموتوراکس میتواند به یک نوموتوراکس فشاری تبدیل شود. هوا در حفره بین ریه ها و دیوار قفس صدر میتواند ریه را از فعالیت باز دارد )نوموتوراکس ساده(. ایجاد فشار )تنش( از یک نوموتوراکس بزرگ می تواند باعث جابجایی و مسدود شدن جریان از عروق بزرگ به قلب شود، زیرا قلب نمی تواند خون کافی را دریافت و به بقیه بدن پمپ کند )نوموتوراکس فشاری(. در نوموتوراکس تنشن، اروا به خطر می افتد. نوموتوراکس تنش را فورا ًبا داخل کردن سوزن تداوی کنید [به مهارت ها مراجعه کنید] اکسیجن و مایعات وریدی بدهید. [بهمهارت ها مراجعه کنید] برای رجعت دهی/انتقال سریع به یک مرکز طبی پیشرفته که قادر به قرار دادن تیوب صدر باشد، برنامه ریزی کنید. فشار خون پایین همراه: مشکلات تنفسی ورید های متوسع گردن عدم موجودیت صداهای تنفسی در سمت ماووفه تشدید بیشتر صدا در سمت ماووفه با قرع یا ضربان انگشت ممکن از بی جا شدن شزن از سمت ماووفه داشته باشد نوموتوراکس تنشی کتاب دستور عملیات اشتراک کننده گان 74 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE حالات اعراض و علایم مدیریت عمیق تشخیص زخم های مکنده صدری مهم است زیرا می توانند به سرعت باعث ایجاد نوموتوراکس تنشی شوند. هنگامی که مریض نفس می کشد، هوا از طریق زخم دیوار قفس سینه وارد جوف صدر )جوف یلورا( می شود. اگر هوا نتواند از آن خارج شود، فشار بالای ریه افزایش می یابد. آکسیجن بدهید )به مهارت ها مراجعه کنید.( یک پانسمان سه طرفه قرار دهید که اجازه می دهد هوا با زفیر خارج شود اما از ورود هوا در هنگام شهیق جلوگیری می کند. [به مهارت ها مراجعه کنید] خطر چسبیدن پانسمان به دیوار قفس سینه با خون لخته شده و ایجاد نوموتوراکس تنشی وجود دارد. پس از پانسمان سه طرفه مریض باید به طور مداوم تحت نظر باشد. در صورت بدتر شدن وضعیت تنفسی یا شواهدی از بدتر شدن اروا، پانسمان را بردارید. برای رجعت دهی / انتقال سریع به یک مرکز طبی پیشرفته که قادر به قرار دادن تیوب صدری است برنامه ریزی کنید. زخم باز در جدار صدری با عبور هوا و ایجاد صداهای حباب یا «مکنده» مشکلات تنفسی درد صدری زخم مکنده صدری (نوموتوراکس باز) tsehC laliF زمانی رخ می دهد که اضلاع از چندین جا میشکند و یک بخش کامل از اضلاع را از دیوار قفس سینه آزاد می کند. بدون اتصال به جدر صدری، این بخش با تنفس به طور غیر نارمل حرکت می کند و از انبساط بخشی از ریه جلوگیری می کند. tsehC laliF نیز معمولا ًبا ترضیض انساج عمیق ریه همراه است. آکسیجن بدهید و درد را کنترول کنید [به مهارت ها مراجعه کنید] خطر بسیار بالایی برای ایجاد مشکلات تنفسی و کمبود آکسیجن وجود دارد. برای رجعت دهی/انتقال سریع به مرکز طبی که قادر به قرار دادن تیوب صدری، باز کردن طرق تنفسی بروش پیشرفته و با فراهم کردن تهویه کافی، برنامه ریزی کنید. مشکلات تنفسی درد صدری حرکت بخشی از دیوار قفس سینه در جهت مخالف بقیه قفس سینه هنگام تنفس کسورمتعدد اضلاع (tsehC lialF) هموتوراکس )خون در فضای بین ریه ها و جدار صدری( میتواند با کاهش یا عدم وجود صداهای تنفسی و یا اصمیت در با قرع در سمت آسیب دیده ظاهر شود. آکسیجن و مایعات وریدی بدهید. برای رجعت دهی / انتقال سریع به یک مرکز صحی با ظرفیت جراحی برنامه ریزی کنید. مشکل در تنفس کاهش صدای تنفس در سمت آسیب دیده اصمیت )ssenlluD( با قرع در سمت آسیب دیده هموتوراکس بزرگ ممکن است باعث شاک شود هیموتوراکس قلوومو معم ددگدمع م:دقودلمدعم 84 حالات دوران خون حالت اعراض و علایم مدیریت عمیق شاک هیپوولمیک میتواند در نتیجه از دست دادن سریع خون )شاک هموراژیک( یا از دست دادن مایعات همراه با سوختگی باشد. یک مریض بالغ در شاک ممکن است فقط تاکی کاردی )بالا رفتن ضربان قلب( و/یا تاکی پنه )تعداد تنفسی بالا( داشته باشد و ممکن است فشار خون پایین نداشته باشد تا زمانی که وضعیت بلافاصله تهدید کننده زندگی باشد. حتی با فشار خون سیستولیک بیش از 09 میلی متر ستون سیماب، در صورت وجود خونریزی شدید یا هر نشانه ای از اروا ضعیف )مانند جلد سرد، مرطوب یا خاسف، تاخیر در برگشت خون به عروق شعریه، تنفس سریع، گیجی، بی قراری، اضطراب( به شاک هیپوولمی مشکوک شوید. خونریزی را با فشار مستقیم متوقف کنید، در صورت زخم های واضیح و باز، تامپون کردن زخم های عمیق، بستن تورنیکت، اتل شکستگی ها و بستن لگن خاصره در صورت لزوم. [به مهارت ها مراجعه کنید} دو کنول وریدی با قطر بزرگ تطبیق و مایعات وریدی بدهید. [به مهارت ها مراجعه کنید] مریضان مشکوک به هموتوراکس بزرگ یا سایر خونریزی های داخلی نیاز به رجعت دهی / انتقال سریع به مرکز با مراقبت های جراحی و قابلیت تطبیق خون دارند. ضربان سریع قلب )aidracyhcaT(، تنفس سریع، جلد خاسف،اندام سرد، تاخیر در برگشت خون به عروق شعریه ممکن است سرچرخی، گیجی یا تغییر وضعیت شعوری داشته باشد ممکن فشار پایین داشته باشد خونریزی خارجی یا خونریزی داخلی )سینه، شکم ، لگن خاصره، عظام فخذ، خون ریزی اوعیه( شاک هایپوولیمیک به یاد داشته باشید... کودکان و نوجوانان می توانند فشار خون طبیعی خود را تا زمانی که تا یک چهارم خون خود را از دست ندهند حفظ کنند. همیشه سایر علایم شاک را بررسی کنید. [به بخش «ملاحظات ویژه در کودکان» مراجعه کنید] تامپوناد پریکارد زمانی اتفاق می افتد که مایع در کیسه اطراف قلب جمع شود. فشار ناشی از این مایع میتواند حفره های قلب را فرو بریزد و از پر شدن آنها جلوگیری کند و مقدار خونی که قلب میتواند پمپ کند را محدود می کند. مایعات وریدی برای بهبود پر شدن قلب بدهید [به مهارت ها مراجعه کنید] مریضان نیاز به رجعت دهی/انتقال فوری به یک ارائه دهنده پیشرفته برای تخلیه مایع دارند. علایم اروا ضعیف )مانند افزایش ضربان قلب، افزایش ریت تنفس، فشار خون پایین، جلد خاسف، نهایات سرد، برگشت خون به عروق شعریه بیش از 3 ثانیه( توسع ورید های عنق خفیف شدن صدای قلبی ممکن است سرچرخی، گیجی، تغییر وضعیت ذهنی داشته باشد تیمپوناد پریکارد قلبی کتاب دستور عملیات اشتراک کننده گان 94 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE حالات ناتوانی حالت اعراض و علایم مدیریت عمیق آسیب های مغزی میتواند از کبودی خفیف تا خونریزی شدید در داخل یا اطراف مغز متفاوت باشد. از آنجایی که جمجمه سخت است، خونریزی نمیتواند گسترش یابد و باعث افزایش فشار بر بالای مغز می شود. اگر فشار بیش از حد زیاد شود، از ورود خون به جمجمه و اروا مغز جلوگیری می کند و میتواند بخشی از مغز را بخصوص قاعده قحف را زیر فشار قرار دهد و باعث مرگ شود. هر گونه ضربه به مغز میتواند تأثیر قابل توجهی بر عملکرد دماغ داشته باشد. همیشه به یاد داشته باشید که ترضیض قحف میتواند با آسیب های ترضیض فقرات همرا باشد. ستون فقرات را بی حرکت کنید و از تکنیک llor-gol برای بررسی پشت بدن استفاده کنید. از مقیاس کوما گلاسکو )یا کودکان UPVA( برای ارزیابی و نظارت بر مریضان مبتلا به آسیب سر استفاده کنید. حتما EDCBA را مرتبا ًمجددا ًارزیابی کنید. اگر نگران شکستگی باز جمجمه هستید، طبق پروتوکول موضعی انتی بیوتیک های وریدی بدهید. همیشه گلوکوز را چک کنید و در صورت نیاز تجویز کنید. از طریق دهان غذا یا نوشیدنی ندهید. برای رجعت دهی زودهنگام/ انتقال به یک مرکز با مراقبت های تخصصی برنامه ریزی کنید. تغییرات بینایی، از دست دادن حافظه، اختلاج/تشنج، استفراغ، سردرد تغییر وضعیت شعوری یا نقص عصبی دیگر جروحات قحفی و/سوشکل جمجمه کبودی در سر )به ویژه در اطراف چشم یا پشت گوش( خون یا مایع از گوش یا بینی عدم تناظر حدقه ها ضعف در یک طرف بدن ترضیض شدید قحفی به یاد به یاد داشته باشید... مصدومین که در ابتدا خوب به نظر می رسند ممکن است آسیب های مخفی تهدید کننده زندگی مانند خونریزی داخلی داشته باشند. ارزیابی مجدد مصدومین با استفاده از سروی ابتدایی بسیار مهم است. هنگامی که یک مشکل در سروی ابتدایی را پیدا کردید و آن را مدیریت کردید، به عقب برگردید و بررسی اولیه را تکرار کنید تا مشکلات جدید را شناسایی کنید و مطمئن شوید که مدیریت کار کرده است. در صورت معمول، روش EDCBA باید هر 51 دقیقه یکبار و با هر تغییری در شرایط بررسی شود. علایم حیاتی باید در پایان بررسی اولیه چک شود مجموعه کامل از علایم حیاتی )فشار خون، ضربان قلب، تعداد تنفس و اشباع اکسیجن در صورت وجود( باید پس از بررسی اولیه انجام شود. مداخلات بررسی اولیه را برای علایم حیاتی به تاخیر نیندازید. قلوومو معم ددگدمع م:دقودلمدعم 05 سوال 2 کتاب تمرین: عملکرد باصدمه با استفاده از بخش کتاب تمرین بالا، پنج وضعیت مهم را که باید در بررسی اولیه تشخیص میکند را بنوسید. 1: 2: 3: 4: ۵: بپرسید: یافته های کلیدی تاریخچه برای مصدومین اطلاعات در مورد فرد مجروح ویا مصدوم و وقوع صدمه میتواند برای پلان مداخلوی حیاتی باشد. کودکان، سالمندان و افراد مبتلا به امراض مزمن در معرض شدید خطر ناشی از صدمه هستند. و ممکن است نیاز به مشاهده چندین ساعت باشد، حتی زمانی که خوب به نظر می رسند. چون مکانیزم های خاص اغلب با صدمات متعدد همراه هستند، که بعضی از آنها ممکن است بلافاصله آشکار نشود. مکانیزم های صدمات که خطرات جدی در قبال دارد عبارتند از: تصادم شخص پیاده با وسیله نقلیه تصادفات موتورسایکل یا هر وسیله نقلیه همراه با سرنشینان بدون کلاه ایمینی؛ سقوط از ارتفاع بیش از 3 متر )یا در کودکان دو برابر قد کودک(؛ جروحات ناشی از مرمی یا چاقو؛ انفجار یا آتش سوزی در فضای بسته. برای بدست آوردن تاریخچه از مختره ELPMAS استفاده کنید. به یاد داشته باشید که ممکن است بتوانید از اطرافیان، خانواده، پولیس، کارکنان اطفایه یا سایر کارکنان مراقبت های صحی راجع به تاریخچه مصدوم اطلاعات کسب کنید. اگر در جریان گرفتن تاریخچه یکی از حالات مربوط به ارزیابی ابتدای را مشاهده میکند گرفتن تاریخچه را توقف دهید و ارزیابی ابتدایی را آغاز کنید. کتاب دستور عملیات اشتراک کننده گان 15 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE S : اعراض و علایم آیا سابقه صدای خشن و خرخری یا سایر تغیرات صدا را دارد؟ تغییر در صدا ناشی از صدمه به سر، گردن یا با سوختگی ممکن است نشان دهنده پندیده گی طرق تنفسی و ممکن سبب مسدود شدن طرق تنفسی شود.. آیا مشکلی در تنفس وجود دارد؟ مشکلات تنفسی ممکن است به مرور زمان ایجاد شود و ممکن است در ارزیابی ابتدایی وجود نداشته باشد. مشکلات تنفسی ممکن است نشان دهد که فرد دچار صدمه به ریه ها، اضلاع، عضلات، جدار صدر یا ستون فقرات شده است. آیا خونریزی گزارش شده است؟ معمولا ًتخمین حجم از دست دادن خون برای مریضان بسیار دشوار است، اما ممکن است دانستن مدت زمان خونریزی، تعداد پانسمان آلوده شده و اینکه آیا خونریزی کمتر یا شدیدتر بوده و مفید است که بدانیم. آیا گیجی یا خواب آلودگی غیرعادی وجود دارد؟ گیجی پس از آسیب ممکن است عرض از ترضیض قخف، کمبود اکسیجن یا شاک )با کاهش دوران خون به مغز( باشد. ترضیض قحف میتواند باعث خونریزی یا افزایش فشار بر روی مغز شود که منجر به گیجی، بی حالی )افزایش خواب آلودگی( و کوما میشود. آیا درد وجود دارد؟ درد کجاست، چه حسی دارد و چقدر شدید است؟ درد نشانه از آسیب دیدگی است. سردرد ممکن است نشان دهد که فرد آسیبی به جمجمه یا مغز دارد. درد در امتداد ستون فقرات میتواند نشان دهنده آسیبی باشد که ممکن است باعث آسیب به نخاع شود. درد در قفس سینه یا شکم ممکن است نشان دهنده آسیب به قلب، ریه ها یا سایر اندام ها باشد. درد در لگن خاصره یا مفاصل لگن خاصره ممکن است نشان دهنده شکستگی در لگن باشد که میتواند باعث خونریزی و شاک جدی شود. درد ممکن است اولین علامت ترضیض داخل صدر، بطت یا لگن خاصره باشد. آیا دلبدی و استفراق وجود دارد؟ این ممکن است نشان دهنده ترضیض بطن و یا قحف باشد. آیا بی حسی یا ضعف گزارش شده است؟ این ممکن است نشان دهنده آسیب ستون فقرات باشد. آیا تغییرات بینایی گزارش شده است؟ ضربه مستقیم به چشم، شکستگی استخوان های اطراف چشم و ترضیض قحفی می توانند باعث تغییرات بینایی شوند. قلوومو معم ددگدمع م:دقودلمدعم 25 A: الرژی یا حساسیت آیا به ادویه جات حساسیت موجود است؟ M: ادویه جات آیا در حال حاضر ادویه ای مصرف می کنید؟ ادویه جات که بر انعقاد خون تأثیر می گذارند )مانند اسپرین، وارفرین، کلوپیدوگریل( می توانند کنترول خونریزی را دشوارتر کرده و خطر خونریزی تاخیری را افزایش دهند. ادویه جات فشار خون می توانند مدیریت شاک را دشوار کنند. در صورت امکان فهرست کامل از ادویه را تهیه کنید یا از اعضای خانواده بخواهید که ادویه جات را بیاورند. P: تاریخچه طبی گذشته آیا فرد حامله است؟ بارداری یا حمل باعث می شود که بعضی از اعضا ها از موقعیت معمول خود بیجا شوند و تغییراتی در بدن ایجاد میشود که باید در هنگام مدیریت صدمه در نظر گرفته شود. همیشه از زنان در سنین باروری هستند در مورد تاریخ آخرین عادت ماهوارشان بپرسید. واکسین تیتانوس؟ فردی که در 5 سال گذشته واکسن تیتانوس را نگرفته است و به اثر صدمه جروحات باز دارد نیاز به واکسین نمودن تیتانوس دارد. آیا شرایط دیگری وجود دارد که فرد را در معرض خطر بیشتری برای آسیب جدی قرار می دهد؟ عوامل پیامدهای ضعیف ناشی از صدمات: سن کمتر از 5 سال یا بیشتر از 55 سال امراض قلبی یا ریوی دیابت عدم کفایه کبدی )سیروز( اضافه وزن شدید حاملگی ضعف سیستم معافیتی )از جمله HIV( اختلالات خونریزی یا مصرف ادویه جاتی رقیق کننده خون )ادویه جاتیی که از لخته شدن خون جلوگیری می کند( کتاب دستور عملیات اشتراک کننده گان 35 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE L: آخرین وعده غذایی آخرین بار چه زمانی فرد خورده یا آشامیده است؟ E: رویداد های مرتبط به ترضیض مکانیزم های خاص صدمات آنقدر پرخطر هستند که مصدومین باید از نزدیک تحت نظر قرار گیرند، حتی اگر به نظر نمی رسد که آسیب قابل توجهی داشته باشند. آیا سقوط از ارتفاع 3 متری یا بیشتر (یا دو برابر قد در کودکان) رخ داده است؟ زمین خوردن یک علت شایع صدمات برای بزرگسالان و کودکان است. فاصله افتادن بیشتر احتمال صدمات جدی را افزایش می دهد. سقوط در بزرگسالان اغلب با سن بالاتر، ناشی از مسمومیت با الکول، یا خرابی تجهیزات محل کار، از جمله تخته های چوبی و زینه ها همراه است. کودکان اغلب از درختان، پنجره ها یا بالکن می افتند. آیا وسیله نقلیه به عابر پیاده یا بایسکل سوار برخورد کرد؟ بزرگسالان و کودکانی که هنگام راه رفتن یا استفاده از وسایل حمل و نقل غیر موتوری )مانند بایسکل( با وسیله نقلیه برخورد می کنند، همیشه در معرض خطر صدمات جدی هستند. کودکان خردسال ممکن است کمتر از بزرگسالان بتوانند رویدادها را گزارش دهند، حتی رویدادهای مهمی مانند برخورد با وسیله نقلیه. همیشه احتمال صدمهی بدون شاهد را در کودکان خردسال در نظر بگیرید. کودکان و بزرگسالان در هنگام برخورد با وسیله نقلیه ممکن است صدمات متعددی را متحمل شوند - هم در اثر برخورد مستقیم به بدن، به خصوص اعضای عمیقه و هم در اثر برخورد ثانوی در صورت پرتاب شدن به شیشه جلو یا جاده، که ممکن است باعث صدمات در هر جایی از بدن شود، از جمله به سر، گردن، صدر و اطراف. در تصادف موترسایکل (یا ریکشا)، آیا راکب دور افتید؟ برخورد موترسایکل اغلب منجر به پرت شدن راکب می شود. بپرسید که آیا موترسایکل سوار کلاه ایمنی به سر داشت و چه فاصله ای از وسیله نقلیه پیدا شده است. محل های صدمات عام عبارتند از: سر )مخصوصا ً زمانی که کلاه ایمنی استفاده نکرده باشد(، ستون فقرات، صدر، بطن و لگن خاصره )هنگامی که راننده با هندل برخورد می کند(، همچنین اندام ها و جلد )در هنگام برخورد راننده به جاده(. تصادف رانندگی با سرعت زیاد رخ داده است؟ آیا فرد از وسیله نقلیه پرتاب شده یا داخل آن محبوس شده است؟ آیا سرنشینان خودرو در این تصادف جان باختند؟ در تصادفات با سرعت بالاتر، نیروی بیشتری به سرنشینان وسیله نقلیه منتقل می شود و خطر صدمات جدی را افزایش می دهد. سرنشینان وسیله نقلیه ممکن است در اثر برخورد با شیشه جلو یا هندل یا نیروهای ناشی از توقف ناگهانی موتر صدمه ببینند. فردی که از یک وسیله نقلیه پرتاب می شود در معرض خطر بسیار بالایی برای صدمات جدی است. اگر شخصی در داخل وسیله نقلیه گیر افتاده باشد، مهم است قلوومو معم ددگدمع م:دقودلمدعم 45 که بفهمیم چه قسمتی از بدن )بازو/پا و غیره( و برای چه مدت به دام افتاده است. صدمات ناشی از حادثه ترافیکی را در فردی که به داخل وسیله نقلیه گیرمانده است در نظر بگیرید. مرگ درحادثه ترافیکی نشان می دهد که نیروی قابل توجهی به وسیله نقلیه و سرنشینان آن وارد شده است. همه مسافران درگیر در تصادف، حتی اگر به نظر رسد که خوبند، در معرض خطر صدمات جدی هستند. در تصادف وسیله نقلیه موتر، آیا مریض کمربند ایمنی بسته بود؟ بعضی از انواع صدمات در مصدومین که کمربند ایمنی نبسته اند )پرتاب شدن از وسیله نقلیه، ترضیض قحف به شیشه جلو، ترضیض صدر به اشترنگ موتر( شایع تر است. با این حال، در تصادفات با سرعت بسیار بالا، کمربند ایمنی نیز میتواند باعث ایجاد انواع خاصی از صدمات )ترضیض ستون فقرات رقبی، ترضیض بطن( شود. آیا از سلاح استفاده شده است؟ هر زمان که سابقه ضربه چاقو یا شلیک مرمی وجود داشته باشد، ممکن است چندین زخم وجود داشته باشد. همیشه تمام بدن را از نظر زخم بررسی کنید. پس از ورود مرمی به بدن ممکن است مسیر مستقیمی را تعقیب نکند و در سراسر بدن بپیچد. بسیاری از اندام های داخلی ممکن است با یک مرمی آسیب ببینند. زخم چاقو یک مسیر مستقیم ایجاد می کند )دانستن طول تیغه ای که استفاده شده مهم است(. به یاد داشته باشید که صدمه یا ترضیض ناشی از اشیایی مانند چوب و بیت میتواند علاوه بر صدمات آشکار مانند شکستگی، کبودی و پارگی به اندام های داخلی آسیب برساند. آیا سوختگی دارد؟ اگر بله، نوع سوختگی چه بوده است؟ سوختگی ناشی از آتش سوزی )سوختگی شعله( شایع ترین هستند. سابقه سوختگی شعله در یک فضای بسته نیز میتواند نشان دهنده آسیب استنشاق یا مجاری هوایی باشد. سوختگی با آب جوش )به دلیل مایعات داغ( در کودکان شایع است. صدمات الکتریکی اغلب از منابع با ولتاژ بالا مانند سیم های برق بالای سر که در تماس با بدن هستند به وجود می آیند. در ظاهر، این آسیب های الکتریکی ممکن است کوچک به نظر برسند، اما می توانند باعث صدمات نسجی و عضلات شوند. جریان الکتریکی اغلب از بدن عبور می کند و کوتاه ترین مسیر را از نقطه تماس با جلد تا زمین طی می کند و اغلب آثار سوختگی ورودی و خروجی را بر جای می گذارد. در مورد سوختگی های کیمیاوی، ممکن است اطلاعاتی در مورد ماده کیمیاوی خاص برای حذف صحیح آن مورد نیاز باشد. برای سوختگی، کمک های اولیه در محل انجام شده؟ مهم است که بدانید پروسه سوختن متوقف شده است یا خیر، و در صورت مواجهه با مواد کیمیاوی، آیا ضدعفونی انجام شده است یا خیر. اگر سوختگی کمتر از 3 ساعت باشد و کمک های اولیه ارائه نشود، زخم باید با آب پاک شسته شود تا پروسه سوختن متوقف شود. اگر سابقه قرار گرفتن در معرض مواد کیمیاوی وجود دارد، از خود در برابر مواد کیمیاوی محافظت کنید و مطمئن شوید که به درستی از روی جلد پاک شده است. آیا فرد دچار صدمات کوبنده؟ آیا درد یا بی حسی شدید وجود دارد؟ آیا ادرار تیره وجود دارد؟ کتاب دستور عملیات اشتراک کننده گان 55 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE صدمات کوبیده شده ممکن است به جلد، عضله، عروق خونی و استخوان آسیب برساند. عضله صدمه دیده میتواند یک محصول جانبی عضلی )موسوم به میوگلوبین( را آزاد کند که میتواند ایجاد شود و به کلیه ها آسیب برساند. مهم است که بدانید یک عضو بدن چه مدت کوبیده شده است. حتی یک ناحیه کوچک خرد شده میتواند باعث آزاد شدن مقدار خطرناکی از میوگلوبین شود )به عنوان مثال زمانی که یک عضو برای مدت طولانی در زیر آوار در حال سقوط گیر می افتد(. اگر فردی که دچار آسیب فشردن شده، ادرار تیره داشته باشد، ممکن است نشانه ای از تجمع میوگلوبین در کلیه ها باشد. آسیب نسجی و پندیدگی ناشی از آسیب فشرده شدن نیز میتواند باعث افزایش فشار )به ویژه در صدمات کوبیده به اعضا( شود که میتواند دوران خون را به عضلات و اعصاب محدود کند )سندروم کمپارتمان(. آیا فرد دچار آسیب ناشی از انفجار شده است؟ صدمات ناشی از انفجار میتواند تمام سیستم های بدن، به ویژه اعضای مجوف را درگیر کند. آسیب های شایع انفجار شامل آسیب به ریه ها، روده ها و گوش ها است. مریضان درگیر در انفجار نیاز به بررسی دقیق و مکرر دارند زیرا این آسیب ها به راحتی از دست می روند. انفجارها همچنین ممکن است با اجسام خارجی در جلد و چشم، سوختگی یا مواد کیمیاوی، و قرار گرفتن در معرض سموم یا تشعشع همراه باشد. سوال سوم کتاب تمرین: عملکرد باصدمه با استفاده از بخش کتاب تمرین بالا، پنج سوالی را که هنگام گرفتن تاریخچه ELPMAS از فردی که در حادثه ترافیک جاده ای مجروح شده است بپرسید: 1: 2: 3: 4: ۵: قلوومو معم ددگدمع م:دقودلمدعم 65 ارزیابی ثانوی صدمه پس از بررسی اولیه و تاریخچه ELPMAS، ارزیابی ثانوی یک معاینه دقیق سر تا پا است که برای شناسایی هرگونه آسیب اضافی یا مسائلی که نیاز به مداخله دارند طراحی شده است. ارزیابی ثانوی به ارائه دهنده روشی طراحی شده برای ارزیابی کل بدن از نظر علایم صدمه که ممکن است در بررسی اولیه آشکار نبوده باشد، می دهد. به یاد داشته باشید که جروحات بسیار دردناک یا ترسناک ممکن است توجه مریضان و ارائه دهندگان را از تشخیص صدمات دیگر منحرف کند. همیشه کل بدن را بررسی کنید. اگر بررسی ثانوی شرایط بررسی اولیه را شناسایی کرد، برای مدیریت آن، فورا ًبه بررسی اولیه بازگردید. سر، گوش، چشم، بینی و گلو (TNEEH) به تعقیب موارد ذیل باشید: زخم یا کبودی جلد سر )placS( سوشکلی های جمجمه خون در دهان یا گلو حدقه های نابرابر یا بی پاسخ که نشان دهنده ترضیض قحف است از دست دادن یا تغییرات بینایی و صدمات چشمی هر گونه مشکل در حرکات چشم خون یا مایع از گوش یا بینی که میتواند نشان دهنده صدمات نسجی یا شکستگی جمجمه باشد صدمات دندان یا دندان های نا منظم علایم سوختگی مجرای تنفسی: خاکستر، موی بینی، پندیدگی جدید یا صدمات شدید لب/دهان گوش دهید به: استریدور که میتواند نشان دهد که طرق تنفسی به زودی مسدود می شود gnilgruG نشان دهنده موجودیت مایع در طرق تنفس است تغییرات در صدا، که میتواند نشان دهنده آسیب طرق هوایی یا حبول صوتی باشد احساس کنید: حساس بودن یا حرکت غیرطبیعی استخوان های وجه که نشان دهنده شکستگی است دندان های لق که ممکن است به طور تصادفی استنشاق شوند نقایص یا کرپیتوس در جمجمه یا استخوان های صورت در صورت شکستگی به تعقیب موارد ذیل باشید: (عنق) کاهش توانائی حرکت گردن یا درد در هنگام حرکت کبودی، خونریزی یا پندیدگی هماتوم )کبودی/خونریزی تحت جلدی( – ممکن است در نهایت باعث انسداد طرق تنفسی شود. زخم های نافذ گردن توسع ورید های عنق )که ممکن است نشان دهنده حالات ازتامپوناد نوموتوراکس تنشی باشد( احساس کنید: آمفیزم - نگران آسیب طرق هوایی یا نوموتوراکس حساس بودن یا تغییر شکل در امتداد ستون فقرات - نگران شکستگی کتاب دستور عملیات اشتراک کننده گان 75 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE مراقب موارد ذیل باشید: صدر یا قفس سینه کبودی، تغییر شکل، زخم عدم تناظر حرکات صدری – مربوط به نوموتوراکس یا tsehc lialF سوختگی بشکل حلقوی در صدر که میتواند باعث اختلال در تنفس شود گوش دهید به: صداهای تنفسی )کاهش، نابرابر یا عدم موجودیت صدای تنفسی، ویزینگ، کریپیتیشن( صداهای خفه شده قلب - نگران کننده تامپوناد پریکارد جس کنید: شخی عضلات کرپیتوس – نگران شکستگی یا نوموتوراکس مراقب موارد ذیل باشید: بطن توسع بطنی جروحات باز بطنی، کبودی یا ساییدگی کبودی در صدرو بطن ممکن است نشان دهنده خونریزی داخلی باشد سوختگی های محیطی شکم )ممکن است باعث مشکلات شدید تنفسی شود( جس کنید: تندرنس رجعی شکم )درد در هنگام آزاد کردن فشار روی شکم( یا محافظتی )انقباض ناگهانی عضلات جدار بطن در هنگام جس کردن بدن(، که نشان دهنده آسیب جدی است. حساسیت بطن که میتواند نشان دهنده صدمه اعضا و یا اوعیه باشد لگن خاصره و اعضای تناسلی (همیشه از حریم خصوصی مریض در جریان معاینه محافظت کنید) مراقب موارد ذیل باشید: کبودی/جروحات حوصله خون در دهانه آلت تناسلی یا رکتوم. ممکن است نشانه تجاوز جنسی باشد. جروحات یا خونریزی محبلی – اینها میتواند نشان دهنده شکستگی باز لگن خاصره، صدمات رحمی ممکن است منبع خون ریزی و ضیا قابل توجع خون باشد. ممکن است نشانه تجاوز جنسی باشد. جروحات اعضای تناسلی پریاپیسم )نعوظ طولانی مدت( میتواند نشان دهنده ترضیض نخاع باشد تغییر رنگ ادرار )ادرار تیره یا خون واضح( که ممکن است نشان دهنده تناقص عضلی یا جروحات کلیوی باشد احساس کنید: حساس شدن یا حرکت غیر نارمل در لگن خاصره مراقب موارد ذیل باشید: نهایات پندیدگی یا کبودی سو شکل، که میتواند نشان دهنده کسور باشد کسور باز قطع عضو سوختگی های محیطی جلد خاسف که میتواند نشان دهنده محدودیت دوران خون باشد جس کنید: عدم موجودیت نبض یا نبض ضعیف سردی جلد که میتواند نشان دهنده محدودیت دوران خون باشد حساسیت عضلی محفظه های عضلی غیر نارمل سخت و دردناک در اعضا ها میتواند نشان دهنده سندروم کمپارتمان باشد. قلوومو معم ددگدمع م:دقودلمدعم 85 شخص را با llor goL همکاری کنید و بعدا:ً ستون فقرات / پشت مراقب موارد ذیل باشید: کبودی سو شکل جس کنید: ssenredneT، کرپیتوس ترتیب و تناظر ستون فقرات )بالای گردن تا پایین کمر( ssenredneT، کرپیتوس یا ناهماهنگی در سایر نواحی با شواهد قابل مشاهده صدمه مراقب موارد ذیل باشید: جلد کبودی خراشیدگی جروحات جس نبض های محیطی در تمام نهایات سوختگی ها سوختگی های محیطی را مشاهده کنید: نظریه ساحه، این سوختگی ها می توانند باعث مشکلات تنفسی )اگر روی قفس سینه باشند( یا سندروم کمپارتمان )اگر در اعضا باشد( موارد ذیل را ارزیابی کنید: عصبی کاهش سطح شعوری )با استفاده از UPVA یا SCG( و اختلاج/تشنج، که ممکن است نشانه های ترتضیض شدید قحفی باشد. حرکت و قدرت در اطراف حسیت در روی، صدر ، بطن، نهایات. اگر نقص حسی وجود دارد، مشخص کنید که از کجا شروع شده پریاپیسم )نعوظ مداوم آلت تناسلی( کاهش حسیت، کاهش قدرت یا پریاپیسم میتواند نشان دهنده ترضیض نخاع باشد کتاب دستور عملیات اشتراک کننده گان 95 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE سوال چهارم کتاب تمرین: عملکرد باصدمه با استفاده از بخش کتاب تمرین، یک شیوه ارزیابی سیستم های زیر را فهرست کنید. سر، گوش، چشم، بینی، گلو: دراصغا: در مشاهده: درجس: صدر: دراصغا: درجس: احساس کنید: حوصله و اعضای تناسلی: در مشاهده: درجس: قلوومو معم ددگدمع م:دقودلمدعم 06 شرایط مهم برای شناخت و مدیریت بر اساس تاریخچه و سروی ثانوی را انجام دهید. مدیریت صدمات خاص در طی بررسی ثانوی حالت اعراض و علایم مدیریت دقیق از آنجایی که دماغ در جمجمه سخت محصور شده است، هرگونه پندیدگی یا خونریزی ناشی از صدمات مغزی میتواند به سرعت زندگی را به خطر بیندازد. سطح شعوری )نشانگر وظایف دماغ( را با استفاده از مقیاس کوما گلاسکو (SCG( یا مقیاس UPVA در کودکان اندازه کنید.[به مهارت ها مراجعه کنید] هر مصدوم که صدمات قابل توجهی به قخف داشته باشد در خطر ترضیض ستون فقرات نیز می باشد. [به مهارت ها مراجعه کنید] مراقت مصدومین بی تحرک باشید ممکن است استفراغات سبب بندش طرق تنفسی شان گردد. اگر نگرانی برای شکستگی باز جمجمه وجود دارد، انتی بیوتیک وریدی بدهید. شکر خون را چک کنید و اگر کمتر از 5.3 میلی مول در لیتر یا قادر به اندازه گیری نیستید، گلوکوز بدهید. هر مریض با SCG کمتر از 9 در صورت امکان باید برای سی تی اسکن در عرض 2 ساعت پس از آسیب منتقل شود. سردردی تغییر وضعیت شعوری عدم تناظر حدقه ها جروات راس و/یا شکستگی جمجمه کبودی در سر )به ویژه در اطراف چشم یا پشت گوش( خون یا مایع شفاف که از بینی یا گوش می آید ضعف در یک طرف بدن اختلاج/تشنج تغییرات بینایی از دست دادن حافظه استفراغ آسیب سر برای شکستگی های باز صورت انتی بیوتیک بدهید )جروحات و کسور عظام( تطبیق واکسین تیتانوس. مشکوک به ترضیض فقرات رقبی باشید و در صورت نیاز ستون فقرات رقبی را بی حرکت کنید. [به مهارت ها مراجعه کنید] به خاطر داشته باشید که مریض را در وضعیتی قرار دهید که از دوران خون در طرق هوایی جلوگیری شود. در صورت مشکوک به کسور عظام وجه از تطبیق تیوب انفی بلعومی و انفی معدوی خودداری کنید. تغییر شکل یا حرکت غیرعادی در استخوان های روی مصدوم گزارش می دهد که الاشه به طور طبیعی بسته نمی شود یا دندان ها هم ردیف نیستند مشکلات حرکات چشم کسور عظام وجه از هرگونه فشار بر روی چشم آسیب دیده خودداری کنید - این میتواند جرحه را بدتر کند اجسام نفوذی به چشم را خارج نکنید. انتی بیوتیک بدهید. در صورت نیاز واکسین تیتانوس را به مصدوم تطبیق کنید. سر را بالا نگه دارید و روی هر دو چشم یک چسب قرار دهید )به چشم فشار ندهید(. برای رجعت دهی/انتقال به یک مرکزطبی پیشرفته برنامه ریزی کنید. هر جسم قابل مشاهده در چشم. سرخی چشم دردناک یا شکایت از احساس چیزی در چشم. دیدن اجسام کوچکی که به چشم نفوذ کرده اند دشوار است. مشکلات بینایی عدم تناظر حدقه ها و ریختن مایع شفاف از چشمان ممکن است نشان دهنده یک جروحات نافزه باشد شواهد ترضیض وجه جروحات نافذ چشم کتاب دستور عملیات اشتراک کننده گان 16 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE مدیریت صدمات خاص در طی بررسی ثانوی حالت اعراض و علایم مدیریت عمیق مریضانی که جروحات نافذه عنق دارند در خطر انسداد )بندش( طرق تنفسی هستند، بنابراین طرق تنفسی را به دقت کنترول کنید. زخم های گردن نیز ممکن است خونریزی قابل توجهی داشته باشند. اقدامات احتیاطی ستون فقرات رقبی را رعایت کنید. [به مهارت ها مراجعه کنید] تثبیت کنید اما اجسام نافذ را خارج نکنید. به محل خونریزی فشار قوی وارد کنید، مراقب باشید طرق تنفسی مسدود نشود. جهت برسی جروحات عمیق چیزی را داخل زخم قرار ندهید - این میتواند باعث آسیب بیشتر شود. تسلیمی/انتقال سریع به یک واحد با مراقبت های جراحی و قابلیت های پیشرفته مدیریت طرق تنفسی را آغاز کنید. جروحات کوچک یا جروحات نافذه ممکن است تنها نشانه صدمات شدید باشد. پندیدگی )پیشنهاد کننده هماتوم( به دقت به مراقب اجسام نافذ باشید جروحات نافذه عنق مشکلات تنفسی ناشی از صدمات ریه که میتواند در طول زمان ایجاد شود را به دقت بررسی کنید. نوموتوراکس تنشی در بررسی اولیه تداوی می شود. با این حال، ترضیضات صدری ممکن است با نوموتوراکس ساده نیز همراه باشد که میتواند به یک نوموتوراکس تنشی تبدیل شود. برای هر مریض مبتلا به نوموتوراکس روی اکسیجن تطبیق گردد و از نظر ایجاد نوموتوراکس تنشی به دقت تحت نظر باشد. کرپیتوس یا تندرنس ممکن است نشانه شکستگی ضلع یا قبرغه باشد که اغلب با ترضیضات صدر و بطن همراه است. برای رجعت دهی/انتقال جهت تطبیق تیوب صدری )نوموتوراکس( یا مدیریت پیشرفته طرق تنفسی و تنفس برنامه ریزی کنید. مشکلات تنفسی کرپیتوس یا حساسیت در جس بالای اضلاع عدم تناظر حرکات صدری یا صداهای نابرابر نفس جروحات صدری درد شدید یا کبودی در ناحیه شکم برای صدمات اعضا یا خونریزی داخلی نگران کننده است. اگر مشکوک به ترضیض بطنی هستید، مایعات وریدی بدهید. به مریض چیزی برای خوردن یا نوشیدن ندهید. اگر امعا ٕقابل مشاهده است: آن را خارج از بدن بگذارید. آن را با گاز استریل با سلاین مرطوب کرده بپوشانید. انتی بیوتیک بدهید اگر نگرانی در مورد ترضیضات بطنی وجود دارد، برای رجعت دهی / انتقال سریع به مرکز صحی با قابلیت جراحی برنامه ریزی کنید. درد بطن یا استفراق بطن حساس، سخت یا متوسع در معاینه انقباضات ناگهانی عضلات جدار بطن هنگام لمس شکم )نگهبانی( در معاینه صداهای معایی بسیار کم یا اصًلا وجود ندارد خونریزی از مقعد زخم قابل مشاهده در دیوار شکم کبودی اطراف سره یا اطراف بطن میتواند نشانه خونریزی داخلی باشد ترضیضات بطنی قلوومو معم ددگدمع م:دقودلمدعم 26 مدیریت صدمات خاص در جریان ارزیابی ثانوی حالت اعراض و علایم مدیریت دقیق بی حرکت کردن ستون فقرات را برای هر فردی که بیهوش است ویا حکایه از صدمه و بی حسی ویا هم درد گردن دارد را انجام دهید. برای بی حرکت کردن ستون فقرات رقبی از یک ورق پیچانده شده یا گردن بند استفاده کنید. [به مهارت ها مراجعه کنید] فراهم کردن وضعیت استجاع ظهری همرا با بی حرکت کردن ستون فقرات. [به مهارت ها مراجعه کنید] هنگام معاینه یا حرکت دادن مصدومین، ستون فقرات باید با استفاده از مانوره llor-gol محافظت شود. [به مهارت ها مراجعه کنید] مایعات وریدی بدهید. [به مهارت ها مراجعه کنید] هر مصدوم با صدمه ستون فقرات احتمالی نیاز به رجعت دهی / انتقال به یک مرکز صحی تخصصی دارد. درد/شخی ستون فقرات مشکلات حسی و حرکی: فلج ااطراف سفلی ضعف، رفلکس های غیر طبیعی مشکلات حسی: گزگز )احساس سوزنک(، از بی حسی اعدم کنترول ادرار یا مدفوع پریاپیسم )نعوذ طولانی آلت تناسلی در مردها( ممکن است فشار خون پاین و برادی کاردی داشته باشد هنگامی که کرپیتوس را در ستون فقرات را لمس می کنید مشاهده نمای ظاهری ستون فقرات که به درستی در یک راستا قرار ندارند مشکلات تنفسی )ترضیض فقرات رقبی علوی( ترضیضات نخاع یاداشت ترضیض ستون فقرات همیشه باز نمی باشد.کسور عظام ستون فقرات میتواند به نخاع آسیب برساند و باعث فلج شود. اگر ترضیض نخاعی در ناحیه فقرات رقبی باشد، فلج میتواند عضلات کنترول کننده تنفس را مصاب کرده و منجر به مرگ شود. یافته های معاینه باید به دقت درح شود تا ارائه دهندگان آینده بتوانند ارزیابی کنند که آیا وضعیت مصدوم تغییر کرده است یا خیر. ترضیضات ستون فقرات نیز میتواند باعث شاک شود. این میتواند زمانی رخ دهد که اعصابی که انقباض و انبساط اوعیه را کنترول می کنند آسیب ببینند. هنگامی که جدار اوعیه شل می شود، باعث توصع اوعیه شده و فشار کاهش می یابد و بلاخره منجر به اروا ضعیف و شاک می شود. در صورت ضیاع خون، خطر بیشتر است، بنابراین مریضان باید به دقت تحت نظر باشند. همیشه ترضیض ستون فقرات را در مریضان و مصدومین مبتلا به شاک در نظر بگیرید که با تداوی بهبود نمی یابد. جهت انتقال مصدومین از سطوح سخت و هموار برای بی حرکت ساختن فقرات استفاده صورت گیرد. زیرا که قرار گرفتن مصدوم درین وضعیت به مدت طولانی سبب ایجاد زخم بستر میشود و بعد از رسیدن به مرجع مطلوب مصدوم را ازین سطوح دور کنید و به بستر های مناسب جابجا کنید. قبل از تشخیص خونریزی، مقدار زیادی خون میتواند در قفس سینه، لگن خاصره، فخذ و بطن از ضایع شود. در صورت امکان خونریزی را متوقف کنید - لگن خاصره یا و یا حوصله را محکم ببندید. [به مهارت ها مراجعه کنید] مایع وریدی بدهید. [به مهارت ها مراجعه کنید] در صورت نیاز برای انتقال خون و مدیریت مداوم جراحی رجعت دهید. کبودی اطراف سره یا اطراف بطن میتواند نشانه ای از خونریزی داخلی باشد کسور حوصله کسور عظام فخذ کاهش صداهای نفس در یک طرف صدر )هموتوراکس( علایم اروا ضعیف )فشار خون پایین ، ضربان شدید قلب، جلد خاسف، مرطوب( خونریزی داخلی (در بررسی اولیه دیده نشد) کتاب دستور عملیات اشتراک کننده گان 36 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE مدیریت صدمات خاص در جریان ارزیابی ثانوی حالت اعراض و علایم مدیریت عمیق تطبیق مایعات وریدی و کنترول درد [به مهارت ها مراجعه کنید] بستن حوصله درصورت کسر جهت تداوم ثبات و حرکات غیر منظم الی رسیدن به مرکز صحی. از باز کردن و تکان دادن لگن خاصره یا انجام معاینات مکرر خودداری کنید زیرا این امر میتواند خونریزی داخلی را بدتر کند. لگن خاصره را با تکه یا بنداژ لگن خاصره تثبیت کنید. [به مهارت ها مراجعه کنید] برنامه ریزی و انتقال به مرکز صحی که خدمات نقل الدم را داشته باشد. درد در هنگام جس کردن حوصله بی ثباتی یا حرکت غیر نارمل استخوان های لگن خاصره خون در مجرای آلت تناسلی یا مقعد کسور حوصله شکستگی ها می توانند رگ های خونی را بیجا کرده و خون رسانی به اعضا را در ناحیه دورتر از شکستگی محدود کنند. مراقب علایم اروا ضعیف پاینتر از محل کسر باشید. نبض را جس کنید. برگشت مجدد خون به عروق شعریه را بررسی کنید. مراقب خاسف شدن جلد باشید. [به مهارت ها مراجعه کنید] اگر شکستگی با نبض ضعیف یا پرفیوژن ضعیف همراه بود، اروا دوباره انساج را فراهم کنید با ارجاع )هم ردیف ساختن مجدد دستی انتهای استخوان برای بازگرداندن اندام به وضعیت طبیعی خود( و گذاشتن اتل بر شکستگی. [به مهارت ها مراجعه کنید] همیشه قبل و بعد از هر گونه ارجاع، نبض، و پرفیوژن )برگشت خون به عروق شعریه( را بررسی و ثبت کنید. برای رجعت دهی / انتقال فوری به یک مرکز صحی تخصصی برنامه ریزی کنید. تغییر شکل یا کرپیتوس استخوان عدم موجودیت نبض فراتر از محل کسر زمان پر کردن مجدد عروق شعریه بیش از 3 ثانیه پس از شکستگی نهایات سرد فراتر ناحیه کسر با رنگ جلد آبی یا خاکستری کسور اطراف همرا با اروا ضعیف اگر زخم )بیش از ساییدگی جلد( در نزدیکی محل شکستگی وجود دارد، هر مریض را با شکستگی باز در نظر بگیرید. شکستگی های باز موارد عاجل هستند زیرا می توانند منجر به منتن شدن انتان های شدید استخوان شوند. خونریزی را با فشار مستقیم کنترول کنید.[به مهارت ها مراجعه کنید] در صورت وجود اروا ضعیف فورا ًشکستگی را ارجاع دهید. [به مهارت ها مراجعه کنید] زخم را به خوبی شستشو کنید. [به مهارت ها مراجعه کنید] زخم را بپوشانید. انتی بیوتیک و واکسن تیتانوس بدهید. زخم را با اتل تثبیت کنید.. برای رجعت دهی/انتقال به یک مرکز صجی تخصصی برنامه ریزی کنید. تغییر شکل یا کرپیتوس استخوان با جروحات داخلی شکستگی باز قلوومو معم ددگدمع م:دقودلمدعم 46 مدیریت صدمات خاص در در جریان ارزیابی ثانوی حالت اعراض و علایم مدیریت دقیق هدف از مراقبت از زخم متوقف کردن خونریزی، جلوگیری از انتان، ارزیابی آسیب به ساختارهای زیرین و بهبودی در حالت زخم است. خونریزی را متوقف کنید. [به مهارت ها مراجعه کنید] زخم ها را به طور کامل با صابون و آب پاک یا ضد عفونی کننده شستتو کنید تا هرگونه کثیفی، اجسام خارجی یا نسج مرده/در حال مرگ را پاک کنید. )در صورت امکان، قبل از پناسمان کردن زخم، بی حسی موضعی بدهید(. در صورت وجود، زخم ها را با گاز استریل بپوشانید. اروا فراتر از ماحول زخم را بررسی کنید )برگشت مجدد خون به عروق شعریه و/یا نبض های بعیده( قبل و بعد از پانسمان زخم ها. اطراف های نهایات را که با پاره گی های بزرگ همراه است برای کنترول درد و التیام سریع اتل بگذارید. [به مهارت ها مراجعه کنید] اجسام نافذه را تثبیت کنید. در واقعه مار گزیدگی طرف را بی حرکت کنید. )مهارت ها را در بخش مدیریت زخم ببینید( برای گزش حیوانات، برای ارزیابی خطر ابتلا به انتان و قرار گرفتن در معرض ربیس یا مرض سگ دیوانه با مرکز صحی پیشرفته مشورت کنید. جهت تطبیق واکسین به مرکز صحی ارجاع کنید و مدیریت زخم ناشی از گزیدگی سگ دیوانه میتواند بسیار حساس باشد. در صورت نیاز واکسن تیتانوس بدهید. جروحات خراشیدگی زخم در ناحیه زیر بغل، ناحیه تناسلی، باسن یا پشت به راحتی از نظر دور میماند. خون ریزی با فشار یا فوران خون نشان دهنده خونریزی شریانی است زخم باز به یاد داشته باشید .... همیشه درد را ارزیابی، تداوی و نظارت کنید. وارد کردن فشار مستقیم بر زخم dnuow a ot erusserp tcerid gniylppA 51 egap کتاب دستور عملیات اشتراک کننده گان 56 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE ملاحظات خاص مدیریت با میکانیزم صدمات حالت اعراض و علایم نگران کننده مدیریت دقیق صدمات تصادم میتواند عوارض جدی داشته باشد. به تعقیب سندروم کمپارتمان )تجمع فشار در محفظه های عضلی که میتواند خون رسانی به عضلات و اعصاب را محدود کند( و ترضیضات کلیه به دلیل محصولات ناشی از آسیب عضلی باشید. نظارت بر طرح ادرار و مشاهده ادرار سرخ قهوه ای )نگرانی در مورد آسیب احتمالی کلیه( مهم است. برای کمک به کلیه ها برای حفظ فعالیت کلیه ها شده، مایعات وریدی بدهید. شکستگی را برای جلوگیری از ایجاد صدمات بیشتر انتهای استخوان اتل گذاری کنید. هر گاه کمپارتمان سندورم پیشرفت میکند برای رجعت زود هنگام جراحی اقدام کنید . مریضان ممکن است مشکلات سیستمیک زیادی در رابطه با آسیب عضلی داشته باشند و همیشه باید به یک ارائه دهنده پیشرفته رجعت دهی داده شوند. شکستگی، کبودی، صدمات انساج رخوه شواهد سندروم کمپارتمان )درد، محفظه عضلات سخت، بی حسی، کاهش نبض یا جلد خاسف( کاهش ادرار و رنگ سرخ قهوه ای زخم های ناشی از تصادف انفجار مواد منفجره میتواند به سه طریق باعث آسیب شود: 1. صدمات قابل مشاهده ناشی از چره )قطعات فلزی که توسط یک وسیله انفجاری آزاد می شود( یا سوختگی ناشی از گرما یا مواد کیمیایی منتشر شده. 2. صدمات داخلی داخلی )اغلب پنهان( ناشی از تغییر فشار ناشی از انفجار. معده و روده، ریه ها و گوش ها معمولا آسیب می بینند. و 3. صدمات اضافی که هنگام پرتاب بدن در اثر انفجار ایجاد می شود. از نظر نوموتوراکس به دقت بررسی شود. در صورت مشکلات تنفسی، اکسیجن بدهید. [به مهارت ها مراجعه کنید] واکسین را تطبیق کنید. سوختگی ها باید پانسمان شوند و نیاز به مایعات بر اساس ناحیه سوختگی محاسبه شود. [به مهارت ها مراجعه کنید] اگر مریض درد شکم دارد، سوراخ شدن امعاء را در نظر بگیرید، مایعات وریدی بدهید [به مهارت ها مراجعه کنید] برای رجعت سریع جراحی آماده شوید. صدمه به اعضای میان خالی )مانند ریه، معده و روده( علایم تاخیری زیاد شدن تعداد تفس، کمبود آکسیجن، درد قفس سینه، سرفه با یا بدون خون درد شکم ، تهوع، استفراغ با یا بدون خون پارگی پرده cinapmyT )پرده گوش(: کاهش شنوایی، صدای زنگ در گوش، درد، خونریزی گوش سایر صدمات، سوختگی ها، قرار گرفتن در معرض مواد کیمیاوی یا سموم صدمات ناشی از انفجار قلوومو معم ددگدمع م:دقودلمدعم 66 مدیریت با اساس میکانیزم صدمات حالت اعراض و علایم نگران کننده مدیریت عمیق سوختگی میتواند کل بدن را تحت تاثیر قرار دهد و باعث صدمات نسج نرم، پندیدگی و شاک ناشی از از دست دادن مایعات ناشی از سوختگی شود. هدف از مدیریت سوختگی متوقف کردن پروسه سوزش، مراقبت از پندیدگی و جبران از دست دادن مایعات است. در اثر سوختگی قابل توجه، مایع به جلد و نسج اطراف نشت می کند و باعث پندیدگی و شاک می شود. سوختگی هایی که مجرای تنفسی را درگیر می کنند می توانند به سرعت باعث انسداد )بندش( طرق تنفسی شوند. بسیاز مهم است تا مایعات ضایع ده جایگزین و نواقص متوقع پیش بینی شود . جهت محاسبه مایعات و تطبیق مایعات وریدی، تعیین عمق سوختگی و تعین فیصدی سطح سوختگی بدن (ASBT( aera ecafrus nruB latoT مهم است [به مهارت ها مراجعه کنید]. تزریق واکسن تیتانوس و تسکین درد در جراحات سوختگی را فراموش نکنید. تمام جواهرات را بردارید و در صورت امکان طرف سوخته را بالا قرار دهید. سوختگی ها حتی با مراقبت خوب در معرض خطر بالایی برای انتان هستند. زخم را با دقت تمیز و پانسمان کنید. [به مهارت ها مراجعه کنید] سوختگی هایی که نیاز به رجعت دهی/انتقال سریع دارند: سوختگی های جدی بیش از 51 درصد بدن.[به مهارت ها مراجعه کنید] سوختگی های دست ها، صورت، ناحیه کشاله ران، مفاصل، سوختگی های محیطی. سوختگی ناشی از استنشاق. سوختگی با سایر صدمهی مرتبط. هرگونه سوختگی در افراد بسیار جوان یا مسن. مریضی قابل توجه قبل از سوختگی )مانند دیابت(. رنگ جلد وابسته به عمق سوختگی است که میتواند از گلابی، سرخ، کم رنگ یا سیاه متغییر باشد. سوختگی ممکن است آبله داشته باشد یا نداشته باشد. موارد زیر ممکن است حاکی از استنشاق یا آسیب طرق تنفسی باشد. دوده )خاکستر( اطراف بینی یا دهان، یا موهای آویزان شده )سوخته( بینی پندیدگی لب یا دهان تغییر صدا جروحات سوختگی کتاب دستور عملیات اشتراک کننده گان 76 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE سوال ۵ کتاب تمرین: عملکرد باصدمه با استفاده از بخش کتاب تمرین بالا، فهرستی از کارهایی که برای مدیریت صدمات زیر انجام می دهید را فهرست کنید. مدیریتآسیب شکستگی لگن 1.خاصره 2. 3. 4. جروحات سوختگی 1.در کاهلان 2. 3. 4. ترضیضات بطنی 1. 2. 3. 4. قلوومو معم ددگدمع م:دقودلمدعم 86 افراد خاص صدمات در جریان حاملگی بر هر مصدوم اناثیه بین 01 تا 05 ساله مطابق شرایط باید تست حاملگی انجام شود. حاملگی باعث تغییرات زیادی در فیزیولوژی می شود و ملاحظات دیگری برای سلامت جنین وجود دارد. حتی صدمات جزئی ممکن است به مادر و جنین آسیب برساند. زنانی که در سه ماه آخر حمل قرار دارند و صدمه دیده اند در معرض خطر جدا شدن پلاسنتا )جایی که پلاسنتا میتواند از دیوار رحم جدا شود و منجر به خونریزی شود(، پارگی رحم و ولادت قبل از وقت هستند. به یاد داشته باشید که احیای مادر باعث احیای جنین می شود. عناصر کلیدی تاریخچه مصدوم سن حاملگی )سن جنین یا تعداد هفته ها از آخرین دوره قاعدگی(. هرگونه اختلاط حاملگی. ارزیابی ابتدایی طرق تنفسی: پندیدگی در حاملگی میتواند انسداد )بندش( طرق تنفسی را بیشتر کند، بنابراین به دقت تحت نظر داشته باشید. تنفس: دیافراگم توسط رحم باردار به سمت بالا فشار داده می شود و فضای کمتری برای تنفس در ریه باقی می ماند. دوران خون: خونریزی محبلی را بررسی کنید. رحم محمل همچنین میتواند رگ های خونی بزرگ را تحت فشار قرار دهد. و باعث فشار خون پایین شود. اقدامات احتیاطی ستون فقرات رقبی مصدوم را در سمت چپ قرار دهید. [به مهارت ها مراجعه کنید] ناتوانی: در صورت بروز اختلاج یا تشنج، همیشه اکلامپسیا را در نظر بگیرید. قرار گرفتن در معرض: مریض را گرم نگه دارید. شرایط شایع ناشی از صدمه زایمان زودرس )قبل ازوقت( با یا بدون پارگی زودرس غشاها )از دست دادن مایع امنیون(. جدا شدن پلاسنتا یا پارگی رحم: باعث از دست دادن خون و شاک می شود. اختلاج / تشنج. ملاحظات ویژه مدیریت برنامه ریزی زودهنگام برای رجعت دهی / انتقال به یک مرکز صحی تخصصی با مراقبت های ولادی نسایی. اگر رحم محمل را در سطح سره )ناف( جس نماید، این به طور کلی نشان می دهد که مریض حداقل هفته 02 حاملگی است. اگر زن بیش از 02 هفته )5 ماه( حامله باشد، رحم محمل میتواند ورید اجوف سفلی، رگ بزرگی که خون را به قلب او بازمی گرداند، تحت فشار قرار گرفته و میتواند باعث شاک شود. هنگامی که به، همیشه در سمت چپ )در صورت لزوم بی حرکتی( روی تخته ستون فقرات قرار دهید. [به مهارت ها مراجعه کنید] صدمه در اواخر حاملگی ممکن است باعث زایمان زودرس شود. برای احیای نوزادان نیز زمانی که ضربه در اواخر حمل اتفاق می افتد، آماده شوید. کتاب دستور عملیات اشتراک کننده گان 96 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE سوال 6 کتاب تمرین: عملکرد باصدمه با استفاده از بخش کتاب تمرین بالا، اختلالات معمول را که در یک زن حامله می تواند در اثر صدمه ایجاد شود فهرست کنید. 1. 2. 3. 4. ۵. قلوومو معم ددگدمع م:دقودلمدعم 07 ملاحظات خاص در اطفال کودکان ممکن است پس از صدمات، خوبتر معلوم شوند و در عین حال ممکن به سرعت بدتر شوند. آنها نمونه های صدمات متفاوتی دارند و آسیب های جدی اعضای داخلی ممکن است بدون شکستگی جمجمه یا اضلاع رخ دهد )استخوان های کودکان انعطاف پذیرتر هستند(. مشکلات رایج مدیریتی شامل احیای بیش از حد یا کم، اشتباهات ادویه آی و عدم تشخیص حرارت پایین بدن و شکر پایین میباشد. در زیر ملاحظات ویژه برای کودکان آسیب دیده ذکر شده است. همچنین برای علایم حیاتی طبیعی کودکان و جزئیات بیشتر به مودل EDCBA مراجعه کنید. طرق تنفسی هنگامی که صدمهی گردن یا آسیب به ستون فقرات رقبی مشکوک است، از بلند کردن الاشه برای باز کردن طرق تنفسی و در عین حال بی حرکتی ستون فقرات گردنی استفاده کنید. کودکان سر بزرگ و زبان بزرگی دارند که ممکن است به راحتی مجاری تنفسی آنها را مسدود کند. کودکان خردسال و نوزادان ممکن است به یک daP زیر شانه ها نیاز داشته باشند تا طرق هوایی را تنظیم کنند [به مهارت ها مراجعه کنید]. تنفس اگر کودک پس از باز کردن طرق تنفسی به اندازه کافی نفس نمی کشد، با ماسک evlav-gab، به طور بهتر با اکسیجن به تنفس کمک کنید. برای کودکان بزرگتر هر 4 ثانیه )51 تنفس در دقیقه( و برای نوزادان هر 3 ثانیه )02 تنفس در دقیقه( یک نفس بدهید [به مهارت ها مراجعه کنید]. stnafni ni noitisop lartueN 2 egap کتاب دستور عملیات اشتراک کننده گان 17 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE دوران خون برای از دست دادن خون مداوم یا شواهدی از اروا ضعیف در کودکان با وضعیت تغذیه طبیعی )همچنین به مهارت ها مراجعه کنید(: طرق وریدی را باز کنید مایعات وریدی داده دوباره ارزیابی کنید برای کودکان دچار سوءتغذیه، مایعات باید تنظیم شوند. [به مهارت ها مراجعه کنید] برای آسیب سوختگی شدید، بولوس اولیه با مایعات حاوی دکستروز است. [به مهارت ها مراجعه کنید] در صورت خونریزی قابل توجه، جهت انتقال خون یا رجعت دهی/انتقال سریع به مرکز صحی که قابلیت انتقال خون را دارد، بدهید. ناتوانی/ معلولیت سطح هوشیاری کودک را با مقیاس UPVA )هشدار، پاسخگو به محرک های کلامی، پاسخگو به محرک های دردناک، بی پاسخ( اندازه کنید. UPVA نسبت SCG در کودکان خورد سال ترجیح داده می شود. اختلاج/تشنج را ارزیابی و مدیریت کنید. ارزیابی و مدیریت هایپو گلاسیمیا را در نظر بگیریدبرهنه ساختن مریض تمام بدن را برهنه کنید اما مراقب )aimrehtopyH( حرارت پایین بدن باشید. همیشه از عفت کودک محافظت کنید. از لاگ رول llor-gol برای ارزیابی باقی مانده پشت و سر کودک استفاده کنید. وزن کودکان را بر اساس سن تخمین کنید وزن بر حسب کیلوگرم = [سن بر حسب سال + 4] × 2 یا از ابزارهای تخمین وزن مانند epat REPWAP، ycreM EPAT یا epat wolesorB و غیره استفاده کنید. عمومی کودکان خورد سال ممکن است کمتر از بزرگسالان بتوانند رویدادها را گزارش کنند، حتی رویدادهای مهمی مانند برخورد با وسیله نقلیه. همیشه احتمال صدمه آی بدون شاهد را در کودکان خردسال در نظر بگیرید. dlihc a ni eslup laihcarb fo noitacoL 53 egap موقعیت نبض براخیال در اطفال قلوومو معم ددگدمع م:دقودلمدعم 27 ضرضیضات قحفی صدمات قحفی یکی از علل شایع مرگ و میر در کودکان است و کودکان اغلب پس از ضربه شدید به سر دچار پندیدگی مغزی حاد می شوند. اگر یک طفل مصدوم دارای علایم ترضیضات قحفی است، فورا ً به یک مرکز صحی با مراقبت های ویژه و/یا ظرفیت جراحی اعصاب منتقل شود. ترضیضات صدری آسیب های قفس سینه میتواند تهدید کننده زندگی باشد و کودکان برای صدمات داخلی جدی تر به نیروی کمتری نیاز دارند. اضلاع نسبت به بزرگسالان انعطاف پذیرتر هستند و ممکن است صدمات شدید قفس سینه بدون شکستگی اضلاع وجود داشته باشد.. ترضیضات بطنی شکم کودکان نسبتا بزرگتر از بزرگسالان است و شکم محل آسیب دیدگی کودکان است. آسیب های طحال و کبد به ویژه شایع است. صدمات شکم ی باید در تمام اطفال مصدوم در نظر گرفته شود زیرا ممکن است تهدید کننده زندگی باشد و باعث خونریزی شدید داخلی شود. جروحات سوختگی کنترول سوختگی در کودکان ممکن است دشوار باشد. آنها به احیای دقیق مایعات، مشاهده دقیق پندیدگی طرق تنفسی و ادویه جاتی مسکن برای تعویض پانسمان نیاز دارند. در کودکانی که دچار سوختگی می شوند، برای رجعت دهی/انتقال سریع به مرکز صحی سوختگی برنامه ریزی کنید.. سوال ۷ کتاب تمرین: عملکرد باصدمه با استفاده از بخش کتاب تمرین بالا، ملاحظات دوران خون را در کودکانی که از صدمه رنج می برند، فهرست کنید. 1. 2. 3. ملاحظات ناتوانی را در کودکانی که از صدمه رنج می برند، فهرست کنید. 1. 2. 3. کتاب دستور عملیات اشتراک کننده گان 37 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE ملاحظات جهت رجعت دهی مصدومین مصدومین ممکن است صدمات پیچیده ای داشته باشند که ممکن است پنهان باشد و میتواند بدتر شود و خیلی سریع بمیرد. همیشه مجروحین که به شدت آسیب دیده اند برای تداوی تخصصی به سطح بالاتری از مراقبت های صحی رجعت دهید. شرایط پرخطر ذیل همیشه نیازمند رجعت دهی/انتقال به یک مرکز صحی تخصصی برای مراقبت مداوم است: مشکل طرق تنفسی که نیاز به مداخله دارد. علایم شاک: - نوموتوراکس تنشی: قبل از انتقال کاهش فشار صدری با سوزن را انجام دهید )به قرار دادن فوری تیوب صدری نیاز است(. - تامپوناد پریکارد: اطمینان حاصل کنید که مایعات وریدی شروع شده و در جریان انتقال ادامه دارد. تغیر وضعیت شعوری )خواب آلود، بی حال، گیج یا بی هوش(. ترضیضات در جریان حمل: برای حمل و نقل در سمت چپ قرار دهید )نیاز به مراقبت های تخصصی ولادی دارد(. در کودک مبتلا به مشکل EDCBA، سوختگی یا هر گونه ترضیض ، قحف، صدر، بطن را در نظر بگیرید. هرگونه جروحات سوختگی جدی: عمق سوختگی و سطح کل سوختگی را ارزیابی کنید، احیای مایع را شروع کنید )ترجیحا ًبه یک واحد سوختگی تخصیصی انتقال دهید(. [به مهارت ها مراجعه کنید] سایر ملاحظات برای انتقال : اگر مریض به اکسیجن نیاز دارد، مد نظر بگیرید که تطبیق اکسیجن را در حین حمل و نقل و پس از رجعت دهی ادامه دهید. اگر فرد آسیب دیده علایم شاک را نشان می دهد، اطمینان حاصل کنید که مایع وریدی شروع شده و در طول انتقال ادامه دارد. اطمینان حاصل کنید که هر گونه خونریزی خارجی در طول حمل و نقل کنترول و نظارت شود.. قلوومو معم ددگدمع م:دقودلمدعم 47 سناریو های قضایا به رهبری داکتر یا تسهیلگر این سناریوهای قضیه یی در گروپ های کوچک ارائه خواهند شد. موارد زیر ارزیابی نخواهند شد و فقط برای تمرین هستند. مهم است که این سناریوها را تمرین کنید زیرا شما در مودل های زیر در مورد نحوه هدایت پرونده مورد ارزیابی قرار خواهید گرفت. برای هر سناریوی قضایا، گروپ باید یافته های حیاتی و مدیریت مورد نیاز را شناسایی کرده و خلاصه ای را برای رجعت دهی، شامل یافته های ارزیابی و مداخلات تدوین کند. برای این سناریوها باید از کارت های سریع استفاده کنید. قضیه شماره 1 : صدمه در بزرگسال راننده تاکسی مردی را می آورد که به شدت مجروح شده است. بیرون می آیید و مردی 03 ساله را می بینید که روی چوکی عقب تاکسی دراز کشیده و درد شدیدی دارد. او در مصافه چند کیلومتری در یک تصادف رانندگی صدمه دیده بنا َپتلون او ملوث به خون است و استخوان از ران راست بیرون از جلد او شده است.. 1. در عملکرد اولیه خود چه کاری باید انجام دهید؟ 2. از ارزیابی اولیه برای ارزیابی و مدیریت این مصدوم استفاده کنید. از تسهیل کننده در مورد یافته های دیدن، گوش دادن و احساس کردن بپرسید. در صورت لزوم از کارت سریع برای مرجع استفاده کنید. مداخلات برای انجام: آیا نیاز مداخله است؟یافته ها ارزیابی نخیر بلی طرق تنفسی نخیربلیتنفس نخیربلیدوران خون نخیربلیناتوانی نخیربلیدر معرض قرار گرفتن 3. خلاصه ای کوتاه از رجعت دهی مریض را بنوسید. واقعه شماره 2 : صدمه در اطفال پسر بچه 5 ساله ای ساعت 8 امشب ظرف آب جوش را که روی اجاق بوده است بصورت تصادفی بالایش میریزد. بنا سمت راستش سوخته. مادرش از ظرف آب سرد برای شستن او استفاده کرده و سپس او را برای ارزیابی می آورد. کودک گریه می کند و به شما می گوید که درد دارد. کف دست راست و بازوی داخلی راست تا آرنج و جلوی قدام بازوی راست الی آرنج و قدام صدر و بطن و قدام ران راست او سوخته است. مادرش نمی داند که وزن کودکش چقدر است. کتاب دستور عملیات اشتراک کننده گان 57 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE 1. در عملکرد اولیه خود چه کاری باید انجام دهید؟ 2. از ارزیابی اولیه برای ارزیابی و مدیریت این مریض استفاده کنید. از تسهیل کننده در مورد یافته ها به اساس دیدن، گوش دادن و احساس کردن بپرسید. در صورت لزوم از کارت سریع برای مرجع استفاده کنید. برای یادداشت های خود از جدول زیر استفاده کنید. مداخلات برای انجام: آیا نیاز مداخله است؟یافته ها ارزیابی نخیر بلی طرق تنفسی نخیربلیتنفس نخیربلیدوران خون نخیربلیناتوانی نخیربلیدر معرض قرار گرفتن A. مجموع فیصدی سطح سوختگی بدن این کودک را محاسبه کنید. برای تخمین ناحیه سوختگی سعی کنید در چارت سوختگی کودکان مشخص کنید. B. توضیح دهید که چگونه تصمیم می گیرید که آیا این کودک به مایعات وریدی نیاز دارد یا خیر. C. محاسبه کنید که چه مقدار مایع مورد نیاز است و روش خود را توضیح دهید. D. از کدام نوع مایعات وریدی استفاده خواهید کرد؟ 3. خلاصه ای کوتاه از این مریض برای رجعت دهی فرمول کنید. قلوومو معم ددگدمع م:دقودلمدعم 67 سوالات چند گزینه ای به سوالات زیر پاسخ دهید. پرسش و پاسخ در جلسه مورد بحث قرار خواهد گرفت. 1. کدام یک از موارد زیر جزء بررسی اولیه صدمه است؟ A. بازوها را از نظر هرگونه شکستگی معاینه کنید B. رنگ و حرارت جلد را بررسی کنید C. گوش ها را از نظر هرگونه تخلیه خون یا مایع شفاف بررسی کنید D. تست جلدی برای اندازه کردن کم آبی بدن را بررسی کنید 2. شما در حال ارزیابی مردی هستید که تصادف کرده به نظر میرسد. او بسیار گیج است، اما بقیه بررسی اولیه او طبیعی است. مگر مریض برای پاسخ دادن به سؤالات شما بیش از حد سردرگم می باشد، چگونه می توانید تاریخچه ELPMAS مریض را بگیرید؟ A. شما نیازی به انجام تاریخچه ELPMAS در یک مریض صدمهیی ندارید B. به طور مکرر از مریض بپرسید تا زمانی که بتواند پاسخ دهد C. از اطرافیان یا اعضای خانواده اطلاعات را بپرسید D. فرض کنید اطلاعات مهمی وجود ندارد 3. یک مرد 32 ساله پس از افتیدن به سر به داخل دریا، به شما آورده میشود. او صحبت می کند و طرق تنفسی او باز است اما نمیتواند راه برود و دست یا پاهایش را حرکت دهد. اولین کاری که باید انجام دهید چیست؟ A. کنول وریدی تطبیق میکنید. B. او را از نظر صدمات دیگر معاینه کنید C. ستون فقرات رقبی او را بی حرکت کنید D. به او واکسین تیتانوس تطبیق میکنید. 4. شما در حال ارزیابی یک مرد 12 ساله هستید که تصادف کرده هستید. وی از موترسایکل به پایین پرتاب شد و از ناحیه وجه، قفس سینه و پاها آسیب دیده است. وقتی لگن خاصره اش را فشار می دهید از درد چیغ می کشد. علایم حیاتی وی عبارتند از: فشار خون 09/04 میلی متر ستون سیماب، ضربان قلب 021 ضربه در دقیقه، تعداد تنفس 52 در دقیقه. قدم بعدی شما چه باید باشد؟ A. حوصله مریض را می بندید. B. تزریق واکسن تیتانوس C. انتی بیوتیک بدهید D. ساییدگی ها را با آب و صابون شستشو می کنید 5. زن جوانی پس از انفجار بشما آورده است. که طرق تنفسی وی باز، تعداد تنفس 03 در دقیقه، ضربان قلب کتاب دستور عملیات اشتراک کننده گان 77 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE 521 ضربه در دقیقه، فشار خون 05/58 میلی متر ستون سیماب، جلد خاسف مرطوبی دارد و از درد بطن شاکی است. او زخم های کوچکی روی جلدش دیده میشود اما خونریزی آشکاری وجود ندارد. برای مدیریت این مریض چه کاری انجام می دهید؟ A. دو کنول وریدی با قطر بزرگ وریدی تطبیق میکنید. B. به او آب می نوشانید. C. حرارت بدن او را بررسی میکنید. D. انتی بیوتیک میدهید. 87 یادداشت کتاب دستور عملیات اشتراک کننده گان 97 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE مودل 3 : مشکلات تنفسی اهداف با تکمیل نمودن این مودل شما قادر به اعمال زیر خواهیم بود.: تشخیص علایم مشکلات تنفسی. . 1 فهرست نمودن علل و عوامل جدی مشکلات تنفسی.. 2 انجام اقدامات حیاتی برای علل خطرات جدی مشکلات تنفسی.. . 3 مهارت های ضروری مانورهای اساسی طرق تنفسی تطبیق وسیله جهت باز نگهداشتن طرق تنفسی مدیریت خفگی تجویز اکسیجن ونتیلیشن یا تهویه با ماسک بگ والو evlav-gaB رفع فشار صدری با سوزن برای نوموتوراکس تنشی پانسمان سه طرفه برای زخم های مکنده صدری اصطلاحات کلیدی تعریف را با استفاده از واژه نامه در پشت کتاب تمرین بنویسید. استفاده عضلات اضافه صدری: )aimenA(: )amhtsA(: مریضی انسدادی مزمن ریوی )DPOC(: سوختگی های محیطی )snruB laitnerefmucriC(: قلووم3معمقمل: مBلدود 08 کریپتوس )sutiperC(: سیانوزیس: کیتو اسیدوز دیابیتیک )AKD(: تعرق)sisorohpaiD(: مشکلات تنفسی )gnihtaerb ni seitlucffiiD( وضع )noitisopsiD(: غرق شدن )gninworD(: هیموتوراکس xarohtomeaH: حمله قلبی )kcatta traeH(: نارسایی قلبی )eruliaf traeH(: هایفس )seviH(: تنفس زیاد )هایپروتلیلایشن(: التهاب: سکیما )نارسایی خون( کنول وریدی با قطر بزرگ: کاهش فشار با سوزن )noisserpmoC eldeeN(: انصباب پری کارد )noisuffe laidracireP(: انصباب پلورا)snoisuffe larulP(: کتاب دستور عملیات اشتراک کننده گان 18 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE پلورایی )citiruelP(: نومونیا: امبولایزم ریوی: سترایدور: ضربان سریع قلب: تنفس سریع: بیجا شدن شزن )tfihs laehcarT(: وضعیت سه پایه )noitisop dopirT(: توبرکلوز (BT): ویزینگ: مرور عمومی مشکلات تنفسی اصطلاحی است که برای توصیف طیفی از حالاتکه از احساس نفس تنگی گرفته تا حرکات تنفسی غیرعادی یا هرگونه تلاش بیشتر برای تنفس مورد استفاده قرار می گیرد. مشکلات تنفسی میتواند ناشی از مشکلات در طروق طرق تنفسی علوی و یا سفلی، ریه ها، قلب یا عضلات مورد استفاده برای تنفس باشد. یا از حالات که ممکن است باعث تنفس سریعتر شود )مانند کم خونی یا عدم تعادل الکترولیت ها(. مشکلات تنفسی میتواند ناشی از موارد زیر باشد: انسداد طرق تنفسی علوی و یا سفلی )انسداد توسط یک جسم اجنبی سپزم طرق تنفسی، مانند استما، پندیدگی به دلیل الرژی، انتان یا آسیب(. مایع در فضاهای هوایی ریه )مانند سینه و بغل یا اذیما ریوی(؛ هوا یا مایع خارج از ریه که باعث کولپس یا فشرده شدن ریه می شود )مانند نوموتوراکس یا افیوژن(. لخته شدن خون در رگ های تامین کننده ریه ها. هر علت دیگر کاهش اکسیجن حمل شده در خون )مانند کم خونی(. قلووم3معمقمل: مBلدود 28 شرایطی که سرعت تنفس را افزایش می دهد مانند مصرف سم، عدم تعادل کیمیاوی )به عنوان مثال در کیتواسیدوز دیابیتیک( یا اضطراب. هدف از ارزیابی اولیه شناسایی علل برگشت پذیر مشکلات تنفسی و تشخیص شرایطی است که نیاز به مداخله فوری یا انتقال سریع دارند. هدف مدیریت حاد اطمینان از باز ماندن طرق تنفسی و کافی بودن تنفس برای رساندن اکسیجن به اعضا بدن است. این مودل شما ره در موارد ذیل رهنمایی میکند: عناصر کلیدی EDCBA بپرسید: یافته های تاریخچه کلیدی )تاریخچه ELPMAS( بررسی کنید: یافته های ارزیابی ثانوی علل احتمالی انجام دهید: مدیریت ملاحظات خاص در کودکان ملاحظات وضع به یاد داشته باشید ... همیشه با عملکرد EDCBA شروع کنید در صورت نیاز مداخله کنید. سپس یک تاریخچه ELPMAS اخذ کنید. سپس یک ارزیابی ثانوی را انجام دهید. EDCBA: عناصر کلیدی برای مریضان با مشکلات تنفسی برای مریضان مبتلا به مشکل در تنفس، موارد زیر عناصر کلیدی است که باید در روش EDCBA در نظر گرفته شود. طرق هوایی فردی که مشکلات تنفسی دارد ممکن است پندیدگی طرق تنفسی ناشی از یک عکس العمل حساسیتی شدید )عکس العمل شدید( یا خفگی )انسداد طرق تنفسی ناشی از جسم خارجی( داشته باشد. استریدور باریک شدن شدید مجرای طرق تنفسی را پیشنهاد می کند. کتاب دستور عملیات اشتراک کننده گان 38 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE تنفس پایین شدن فشار خون همراه با عدم موجودیت صداهای تنفس در یک طرف - به ویژه با رگهای گردن متوسع )پندیدگی یا بزرگ شده( یا بیجا شدن شزن - ممکن است نشان دهنده نوموتوراکس تنشی باشد. ویزینگ ممکن است نشان دهنده استما یا عکس العمل حساسیت شدید باشد. دوران خون شاک، حمله قلبی، نارسایی قلبی و انتان شدید همگی می توانند با اروا ضعیف و مشکلات تنفسی ظاهر شوند. اروا ضعیف سیگنال های را به مغز می فرستد تا سرعت تنفس را افزایش دهد، که میتواند احساس و شبیه مشکلات تنفسی باشد. با بررسی برگشت خون به عروق شعریه، ضربان قلب و فشار خون، علایم شاک را بررسی کنید. پندیدگی در پاها یا selkcarc در ریه ها میتواند نشان دهنده نارسایی قلبی و اضافه بار مایعات به عنوان دلیل مشکلات تنفسی باشد. ناتوانی یا معلولیت مریضانی که سطح هوشیاری آنها کاهش یافته است ممکن است نتوانند از طرق تنفسی خود محافظت کنند. ادویه جات، انتان یا جراحت می توانند مستقیما ً بر بخشی از مغز که تنفس را کنترول می کند، تأثیر بگذارند. شرایط فلج کننده را که بر عضلات تنفسی تأثیر می گذارد، ارزیابی کنید. سطح هوشیاری را با مقیاس UPVA بررسی کنید: A: هوشیار V: پاسخ به صدا P: پاسخ به درد U: بی پاسخ برهنه ساختن مریض را برای ارزیابی حرکت غیرطبیعی دیوار قفس سینه و هرگونه نشانه ای از صدمه به طور کامل برهنه سازید. صدمهی نافذ به پشت، قفس سینه، زیر بغل یا بطن ممکن است باعث صدمه ریه شود و اغلب نادیده گرفته می شود. قلووم3معمقمل: مBلدود 48 بپرسید: یافته های تاریخچه کلیدی برای مریضان با مشکلات تنفسی از روش ELPMAS برای گرفتن شرح حال از مریض و/یا خانواده استفاده کنید. اگر تاریخچه یک وضعیت EDCBA را مشخص کرد، برای مدیریت آن، فورا ًبه EDCBA برگردید. S: اعراض و علایم علایم از چه زمانی شروع شده و آیا ناگهانی شروع شده؟ آیا می آیند و می روند و چقدر دوام می آورند؟ آیا آنها در طول زمان تغییر کرده اند و آیا قبًلا قسمت مشابهی وجود داشته است؟ مشکل ناگهانی در تنفس میتواند نشان دهنده انسداد )بندش( طرق تنفسی مانند یک جسم اجنبی باشد. پندیدگی طرق تنفسی در اثر عکس العمل حساسیتی یا انتان؛ صدمه به طرق تنفسی، ریه ها، قلب یا جدار صدر؛ یا استنشاق گازهای داغ یا دود. مشکلات حاد قلبی مانند حمله قلبی، ریتم غیرطبیعی قلب یا مشکلات دسامی میتواند باعث شروع سریع مشکلات تنفسی شود. سابقه تنفس سریع یا عمیق ممکن است نشان دهنده مسمومیت، سطح اسید بالا در خون )انتان یا کتواسیدوز دیابیتیک( یا اضطراب باشد. مشکلات تنفسی که به آرامی شروع می شود با انتان و شرایط مزمن مانند تجمع تدریجی مایع در اطراف ریه ها )مانند توبرکلوز و نارسایی قلبی( ، مایع اطراف قلب )از مریضی توبرکلوز یا مریضی کلیوی( ، سرطان ریه یا مریضی ها شایع تر که بر عملکرد جدار صدر تأثیر می گذارد. مشکلات مکرر در تنفس همراه با ویزینگ ممکن است نشان دهنده استما یا DPOC باشد. آیا چیزی باعث ایجاد مشکل در تنفس شده و چه چیزی آن را بهتر یا بدتر می کند؟ سابقه الرژی ممکن است نشان دهد که طرق تنفسی در اثر پندیدگی به دلیل عکس العمل حساسیتی شدید مسدود شده است. استنشاق دود یا گاز داغ )مانند آتش سوزی( یا بعضی مواد کیمیاوی ممکن است باعث ایجاد مشکلات تنفسی از باعث صدمات و پندیدگی طرق تنفسی علوی شود. قرار گرفتن در معرض مواد کیمیاوی )مانند بعضی از ضد عفونی( میتواند باعث تجمع مایع در مجاری تنفسی و ضعف در عضلات درگیر در تنفس شود. مشکلات تنفسی که وقتی فرد هموار دراز می کشد بدتر می شود میتواند به دلیل وجود مایع در ریه ها باشد. آیا پندیدگی زبان یا لبان یا تغییر صدا وجود دارد؟ پندیدگی دهان، لبان، زبان یا قسمت فوقانی گلو یا تغییر در صدا میتواند نشان دهنده یک عکس العمل حساسیتی شدید یا سایر التهابات طرق تنفسی باشد. آیا صداهای غیر نارمل همراه با تنفس وجود دارد؟ صداهای بلند یا «جیرجیر» هنگام تنفس کردن ممکن است استریدور باشد که در اثر باریک شدن طرق کتاب دستور عملیات اشتراک کننده گان 58 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE تنفسی علوی ایجاد می شود و ممکن است نشان دهنده عکس العمل حساسیتی شدید یا سایر انسداد )بندش( طرق هوایی باشد. ویزینگ - صدای بلند در بیرون کردن تنفس - در اثر باریک شدن یا اسپزم طرق تنفسی سفلی در ریه ها ایجاد می شود و میتواند نشان دهنده استما، DPOC، نارسایی قلبی یا عکس العمل های حساسیتی باشد. صداهای وصف جوشیدن آب همراه با تنفس حاکی از وجود مخاط، خون یا مایعات دیگر در طرق هوایی است. آیا درد همراه با مشکلات تنفسی وجود دارد؟ مشکل در تنفس همراه با درد قفس سینه میتواند نشان دهنده حمله قلبی، نوموتوراکس، نومونیا یا سینه و بغل یا ترضیض ریه ها، اضلاع یا عضلات صدری باشد. به ویژه، دردی که با نفس های عمیق بدتر می شود )درد پلورتیک( ممکن است نشان دهنده انتان یا لخته شدن خون در ریه باشد )آمبولی ریه(. آیا تب یا سرفه وجود دارد؟ تب نشان دهنده انتان است. انتان ریه و هر انتان شدید ممکن است باعث ایجاد مایع در ریه ها شود. سرفه ممکن است نشان دهنده وجود مایع در ریه های ناشی از سینه و بغل یا اذیما )پندیدگی( باشد. سرفه و ویزینگ ممکن است نشان دهنده استما یا DPOC باشد. آیا پندیدگی پا یا ساق پا یا حمل اخیر وجود داشته؟ مشکلات تنفسی همراه با اذیما )پندیدگی( هر دو پا و ساق پا میتواند نشان دهنده نارسایی قلبی با تجمع مایع به ریه ها و بدن باشد. مشکلات تنفسی همراه با پندیدگی و درد در یک پا ممکن است نشان دهنده وجود لخته در ورید پا باشد که به ریه رفته است )آمبولی ریه(. حامله داری یک عامل خطر برای آمبولی ریه و نارسایی قلبی است. A : الرژی یا حساسیت الرژی به ادویه جات یا مواد دیگر دارید؟ آیا اخیرا ًتوسط حشره ی گزیده شده اید؟ عکس العمل های حساسیتی شدید ممکن است به دلیل پندیدگی طرق تنفسی باعث مشکلات تنفسی شود. افراد تقریبا ً به هر چیزی ممکن است عکس العمل های حساسیتی شدید داشته باشند، اما غذا، گیاهان، ادویه جات و نیش/گزش حشرات شایع ترین موارد هستند. M : ادویه جات یا ادویه ها در حال حاضر کدام ادویه را مصرف می کنید؟ در مورد ادویه جاتی جدید و تغییرات در دوز بپرسید. ادویه جاتی جدید می توانند الرژی همراه با مشکلات تنفسی ایجاد کنند. مصرف بیش از حد تصادفی بعضی ادویه جات میتواند تنفس را متوقف یا کند کند. قلووم3معمقمل: مBلدود 68 P : تاریخچه طبی گذشته آیا سابقه استما یا مریضی انسدادی مزمن ریه (DPOC) وجود دارد؟ استما و DPOC اغلب باعث مشکلات تنفسی می شوند. سابقه بستری یا انتیوبیشن قبلی برای این شرایط نشان دهنده وجود یک مرض با خطرات جدی تلقی میشود. آیا سابقه مریضی قلبی یا مریضی کلیوی وجود دارد؟ افرادی که سابقه نارسایی قلبی یا کلیوی دارند ممکن است مایعی در ریه ها داشته باشند. حمله قلبی ممکن است با مشکلات تنفسی ظاهر شود. آیا سابقه توبرکلوز (BT) یا سرطان وجود دارد؟ شرایطی مانند توبرکلوز و سرطان می توانند باعث تجمع مایع در جوف پریکارد )پریکاردیل افیوژین( یا تجمع مایع در جوف پلورا شوند که هر دو می توانند باعث ایجاد احساس مشکلات تنفسی شوند. آیا سابقه مرض شکر/دیابت وجود دارد؟ دیابت میتواند باعث بحران دیابت )کتواسیدوز دیابیتیک یا AKD( شود. AKD باعث تنفس سریع می شود که ممکن است به عنوان مشکلات تنفسی گزارش شود. آیا سابقه سیگار کشیدن وجود دارد؟ سیگار خطر ابتلا به استما، DPOC، سرطان ریه و حمله قلبی را افزایش می دهد. آیا سابقه VIH وجود دارد؟ انتان VIH خطر ابتلا به سایر انتانات را افزایش می دهد. L: آخرین مصرف خوراکی آخرین بار چه زمانی غذا خورده یا نوشیدند؟ شکم پر مریض را در معرض خطر استفراغ و خفگی احتمالی قرار می دهد. E: رویداد های مرتبط به مریضی وقتی مشکل تنفس شروع شد، شخص چه کار می کرد؟ اگر مشکل در تنفس هنگام خوردن یا نوشیدن شروع شد، همیشه خفگی را در نظر بگیرید. مشکلات تنفسی با ورزش ممکن است به دلیل حمله قلبی باشد، به خصوص زمانی که درد قفس سینه نیز وجود دارد. کتاب دستور عملیات اشتراک کننده گان 78 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE آیا مریض در آب یا نزدیک آن پیدا شده؟ همیشه غرق شدن )استنشاق آب( را در فردی که در داخل یا نزدیک آب یافت می شود در نظر بگیرید. حتی مقدار کمی آب استنشاق شده میتواند باعث آسیب جدی ریوی شود که با گذشت زمان بدتر می شود. آیا قرار گرفتن در معرض حشره کش ها یا سایر مواد کیمیاوی بوده است؟ مواد کیمیاوی استنشاقی می توانند با تحریک طرق تنفسی و ریه ها باعث ایجاد مشکلات تنفسی شوند. بعضی از حشره کش های مورد استفاده در زراعت می توانند از طریق جلد جذب شوند و باعث تجمع مایع در طرق تنفسی و ریه ها می شوند. قرار گرفتن در معرض گازهای ناشی از آتش سوزی اغلب با استنشاق مواد کیمیاوی همراه است. آیا اخیرا ًصدمه وجود داشته است؟ مشکل در تنفس با صدمه برای شکستگی اضلاع، نوموتوراکس، هموتوراکس و کبودی قلب یا ریه نگران کننده است.. سوال اول کتاب تمرین: مشکلات تنفسی با استفاده از بخش کتاب تمرین بالا، پینج سوالی را لیست کنید که در باره تاریخچه گذشته طبی به اساس میپرسید. ELPMAS اختصاریه. 1. 2. 3. 4. ۵. بررسی: یافته های ارزیابی ثانوی برای مریضان با مشکلات تنفسی مشکل در تنفس ممکن است با تغییرات در تعداد تنفس، تلاش تنفسی یا اشباع کم اکسیجن تظاهر کند. همیشه ابتدا EDCBA را ارزیابی کنید. عملکرد اولیه EDCBA شرایط تهدید کننده زندگی را شناسایی و مدیریت می کند. ارزیابی ثانوی به تعقیب تغییرات در وضعیت مریض یا دلایل کمتر واضحی است که ممکن است در طول EDCBA از قلم افتاده باشد. اگر در جریان ارزیابی ثانوی مشکل درهریکی از EDCBA اجزای شناسایی می شود. برای مدیریت آن، فورا ًبه EDCBA برگردید. قلووم3معمقمل: مBلدود 88 مشاهده به تعقیب علایم نارسایی تنفسی باشید: استفاده از عضلات اضافی تنفسی و افزایش کار تنفس. مشکل در صحبت کردن در جملات کامل. ناتوانی در دراز کشیدن یا تکیه دادن به پشت. دیافروزیس )تعریق بیش از حد( و جلد خالدار. گیجی، تحریک پذیری، بی قراری. حرکت ضعیف جدار صدری. سیانوز )رنگ جلد آبی به خصوص لبان و نوک انگشتان(. اندازه و عکس العمل حدقه ها را مشاهده کنید: حدقه های خیلی کوچک احتمال مصرف بیش از حد مواد مخدره یا قرار گرفتن در معرض مواد کیمیاوی )از جمله حشره کش ها( را دارند. عدم تناظر حدقه ها نشان دهنده مشکلات قحفی است که میتواند باعث تنفس غیر نارمل شود.. مشاهده روی ؛ بینی و دهان: سیانوز اطراف لبان بینی نشان دهنده سطح پایین آکسیجن در خون است. خسافت منظمه نشان دهنده کم خونی شدید است. پندیدگی لبان، زبان و دهان نشان دهنده یک عکس العمل حساسیتی است. دوده اطراف دهان یا بینی، موهای سوخته صورت یا سوختگی صورت نشان دهنده استنشاق دود و سوختگی طرق تنفسی است. خونریزی یا پندیدگی طرق تنفسی ممکن است به دلیل صدمات باشد. مشاهده عنق و صدر: توسع وریدهای گردن میتواند به دلیل برگشت خون به دلیل نارسایی قلبی، نوموتوراکس تنشی یا تامپوناد پریکارد باشد. استفاده بیش از حد از عضلات گردن و عضلات بین ضلعی صدری نشان دهنده مشکلات تنفسی قابل توجه است. اگر شزن به یک طرف منتقل شد، به نوموتوراکس تنشی یا تومور فکر کنید. تورم و سرخی گردن نشان دهنده انتان یا ترضیض است. تمام گردن و قفس سینه را از نظر کبودی، زخم یا سایر علایم صدمه به دقت بررسی کنید. مشاهده سرعت و نوع تنفس: افراد مبتلا به ویزینگ ممکن است به دلیل تنگ شدن مجرای تنفسی سفلی در ریه، مدت طولانی تری را میگیرد تا تنفس کند. تنفس سریع میتواند به دیهادریشن، انتان شدید، عدم تعادل الکترولیت ها در خون، مسمومیت یا اضطراب باشد. کتاب دستور عملیات اشتراک کننده گان 98 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE تنفس آهسته و کم عمق ممکن است به دلیل مصرف بیش از حد مواد مخدره باشد. به مراقب حدقه های بسیار کوچک و تغیر وضعیت شعوری باشید. صدمه بر جدار صدر اغلب با درد همراه است که توانائی نفس کشیدن عمیق را محدود می کند. tsehc lialF زمانی واقع میشود که شکستگی های متعدد عضلاع باعث جدا شدن بخشی از قفس سینه از بقیه جدار صد شود. این بخش ممکن است در نوع تنفس در جهت مخالف بقیه صدر به نظر برسد. مشاهده اطراف سفلی ویا پاها: پندیدگی هر دو ساق پا نشان دهنده نارسایی قلبی به عنوان دلیل مشکلات تنفسی است. پندیدگی یک پا ممکن است به دلیل لخته شدن خون در پا باشد. اگر در تنفس نیز مشکل وجود داشته باشد، ممکن است به این معنی باشد که باعث امبولی در ریه شده است. مشاهده جلد: نشانه از گزیدن حشرات میتواند منبع عکس العمل حساسیتی باشد. دانه های جلدی، مانند هایف، میتواند نشان دهنده عکس العمل حساسیتی باشد. هنگامی که مشکلات تنفسی همراه است، دانه های جلدی میتواند نشان دهنده انتان گسترده )سیستمیک( باشد. رنگ پریدگی )خاسف بودن جلد( میتواند نشان دهنده کم خونی به دلیل مشکلات تنفسی باشد. سوختگی های مدور تنه به قفس سینه میتواند انبساط دیوار صدری را محدود کرده و تنفس را محدود کند.. گوش دهید به صدای تنفس گوش دهید: استریدور نشان دهنده انسداد )بندش( جزئی طرق تنفسی علوی است که ممکن است به دلیل یک جسم خارجی، کتلات یا التهابات ناشی از صدمه یا انتان باشد. کاهش یا عدم وجود صداهای تنفسی حاکی از حرکت غیر نارمل هوا در ریه ها است. این میتواند به دلیل تجمع هوا یا مایع در جوف پلورا )نوموتوراکس، هموتوراکس، افیوژن(، باریک شدن یا انسداد جسم خارجی طرق تنفسی، و انتان یا تومور در داخل یا اطراف ریه باشد. ویزینگ سینه، به طور خاص، نشان دهنده انسداد )بندش( طرق تنفسی سفلی مانند استما، DPOC، عکس العمل حساسیتی ، جسم خارجی یا تومور است. noitatiperC ro selkcarC نشان دهنده وجود مایع در فضاهای هوایی ریه است. به صداهای قلب گوش دهید: ریتم غیر نارمل قلب میتواند باعث شود قلب به طور غیرعادی خون را پمپ کند و منجر به اروا ضعیف و مشکلات تنفسی شود. مشکل در تنفس همراه با مرمر قلبی میتواند نشان دهنده مشکلات دسامی قلب باشد. صداهای خفه شده یا مافل همراه با فشار خون پایین، ضربان قلب سریع و رگ های گردن متوسع، نشان دهنده تامپوناد پریکارد است. قلووم3معمقمل: مBلدود 09 جس کنید جس اضلاع و جدار صدر: تغییر شکل و حرکت غیر نارمل هنگام جس صدری نشان دهنده شکستگی ضلع است. کرپیتوس )ترق زدن یا احساس لغزیدن اضلاع بروی همدیگر( ممکن است نشان دهنده کسور اضلاع و یا موجودیت هوای زیر جلد باشد )مرتبط با نوموتوراکس(. اعدم تناظر صدری قفس سینه نشان دهنده نوموتوراکس، هموتوراکس یا tsehc lialF است.. قرع صدری: صداهای با تون بلند یا طبلیت )ecnanoserrepyH( در یک طرف هنگام ضربه زدن به دیوار قفس سینه نشان دهنده نوموتوراکس است. اصمیت در قرع صدری ممکن است نشان دهنده تجمع مایع یا خون در جوف پلورا باشد. کتاب دستور عملیات اشتراک کننده گان 19 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE سوال شماره 2 کتاب تمرین: مشکلات تنفسی با استفاده از بخش کتاب تمرین بالا، سه علامتی را که باید در مریضان مبتلا به مشکل در تنفس جستجو کنید، فهرست کنید. 1. 2. 3. چهار صدای را که در مریضانی که دچار مشکلات تنفسی هستند را میشنوید، فهرست کنید. 1. 2. 3. 4. سه موردی را که در جس صدری مریضان مبتلا به مشکلات تنفسی دریافت میکنید را فهرست کنید. 1. 2. 3. عوامل احتمالی مشکلات تنفسی علل مشکلات تنفسی را می توان بر اساس ناحیه بدن سازماندهی کرد: طرق تنفسی، ریه، قلب یا تمام بدن. عوامل کلیدی طرق تنفسی حالت اعراض و علایم مشکل حاد تنفسی ترشحات قابل مشاهده، استفراغ یا جسم خارجی در طرق تنفسی صداهای غیر نارمل از طرق تنفسی )مانند استریدور، خروپف، وصف جوشیدن آب( سرفه کردن آب دهان بندش طرق تنفسی ناشی از جسم اجنبی قلووم3معمقمل: مBلدود 29 پندیدگی لبان، زبان و دهان استریدور و/یا ویزینگ راش یا لکه های جلدی ممکن است ضربان سریع )aidracyhcaT( و فشار پایین خون داشته باشد قرار گرفتن در معرض آلرژن شناخته شده عکس العمل حساسیتی شدید استریدور صدای خشن آب دهان یا مشکل در بلع )نشان دهنده پندیدگی شدید( قادر به دراز کشیدن نیست ممکن است تب داشته باشد )با انتان( پندیدگی طرق تنفسی (به دلیل التهاب/انتان) حکایه از قرار گرفتن در معرض مواد کیمیاوی یا آتش سوزی سوختگی سر و گردن )یا موی صورت یا دوده اطراف بینی یا دهان( استریدور تغییر در صدا سوختگی در طرق هوایی علت اصلی ریه ها حالت اعراض و علایم تب و سرفه به تدریج تنفسی سخت تر میشود درد شدیدتر با تنفس )پلورتیک( معاینه غیر نارمل ریه )selkcarC( نومونیا ( سینه و بغل ) ویزینگ سرفه استفاده از عضلات اضافی وضعیت ترای پود )شکل را ببینید( ممکن است سابقه مصرف سگرت یا الرژی داشته باشد استما/DPOC کاهش صداهای نفس در یک طرف صدر شروع ناگهانی صداهای تون بلند هایپررسونانس )ecnanoserrepyH( به قرع در سمت آسیب دیده [به مهارت ها مراجعه کنید] ممکن است دردی داشته باشد که با تنفس بدتر شود ممکن است سابقه صدمه یا شواهدی از شکستگی اضلاع داشته باشد فشار خون پایین همراه با وریدهای گردن متوسع و کاهش صدای نفس در یک طرف نشان دهنده نوموتوراکس تنشی است. نوموتوراکس کاهش صداهای تنفسی در سمت آسیب دیده شنیدن اصمیت با قرع [به مهارت ها مراجعه کنید] ممکن است سابقه صدمه، سرطان یا شاک توبرکلوز )در صورت هموتوراکس بزرگ( داشته باشد. هیموتوراکس کاهش صداهای تنفسی در یک یا هر دو طرف شنیدن اصمیت با قرع [به مهارت ها مراجعه کنید] ممکن است سابقه سرطان، توبرکلوز، مریضی قلبی یا مریضی کلیوی داشته باشد مشکل حاد یا مزمن در تنفسی افیوژن پلورایی کتاب دستور عملیات اشتراک کننده گان 39 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE سابقه مریضی حجره خون داسی شکل درد صدری تب کمبود اکسیجن سندروم حاد صدری در مریض مبتلا به مریضی داسی شکل عوامل اصلی قلب حالت اعراض و علایم فشار، سختی یا احساس گرنگی در قفس سینه دیافورز یا تعرق و جلد خالدار حالت تهوع یا استفراغ علایم نارسایی قلبی سابقه مصرف سگرت، مریضی قلبی، فشار خون بالا، دیابت، کلسترول بالا، سابقه خانوادگی مشکلات قلبی حمله قلبی با فعالیت فزیکی اعراض و خیم تر میشود. وقتی هموار دراز بکشید بدتر است پندیدگی هر دو پا وریدهای گردن متوسع شده ممکن است صدای کرکل در ریه ها شنیده شود ممکن است درد قفس سینه داشته باشد نا رسایی قلب علایم اروا ضعیف )ضربان شدید قلب، بیشتر شدن تعداد تنفس، فشار پایین خون، جلد خاسف، سردی نهایات، برگشت خون به عروق شعریه بیش از 3 ثانیه( توسع ورید های عنق صدای قلب خفه شده )dnuoS traeH delffuM( ممکن است سرچرخی، گیجی، تغییر وضعیت ذهنی داشته باشد سابقه توبرکلوز، صدمه، خباثت، نارسایی کلیه تمپوناد پریکارد noitisop dopirT 23 egap وضعیت سه پایه )ترای پود( قلووم3معمقمل: مBلدود 49 عوامل کلیدی سیستمیک حالت اعراض و علایم خسافت منظمه ضربان سریع )aidracyhcaT( تنفس سریع )aenpyhcaT( سابقه خونریزی، سوء تغذی، سرطان، بارداری، مالاریا، مریضی حجره داسی شکل )llec elkciS esaesid( ، نارسایی کلیه کمخونی/انیمیا استفاده کلینیکی یا تفریحی مواد افیونی تغییر وضعیت ذهنی حدقه های بسیار کوچک تنفس آهسته و کم عمق مصرف بیش از حد مواد DOIPO ممکن است سابقه دیابت شناخته شده باشد تنفس عمیق یا سریع تکرر ادرار نفس بوی شیرین گلوکوز بالا در خون یا ادرار ضیاع مایعات بدن کتواسیدوز دیابیتیک سوال شماره 3 کتاب تمرین: مشکلات تنفسی با استفاده از بخش کتاب تمرین بالا، علت احتمالی مشکلات تنفسی را در کنار تاریخچه و یافته های فیزیکی زیر فهرست کنید.. علت احتمالیتاریخچهه و یافته های فزیکی یک مرد 02 ساله با مشکلات تنفسی، ویزینگ: • پندیدگی لبان، زبان و دهان مراجعه می کند. دانه های جلدی یا هایفس (لکه های رنگ پریده یا سرخ، خارش دار، گرم و پندیدگی جلد) ضربان سریع (aidracyhcaT) و فشار خون پایین سابقه الرژی قرار گرفتن در معرض آلرژن شناخته شده یک زن 0۵ ساله با مشکلات تنفسی، علایم اروا ضعیف (ضربان سریع (aidracyhcaT)، تنفس سریع، فشار پایین خون، جلد خاسف، نهایات سرد، برگشت مجدد خون بر عروق شعریه بیش از 3 ثانیه) و: توسع ورید های عنق صدای قلب خفه شده (dnuoS traeH delffuM) سابقه توبرکلوز کتاب دستور عملیات اشتراک کننده گان 59 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE انجام دادن: مدیریت ابتدا ارزیابی EDCBA را انجام دهید و برای شرایط تهدید کننده زندگی مداخله کنید. ارزیابی و مدیریت طرق تنفسی و ارائه تهویه توسط امبو بگ (MVB) برای مریضان که نفس نمی کشد یا به اندازه کافی تنفس نمیتواند )نظر به سن بسیار آهسته و یا هم بسیار به مقدارکم(. هر مریض بیهوش با تنفس غیر نارمل )آهسته، کم عمق، نفس نفس زدن یا پر سر و صدا(؛ یا مریضانکه با نبض دارد ولی نفس نمی کشد. برای مریضان بدون نبض، پروتوکول های RPC مربوطه را تعقیب کنید. حالت اعراض و علایم مریضان را آرام نگه دارید. اگر می توانید این کار را بدون ناراحتی مریض انجام دهید، به او آکسیجن بدهید. [به مهارت ها مراجعه کنید] اگر مریض کامًلا هوشیار باشد و مشکوک به آسیب نخاعی نباشد، وضعیت نشسته ممکن است راحت تر باشد. مریضان مبتلا به سوختگی طرق تنفسی ممکن است نیاز به انتوبیشن داشته باشند زیرا طرق تنفسی میتواند به سرعت پندیده و مسدود شود. تاخیر ممکن است تیوب گذاری را دشوارتر کند. فردی که دچار التهاب یا سوختگی طرق تنفسی است نیاز به انتقال/رجعت دهی فوری دارد. التهاب طرق تنفسی یا سوختگی از ضربه های قفس سینه / ضربه های بطنی / ضربه های پشت مناسب سن استفاده کنید. [به مهارت ها مراجعه کنید] خفگی (بندش طرق تنفسی) در صورت امکان ماده حساسیت زا را حذف کنید. برای عکس العمل های حساسیتی شدید با مشکل در تنفس، در اسرع وقت ادرینالین عضلی بدهید. برای موارد شدید اکسیجن بدهید. [به مهارت ها مراجعه کنید] عکس العمل حساسیتی در اسرع وقت سالبوتامول را تجویز کنید. در صورت لزوم آکسیجن بدهید. [به مهارت ها مراجعه کنید] استما / DPOC اگر انتان علت مشکل تنفسی باشد، در اسرع وقت انتی بیوتیک بدهید. اگر مریض علایم اروا ضعیف دارد، مایعات وریدی را با احتیاط تجویز کنید. [به مهارت ها مراجعه کنید] تب اسپرین بدهید در حالی که اکسیجن دیگر در همه مریضان مبتلا به حمله قلبی توصیه نمی شود، اما در ابتدا باید به مریضان شاک یا مشکل در تنفس داده شود. [به مهارت ها مراجعه کنید] برای آن دسته از مریضانی که از قبل نیتروگلیسیرین دارند، می توانید به آنها در مصرف آن کمک کنید. حمله قلبی مایعات وریدی را آهسته تر بدهید و ریه ها را بطور مکرر از نظر کرکل )بیش از حد مایعات( بررسی کنید. [به مهارت ها مراجعه کنید] این مریضان ممکن است نیاز به انتقال/رجعت دهی برای انتقال خون داشته باشند. کم خونی مزمن و شدید مایعات وریدی بدهید. [به مهارت ها مراجعه کنید] یک فرد مبتلا به کتواسیدوز دیابیتیک که وخیم است و نیاز به انتقال فوری به یک مرکز طبی پیشرفته دارد. کتواسیدوز دیابیتیک مصرف بیش از حد در صورت نیاز با ksam-evlav-gab تنفس را پشتیبانی کنید. نالوکسون بدهید [به مهارت ها مراجعه کنید] مواد افیونی DOIPO اکسیجن بدهید [به مهارت ها مراجعه کنید] فورا ً برای رجعت دهی/انتقال ترتیب دهید. بسیاری از این مریضان به تیوب قفس سینه یا دریناژ دیگر نیاز دارند. پلورال افیوژن یا هموتوراکس به همه مریضان صدمهیی که دچار مشکل تنفسی هستند باید اکسیجن داده شود. در صورت مشکوک بودن به تامپوناد پریکارد یا نوموتوراکس تنشی باید مایع وریدی داده شود تا به پر شدن قلب کمک کند. در صورت مشکوک بودن به نوموتوراکس تنشی باید رفع فشار سوزنی انجام شود. نوموتوراکس را با یک پانسمان 3 طرفه تداوی کنید. [به مهارت ها مراجعه کنید] اگر برداشتن فشار با سوزن انجام شود یا یک پانسمان 3 طرفه اعمال شود، مریض نیاز به انتقال/رجعت دهی فوری برای تیوب قفس سینه دارد. صدمه سندروم حاد صدری اکسیجن، مایعات وریدی، انتی بیوتیک بدهید. ممکن است برای مدیریت پیشرفته نیاز به انتقال داشته باشد. قلووم3معمقمل: مBلدود 69 سوال شماره 4 کتاب تمرین: مشکلات تنفسی با استفاده از بخش کتاب تمرین بالا، فهرستی از کارهایی را که برای مدیریت شخصی انجام می دهید را فهرست کنید: مشکلات تنفسی، سرفه مشکوک به خفگی هستید. 1. 2. مشکلات تنفسی، تب بالا، سرفه. شما مشکوک به 1.انتان جدی هستید. 2. مشکلات تنفسی، صدای خشن و استرایدور در هنگام 1.تنفس. شما مشکوک به التهاب طرق هوایی هستید. 2. 3. کتاب دستور عملیات اشتراک کننده گان 79 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE ملاحظات خاص در کودکان علایم خطر در کودکان عبارتند از: علایم انسداد )بندش( طرق تنفسی )عدم توانائی در بلع لعاب دهن / ترشح آب دهان یا استریدور(. افزایش تلاش تنفسی )تنفس سریع، گشاد شدن بینی، وصف جوشیدن آب کردن، باز شدن قفس سینه یا عقب رفتن(. سیانوز )رنگ آبی جلد، به ویژه در لب ها و نوک انگشتان(. تغییر وضعیت ذهنی )بی حالی یا خواب آلودگی غیر معمول، بی قراری(. تغذیه یا آشامیدن ضعیف. همه چیز را استفراغ می کند. تشنج/اختلاج. درجه حرارت پایین هایپوترمیا )aemrehtopyH(. به یاد داشته باشید... ویزینگ در کودکان میتواند ناشی از انتان ویروسی، استما یا یک جسم استنشاقی باشد که طرق تنفسی را مسدود می کند. استریدور در کودکان میتواند ناشی از گیرکردن یک شی در طرق علوی یا پندیدگی طرق تنفسی باشد. کودکان ممکن است با تنفس سریع به عنوان تنها علامت نومونیا یا سینه و بغل ظاهر شوند. تنفس سریع همچنین میتواند نشان دهنده بحران دیابت (AKD( باشد که ممکن است اولین علامت دیابت در کودک باشد. قلووم3معمقمل: مBلدود 89 سوال شماره ۵ کتاب تمرین: مشکلات تنفسی با استفاده از بخش کتاب تمرین بالا، علایم خطر کودکان را فهرست کنید. 1. 2. 3. 4. ۵. 6. ۷. 8. ملاحظات انتقال و تسلیم دهی به خاطر داشته باشید که اثرات ادویه جاتی استنشاقی مانند سالبوتامول تنها تقریبا ً3 ساعت باقی می ماند. مریضان نیاز به نظارت دقیق دارند. در صورتیکه مریض دچار عکس العمل شدید الرژی باشد و به او ادرینالین زرق گردیده باش با از بین رفتن تاثیر ادرینالین این عکس العمل میتواند عود کند. بنا مریضان نیاز به نظارت دقیق دارند. نالوگزان فقط در حدود 1 ساعت می باشد. در حالیکه اوپیاد ها تاثیرات طولانی تر نسبت به نالیگزان دارند. بنابراین مریضان ممکن است نیاز به تکرار دوز نالوگزان داشته باشند. به تعقیب غوطه ور شدن در آب )غرق شدن(، ممکن است فرد پس از چند ساعت علایم دیررس مشکلات تنفسی را نشان دهد و باید از نزدیک تحت نظر باشد. هرگز مریضانی را که ممکن است نیاز به وسایل محافظت طرق تنفسی داشته باشند را در حین رجعت دهی/انتقال بدون نظارت رها نکنید. اطمینان حاصل کنید که وسایل محافظت طرق تنفسی. هر چه زودتر برای هر مریضی که ممکن است نیاز به تهویه کمکی داشته باشد، مقدمات انتقال را فراهم کنید. کتاب دستور عملیات اشتراک کننده گان 99 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE سناریوهای قضیه یی به رهبری داکتر یا تسهیلگر این سناریوهای قضیه یی در گروه های کوچک ارائه خواهند شد. یک شرکت کننده به عنوان پیشرو شناخته میشود و ارزیابی میشود در حالی که بقیه گروه پاسخ ها را در کتاب تمرین می نویسند. برای تکمیل یک سناریوی قضیه یی، گروه باید یافته های حیاتی و مدیریت مورد نیاز را شناسایی کند و یک خلاصه یک خطی برای رجعت دهی، که شامل یافته های ارزیابی و مداخلات است، تدوین کند. هنگام ارزیابی باید از کارت های سریع برای این سناریوها استفاده کنید. مورد شماره 1: بزرگسالان با مشکلات تنفسی مردی 22 ساله با تاکسی از راه می رسد. او در راه مورد سرقت قرار گرفت و با چاقو به قفس سینه سمت چپ او ضربه زدند. او اکنون به شدت در تنفس دچار مشکل شده است. 1. در عملکرد اولیه خود چه کاری باید انجام دهید؟ 2. از روش EDCBA برای ارزیابی و مدیریت این مریض استفاده کنید. از تسهیل کننده در مورد یافته ها، گوش دادن و احساس کردن بپرسید. در صورت لزوم از کارت های سریع برای مرجع استفاده کنید. مداخلات برای انجام: آیا نیاز مداخله است؟یافته ها ارزیابی نخیر بلی طرق تنفسی نخیربلیتنفس نخیربلیدوران خون نخیربلیناتوانی نخیربلیدر معرض قرار گرفتن 3. یک جمله برای خلاصه کردن این مریض برای رجعت دهی دادن مشکلات تنفسی. مورد شماره 2: مریض کودک با مشکلات تنفسی مادری پسر 6 ساله خود را به دلیل مشکلات نفسی نزد شما می آورد. این مادر بیان می کند که پسرش از 3 روز گذشته دچار مشکل تنفسی شده است. او می گوید که طفلش هنگام نفس گرفتن صدای عجیبی را میکشد. 1. در عملکرد اولیه خود چه کاری باید انجام دهید؟ قلووم3معمقمل: مBلدود 001 2. از روش EDCBA برای ارزیابی و مدیریت این مریض استفاده کنید. از تسهیل کننده در مورد یافته ها، گوش دادن و احساس کردن بپرسید. در صورت لزوم از کارت سریع برای مرجع استفاده کنید. مداخلات برای انجام: آیا نیاز مداخله است؟یافته ها ارزیابی نخیر بلی طرق تنفسی نخیربلیتنفس نخیربلیدوران خون نخیربلیناتوانی نخیربلیدر معرض قرار گرفتن 3. خلاصه یافته های خود را در یک جمله برای رجعت دهی مریض نوشته کنید. سوالات چند گزینه ای به سوالات زیر پاسخ دهید. پرسش و پاسخ در جلسه مورد بحث قرار خواهد گرفت 1. شما در حال ارزیابی یک زن 43 ساله هستید که از مشکلات تنفسی، سرفه و تب به مدت 3 روز شکایت دارد. کدام یک از اقدامات زیر را ابتدا باید انجام دهید؟ A. فشار خون را چک می کنید B. انتی بیوتیک تجویز می کنید C. کنول وریدی را تطبیق میکنید. D. صداهای ریه را مشنوید. 2. مردی 76 ساله با سابقه سکته قلبی از مشکل تنفسی شکایت دارد که هر زمان که هموار دراز بکشد بدتر می شود. هر دو پاهای مریض تورم کرده است. که در 2 هفته گذشته بدتر شده است. احتمالی ترین علت مشکل تنفسی او چیست؟ A. نارسایی قلبی B. استما C. نوموتوراکس D. نمونیا در خانه ای نزدیک آتش سوزی شده و مریضی را با موهای سوخته بینی و تنگی نفس نزد شما می آورند. اول باید چی کار کنید؟ کتاب دستور عملیات اشتراک کننده گان 101 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE A. اکسیجن بدهید B. ادرینالین عضلی بدهید C. یک ورید را باز کنید D. رفع فشار صدري سوزنی را انجام دهید 4. زن 03 ساله ای توسط زنبور نیش زده شد و اکنون دچار مشکل تنفسی، پندیدگی صورت و دانه های جلدی شده است. او سابقه عکس العمل های حساسیتی شدید به نیش زنبور را دارد. کدام نوع ادویه جات ذیل را باید به او بدهید؟ A. نالوگزان B. بنزودیازپین C. ادرینالین D. اسپرین 5. شما یک بچه یک ساله را از نگاه مشکلات تنفسی ارزیابی میکنید. متوجه می شوید که جلد نوک انگشتان و اطراف دهانش آبی رنگ شده. این علامه را به صطلاح طبی چه می نامند؟ A. انقباضات B. گشاد شدن بینی C. کرپیتوس D. سیانوز قلوومبول معم:1 لدومعلمدلم 201 مودل چهارم: عملکرد با شاک اهداف با تکمیل این مودل باید بتوانید تا: علایم شاک/اروا ضعیف را تشخیص دهید.. 1 اقدامات حیاتی برای مریضان مبتلا به شاک را انجام دهید.. 2 وضعیت مایع. را ارزیابی کنید. . 3 مایع مناسب را بر اساس سن، وزن و وضعیت مریض برای تجویز انتخاب کنید.. 4 سوء تغذی، کم خونی و سوختگی و تنظیم احیای مایعات را تشخیص کنید. . 5 مهارت های ضروری تجویز اکسیجن باز نمودن ورید ارزیابی وضعیت مایع احیای مایع وریدی مدیریت سوختگی رفع فشار صدري با سوزن پانسمان سه طرفه فشار مستقیم برای کنترول خونریزی ماساژ رحم برای کنترول خونریزی بررسی ثانوی صدمه اصطلاحات کلیدی تعریف را با استفاده از واژه نامه در پشت کتاب تمرین بنویسید. بولس suloB: برادی کاردیا: کتاب دستور عملیات اشتراک کننده گان 301 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE دوباره پر شدن عروق emiT gnillfieR yrallipaC: کولرا: تعرق: ضیاع مایعات بدن: دیابیتیک کیتو AKD: توسع )اوعیه های خون(: وضع: حمل خارج رحمی: حالت مایع: فونتنیل: گاستروانتریت: باز نمودن ورید کلان: بیحالی: محلول مایع گرفتن خوراکی )SRO(: اروا تمپوناد پریکارد: احیای مجدد: شاک: تست نیشگون )ُچندی( گرفتن جلد: قلوومبول معم:1 لدومعلمدلم 401 مرور عمومی اروا ضعیف زمانی است که بدن نمیتواند خون حامل آکسیجن کافی را به اعضا های حیاتی برساند. هنگامی که فعالیت عضو تحت تاثیر قرار می گیرد، این شاک نامیده می شود و میتواند به سرعت منجر به مرگ شود. نوزادان، کودکان و بزرگسالان بیشتر در معرض شاک قرار می گیرند. علل اروا ضعیف که ممکن است منجر به شاک شود عبارتند از: از ضیاع خون )خونریزی(؛ از ضیاع مایعات به دلیل اسهال، استفراغ، سوختگی های شدید یا ادرار زیاد )مانند ناشی از شکر خون بالا(. مصرف ضعیف مایعات. اطفال خورد سن، سالمندان و افراد بسیار مریض ممکن است نتوانند بدون کمک مایعات کافی بنوشند و در معرض خطر دیهایدریشن بدن قرار دارند. شل شدن و بزرگ شدن غیر نارمل )توسع( عروق خونی )با همان مقدار خون در داخل رگ( میتواند فشار خون را کاهش دهد. این میتواند در انتان شدید، آسیب نخاعی و عکس العمل حساسیتی شدید رخ دهد. پر شدن ضعیف قلب میتواند ناشی از خون یا مایعات دیگر در کیسه اطراف قلب )تامپوناد پریکارد(، یا افزایش فشار در قفس صدر که میتواند اوعیه باز گرداننده خون به قلب را مسدود و یا هم بیجا کند )نوموتوراکس تنشی(. عدم پمپ نمودن موثر عضله قلب میتواند به دلیل حمله قلبی باشد )انسداد )بندش( عروق که باعث آسیب حاد عضله قلب می شود(. التهاب یا سایر مریضی های خود عضله قلب؛ ریتم غیر نارمل یا مشکلات وال های قلب )شاک ناشی از ناتوانی قلب در پمپ مؤثر، گاهی اوقات شاک قلبی نامیده می شود.( هدف از ارزیابی اولیه، شناسایی شاک و هرگونه علل برگشت پذیر شاک است. هدف مدیریت حاد بازگرداندن اروا )ارسال اکسیجن به اعضای بدن( و عملکرد بااز دست دادن مداوم مایع در صورت امکان است. این مودل شما را در موارد زیر راهنمایی می کند: عناصر کلیدی EDCBA بپرسید: یافته های تاریخچه کلیدی )سابقه ELPMAS( بررسی: یافته های معاینه ثانوی علل احتمالی انجام دادن: مدیریت ملاحظات خاص در کودکان ملاحظات حین انتقال به یاد داشته باشید... کتاب دستور عملیات اشتراک کننده گان 501 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE همیشه با عملکرد EDCBA شروع کنید و در صورت نیاز مداخله کنید. سپس یک تاریخچه ELPMAS انجام دهید. سپس یک معاینه ثانوی انجام دهید. EDCBA : عناصر کلیدی در شاک برای فرد در شاک، موارد زیر عناصر کلیدی هستند که باید در روش EDCBA در نظر گرفته شوند. طرق هوایی پندیدگی روي / دهان یا تغییرات صدا میتواند نشان دهنده یک عکس العمل حساسیتی باشد. یک عکس العمل حساسیتی شدید میتواند باعث شاک شود. نفس گرفتن ویزینگ میتواند نشان دهنده یک عکس العمل حساسیتی شدید باشد که میتواند باعث شاک شود. شاک، مشکل در تنفس و کمبود صداهای نفس در یک طرف میتواند نشان دهنده نوموتوراکس تنشی باشد. خود اروا ضعیف گاهی اوقات میتواند باعث تنفس سریع شود، زمانی که اندام های حیاتی اکسیجن کافی دریافت نمی کنند. نارسایی شدید قلبی میتواند باعث اروا ضعیف با مشکل در تنفس شود، زمانی که مایع به داخل ریه ها برمی گردد. هر انتان که به اندازه کافی شدید باشد که باعث ایجاد شاک شود ممکن است با التهاب ریه همراه باشد که باعث مشکل در تنفس می شود. دوران خون شاک میتواند ناشی از انواع مختلفی از خونریزی ها باشد )از معده یا روده، مربوط به بارداری و خونریزی داخلی و خارجی ناشی از ضربه(. شاک همچنین می تواند ناشی از از دست دادن مایعات مرتبط با اسهال، استفراغ، سوختگی های شدید یا ادرار زیاد )مانند شکر خون بالا( باشد. ناتوانی/معلولیت گیجی در فردی با اروا ضعیف نشان دهنده شاک شدید است. فلج ممکن است نشان دهنده آسیب نخاعی باشد که باعث شاک می شود. در معرض قراردادن و یا ارزیابی کامل بدن به تعقیب علایم خونریزی، ضربه، و تعریق بیش از حد )دیافورز( باشید. کهیر میتواند نشان دهنده عکس العمل حساسیتی باشد و خال های جلدی دیگر میتواند نشان دهنده انتان سیستمیک باشد. قلوومبول معم:1 لدومعلمدلم 601 بپرسید: یافته های کلیدی تاریخچه شاک از روش ELPMAS برای گرفتن تاریخچه از مریض و/یا خانواده استفاده کنید. اگر تاریخچه یک وضعیت EDCBA را مشخص کرد، برای مدیریت آن، فورا ًبه EDCBA برگردید. S: اعراض و علایم آیا استفراغ و/یا اسهال وجود داشته است؟ برای چه مدت؟ از دست دادن مایعات از طریق استفراغ و اسهال میتواند شدید باشد و میتواند منجر به شاک شود. میزان استفراغ یا اسهال میتواند به تخمین خطر شاک کمک کند، بنابراین همیشه در مورد دفعات استفراغ و اسهال سوال کنید. آیا فرد خون در مدفوع یا استفراغ داشته است؟ خونریزی در معده و/یا روده میتواند قبل از تشخیص شدید باشد. یک فرد میتواند بخش قابل توجهی از حجم خون خود را در روده از دست بدهد. خون ممکن است هم در استفراغ و هم در مدفوع سیاه به نظر برسد. آیا خونریزی واژینال ( مهبلی ) وجود داشته است؟ خونریزی مهبل ممکن است مربوط به بارداری در زنان در سنین باروری باشد. همیشه در مورد وضعیت بارداری، آخرین دوره قاعدگی، هرگونه قاعدگی از دست رفته یا بارداری اخیر شناخته شده سوال کنید. از دست دادن خون ناشی از زایمان طبیعی یا سقط جنین میتواند باعث شاک شود. بارداری خارج از رحم )حاملگی خارج از رحم( نیز در صورت پارگی میتواند تهدید کننده زندگی باشد. پارگی حاملگی خارج از رحم ممکن است حتی قبل از اینکه زن بداند باردار است رخ دهد. سایر علل خونریزی واژینال ) مهبلی ( وجود کتله در دهانه رحم یا رحم است. آیا فرد درد قفس سینه داشته است؟ درد قفس سینه ممکن است نشان دهد که فرد دچار حمله قلبی شده است. آسیب عضله ای به قلب در اثر حمله قلبی میتواند توانائی آن در پمپ خون در بدن را کاهش دهد که میتواند باعث شاک شود. آیا تب بوده است؟ تب ممکن است انتان را به عنوان علت شاک نشان دهد. انتان شدید هم باعث متوسع شدن رگ های خونی )که فشار خون را کاهش میدهد( و هم باعث نشت مایع از رگ های خونی )با از دست دادن مایع به داخل انساج( میشود. آیا قرار گرفتن در معرض سموم، ادویه جات، نیش حشرات یا مواد دیگر بوده است؟ عکس العمل های حساسیتی شدید میتواند منجر به شاک شود. علاوه بر این، بسیاری از ادویه جات، از جمله فشار خون و ادویه جات تشنج/اختلاج، می توانند باعث شاک شوند. کتاب دستور عملیات اشتراک کننده گان 701 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE آیا تغییر وضعیت ذهنی یا خواب آلودگی غیرعادی وجود داشته است؟ مغز یکی از آخرین ارگان هایی است که تحت تأثیر اروا ضعیف قرار می گیرد، بنابراین تغییر وضعیت ذهنی ممکن است نشانه شاک شدید باشد. A: الرژی یا حساسیت آیا فرد الرژی شناخته شده ای دارد؟ عکس العمل های حساسیتی میتواند با ایجاد توسع غیر نارمل رگ های خونی منجر به شاک شود. M: ادویه جات در حال حاضر ادویه مصرف می کنید؟ لیست کامل ادویه را از شخص یا خانواده دریافت کنید. دانستن لیست ادویه جات مریض میتواند به درک اینکه چرا مریض در شاک است )مانند ادویه جاتی قلبی( کمک کند. مصرف بیش از حد ادویه جات فشار خون یا تشنج/اختلاج میتواند باعث شاک شود، و ممکن است تداوی شاک به هر دلیلی در مریضانی که از این ادویه جات استفاده می کنند دشوارتر باشد. ادویه جات که خون را رقیق می کنند می توانند خونریزی را بدتر کنند. همیشه در مورد ادویه جات جدید به ویژه و تغییرات اخیر دوز برای ارزیابی عکس العمل حساسیتی یا عوارض جانبی غیر منتظره سوال کنید. P: تاریخچه طبی گذشته: سابقه بارداری یا سقط یا ولادت اخیر؟ اگر رحم به خوبی منقبض نشود، از دست دادن خون پس از ولادت میتواند شدید باشد. از دست دادن خون پنهان که منجر به شاک می شود، میتواند با پاره شدن حاملگی خارج از رحم، حتی در زنانی که از بارداری خود اطلاعی ندارند، رخ دهد. هر زن در سن باروری که شاک داشته باشد باید از نظر بارداری مورد ارزیابی قرار گیرد. سابقه جراحی اخیر یا سقط عمدی؟ خونریزی داخلی یا انتان پس از جراحی میتواند منجر به شاک شود. سابقه مریضی قلبی (سکته قلبی یا مشکلات دریچه قلب)؟ مریضان مبتلا به مریضی قلبی در معرض خطر بدتر شدن عملکرد قلب هستند که ممکن است منجر به شاک یا بدتر شدن شاک ناشی از دلایل دیگر شود. آیا سابقه VIH وجود دارد؟ VIH خطر انتان را افزایش می دهد. قلوومبول معم:1 لدومعلمدلم 801 L: آخرین مصرف خوراکی آخرین بار چه زمانی غذا خورده یا نوشیدند؟ فردی که خوب غذا نمی خورد یا نمی نوشد می تواند دچار کم آبی شدید شود که منجر به شاک شود. E : رویداد های مرتبط به مریضی آیا مریض اخیرا ًصدمه دیده است؟ صدمه میتواند باعث خونریزی داخلی مخفی، نوموتوراکس فشاری و کبودی یا خونریزی در اطراف قلب شود که همگی ممکن است دوران خون را کاهش داده و باعث شاک شوند. علاوه بر این، ضربه به گردن یا پشت که باعث آسیب نخاعی می شود، میتواند با توانائی عروق خونی برای حفظ فشار خون تداخل ایجاد کند. آیا در این اواخر کدام مریضی وجود داشته است؟ هر انتانی میتواند باعث انتانی شدن خون شود که میتواند در سراسر بدن پخش شود و منجر به شاک شود. سوال شماره 1 کتاب تمرین: شاک با استفاده از بخش کتاب تمرین بالا، شش سؤال در مورد علایم و نشانه هایی را که هنگام گرفتن سابقه ELPMAS از آنها می پرسید، فهرست کنید. 1. 2. 3. 4. ۵. 6. کتاب دستور عملیات اشتراک کننده گان 901 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE بررسی کنید: یافته های معاینه ثانوی در شاک فرد مبتلا به شاک علایم اروا ضعیف را خواهد داشت که ممکن است شامل ضربان قلب سریع، فشار خون سیستولیک پایین، تنفس سریع، جلد رنگ پریده و خنک، پر شدن آهسته عروق شعریه یا سرچرخی، گیجی، تغییر وضعیت ذهنی، کاهش خارج کردن یا تعرق.بیش از حد. به یاد داشته باشید: اروا میتواند حتی قبل از کاهش فشار خون محدود شود، به خصوص در جوانان. فشار خون پایین همراه با اروا ضعیف یک علامت بسیار جدی است. همیشه ابتدا EDCBA را ارزیابی کنید. عملکرد اولیه EDCBA شرایط تهدید کننده زندگی را شناسایی و مدیریت می کند. معاینه ثانوی به تعقیب تغییراتی در وضعیت مریض یا دلایل کمتر واضحی است که ممکن است در طول EDCBA از قلم افتاده باشد. اگر معاینه ثانوی یک وضعیت EDCBA را شناسایی کرد، برای مدیریت آن، فورا ًبه EDCBA برگردید. به یاد داشته باشید: کودکان دارای وسعت علایم حیاتی طبیعی متفاوتی هستند و کودکان مبتلا به شاک ممکن است تا زمانی که به شدت مریض نشوند، تغییراتی در علایم حیاتی نداشته باشند. همیشه یک معاینه دقیق برای هر نشانه شاک انجام دهید. صداهای نفس و تعداد تنفس را بررسی کنید: تنفس غیر نارمل یا پر سر و صدا میتواند نشان دهنده نومونیا یا سینه و بغل به عنوان منبع انتان در سراسر سیستم باشد که باعث شاک می شود. سطوح بالای شکر میتواند منجر به عدم تعادل کیمیاوی )کتواسیدوز دیابیتیک( شود که بدن سعی می کند با تنفس سریع تر یا عمیق تر آن را برطرف کند. این وضعیت همچنین ممکن است منجر به بوی شیرین یا «میوه ای» شود. از آنجایی که افزایش سطح گلوکوز خون باعث افزایش ادرار می شود، کم آبی شدید و شاک میتواند منجر شود. برای خونریزی برسی کنید: تمام خونریزی های خارجی باید با فشار مستقیم کنترول شود. [به مهارت ها مراجعه کنید] خونریزی شریانی ممکن است به صورت نبض یا خونریزی با فشار بالا ظاهر شود و حجم قابل توجهی خون در عرض چند دقیقه از بین می رود. خونریزی واژینال ) مهبلی ( ممکن است منبع مهمی برای از دست دادن خون ناشی از خونریزی های مرتبط با بارداری )حتی در کسانی که فکر میکنند باردار نیستند( یا خونریزی از کتله های دهانه رحم یا رحم باشد. حالت مایعات را بررسی کنید: در حالت های ضیاع مایعات بدن، مریض ممکن است احساس تشنگی کند یا لب ها و دهان خشک، نیشگون )ُچندی( گرفتن غیرطبیعی جلد، بی حالی و تاخیر در پر شدن مویرگ ها داشته باشد. مریضان مبتلا به نارسایی قلبی ممکن است با اضافه بار مایعات در شاک باشند و ممکن است پندیدگی پایین بدن )معمولا ًدر هر دو پا(، elkcarC در معاینه ریه و توسع وریدهای عنق داشته باشند. قلوومبول معم:1 لدومعلمدلم 011 خسافت منظمه (داخل پلک پایین) را بررسی کنید: صرف نظر از رنگ جلد فرد، داخل پلک باید صورتی و مرطوب به نظر برسد. اگر قسمت داخلی پلک )ملتحمه( خاسف، ممکن است نشان دهنده از دست دادن خون قابل توجه باشد. می توانید ملتحمه مریض را با فرد سالم دیگری مقایسه کنید یا به خودتان در آینه نگاه کنید. وضعیت روانی را بررسی کنید: سردرگمی در مریض با سایر علایم اروا ضعیف نشان دهنده شاک شدید است. تب را بررسی کنید: تب در مریض مبتلا به شاک نشان دهنده انتان شدید است. شکر خون را بررسی کنید: شکر خون پایین گاهی اوقات میتواند مانند شاک به نظر برسد. اگر نمی توانید شکر خون را چک کنید، اما وضعیت ذهنی فرد تغییر کرده است، سابقه دیابت یا دلیل دیگری برای کاهش شکر دارد )مثًلا کینین برای مالاریا مصرف می کند، بسیار مریض است یا بسیار سوء تغذی دارد(، گلوکوز بدهید. [به مهارت ها مراجعه کنید] درد شدید شکم یا شکم بسیار سخت را بررسی کنید: اگر فرد درد شدید شکم داشته باشد، این میتواند نشانه خونریزی یا انتان در شکم باشد. در یک مریض که ممکن است باردار باشد، این میتواند نشانه حاملگی خارج از رحم باشد. ادرار را بررسی کنید: رنگ و حجم ادرار را بررسی کنید. مقادیر کمی ادرار تیره تر ممکن است نشان دهنده کم آبی بدن باشد. مواد غایطه را بررسی کنید: هر اسهال قابل توجهی میتواند باعث کم آبی بدن شود. مقدار زیادی مدفوع آبگین و «شبه آب برنج» نشان دهنده ابتلا به کولرا است که میتواند به سرعت باعث کم آبی شدید بدن و شاک شود. مدفوع سیاه، تیره یا سرخ رنگ میتواند نشانه خونریزی معده یا روده باشد. سوء تغذی را بررسی کنید [به مهارت ها مراجعه کنید]: اگر به نظر می رسد که فرد دچار سوء تغذی است، مایعات باید تنظیم شود [به مهارت ها مراجعه کنید]. حتما در مورد تغییرات اخیر وزن بپرسید. noitirtunlam htiw nerdlihc ni amede gnittip rof gnissessA 22 egap noi irtunlam htiw nerdlihc ni amede gn ttip rof gnissessA 2 egap noitirtunlam htiw nerdlihc ni amede gnittip rof gnissessA 22 egap معاینه اذیمای پاها در اطفال سوء تغذی dlihc a ni gnitsaw ereves elbisiV 32 egap ضایعات شدید قابل مشاهده در اطفال کتاب دستور عملیات اشتراک کننده گان 111 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE پندیدگی، دانه های جلدی و تعرق بیش از حد را بررسی کنید: پندیدگی دهان یا بدن میتواند نشان دهنده یک عکس العمل حساسیتی باشد. دانه های جلدی میتواند نشان دهنده عکس العمل حساسیتی )الرژی( یا انتان سیستمیک باشد. پندیدگی هر دو پا میتواند نشان دهنده نارسایی قلبی باشد. عرق کردن ممکن است با شاک متوسط تا شدید رخ دهد. سوال شماره 2 کتاب تمرین: شاک با استفاده از بخش کتاب تمرین بالا، مواردی را که باید در یک فرد شاک بررسی کنید، فهرست کنید. 1. 2. 3. 4. ۵. 6. ۷. 8. 9. 01. قلوومبول معم:1 لدومعلمدلم 211 عوامل احتمالی شاک اروا ضعیف به دلیل توسع شدن رگ های خونی حالت اعراض و علایم تب ضربان سریع قلب تنفس سریع ممکن است فشار خون پایین داشته باشد ممکن است منبع انتانی آشکاری داشته باشد یا نداشته باشد: انتان جلدی قابل مشاهده، سرفه و selkcarC در یک ناحیه از ریه ها )اغلب با تنفس سریع(، سوزش همراه با ادرار، ادرار مکدر یا بدبو، یا هر درد موضعی همراه با تب انتان شدید سابقه و یا علایم صدمه )تروما( ممکن است درد/حساسیت ستون فقرات، مهره ها در یک خط نبوده یا کرپیتوس داشته باشد )قرچ قرچ کردن( هنگامی که استخوان های ستون فقرات را لمس می کنید مشکلات حرکتی: فلج، ضعیفی، رفلکس های غیر طبیعی مشکلات حسیت: سوزنک زدن )سوزش و گزگز(، از دست دادن حس قادر به کنترول ادرار و مدفوع نیست پریاپیسم )نعوذ طولانی مدت( ممکن است فشار خون پایین یا برادی کاردی داشته باشد مشکل در تنفس با آسیب ستون فقرات رقبی بالا آسیب نخاعی پندیدگی دهان مشکل در تنفس همراه با استریدور و/یا ویزینگ دانه های جلدی ضربان سریع قلب فشار خون پایین عکس العمل حساسیتی شدید اروا ضعیف به دلیل از دست دادن مایعات حالت اعراض و علایم ممکن است سابقه دیابت شناخته شده باشد تنفس سریع یا عمیق تکرر ادرار نفس خوشبو گلوکوز بالا در خون یا ادرار کم آبی بدن کتواسیدوز دیابیتیک (AKD) نیشگون )ُچندی( گرفتن غیر نارمل جلد کاهش مصرف مایعات یا افزایش از دست دادن مایعات )استفراغ، اسهال، ادرار زیاد( غشاهای مخاطی خشک ضربان سریع )aidracyhcaT( کم آبی شدید نواحی سرخ، سفید یا سیاه جلد وابسته به عمق سوختگی ممکن است آبله داشته باشد ممکن است علایم آسیب استنشاقی داشته باشد جراحت سوختگی کتاب دستور عملیات اشتراک کننده گان 311 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE اروا ضعیف به دلیل از دست دادن خون حالت اعراض و علایم سابقه صدمه خونریزی قابل مشاهده استفاده از ادویه جات رقیق کننده خون خونریزی خارجی سابقه صدمه درد یا حرکت غیر نارمل لگن خاصره، خون در مجری آلت تناسلی ورکتوم )شکستگی لگن( تغییر شکل یا کرپیتوس استخوان ران، کوتاه شدن ساق پا با آسیب )شکستگی استخوان ران( شکستگی استخوان بزرگ کبودی اطراف ناف یا دو طرف پهلو ها )فلانک( میتواند نشانه خونریزی داخلی باشد درد شکم شکم بسیار سخت خونریزی شکم خون در استفراغ یا مدفوع استفراغ یا مدفوع سیاه سابقه مصرف الکول خونریزی در معده یا روده مشکل در تنفس کاهش صداهای تنفس در سمت آسیب دیده صداهای خفه )مبهم( کننده با با قرحه در سمت آسیب دیده شاک )در صورت خونریزی زیاد( هموتوراکس سابقه بارداری، عقب افتادن سیکل قاعدگی یا هر زن در سنین باروری درد شکم خونریزی واژینال ) مهبلی ( حاملگی خارج رحمی آخرین ولادت خونریزی شدید مهبل: پد یا پارچه در کمتر از 5 دقیقه ملوث شده است تراوش مداوم خون خونریزی بیش از 052 میلی لیتر رحم نرم / پایین شکم خونریزی پس از زایمان اروا ضعیف به دلیل مشکلات قلب حالت اعراض و علایم مشکل در تنفس با تلاش یا هنگام هموار دراز کشیدن پندیدگی هر دو پا وریدهای گردن متوسع شده ممکن است صدای تروق یا selkcarC در ریه ها شنیده شود ممکن است درد قفس سینه داشته باشد نارسایی قلبی فشار، سختی، درد یا احساس گرنگ شدن در قفس سینه تعرق و جلد خالدار مشکل در تنفس حالت تهوع یا استفراغ حرکت درد به سمت الاشه یا بازوها علایم نارسایی قلبی سابقه سیگار کشیدن، مریضی قلبی، فشار خون بالا، دیابت، کلسترول بالا، سابقه خانوادگی مشکلات قلبی حمله قلبی قلوومبول معم:1 لدومعلمدلم 411 نبض خیلی سریع یا خیلی آهسته نبض نامنظم ریتم غیر نارمل قلب سابقه تب روماتیسمی یا مریضی قلبی مرمر مشکل دریچه قلب علایم اروا ضعیف )نبض سریع، تنفس سریع، فشار خون پایین، جلد خاسف، اندام سرد، پر کردن مجدد مویرگی بیش از 3 ثانیه( وریدهای گردن متوسع شده صدای قلب خفه شده است ممکن است سرچرخی، گیجی، تغییر وضعیت شعوری داشته باشد سابقه توبرکلوز، تروما یا صدمه، سرطان، نارسایی کلیه تامپوناد پریکارد فشار خون بالا با موارد زیر: مشکل در تنفس عدم وجود صداهای تنفسی در سمت آسیب دیده تشدید بیش از بیش از حد صدا با قرع با قرع در سمت آسیب دیده توسع وریدهای گردن ممکن است شزن از سمت آسیب دیده بیجا شود نوموتوراکس تنشی به یاد داشته باشید... هایپوگلایسیمی میتواند مانند شاک به نظر برسد. علایم و نشانه ها عبارتند از: تعریق )عرق کردن زیاد( تشنج/اختلاج گلوکوز خون <5.3 L/lomm وضعیت شعوری تغییر یافته )از گیجی تا بیهوشی( سابقه دیابت، مالاریا یا یک مریضی شدید، به ویژه در کودکان کتاب دستور عملیات اشتراک کننده گان 511 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE سوال شماره 3 کتاب تمرین: شاک با استفاده از بخش کتاب تمرین بالا، علت احتمالی شاک را در کنار تاریخچه و یافته های فیزیکی زیر فهرست کنید. علت احتمالیتاریخچه و دریافت های فزیکی خانمی ۵3 ساله با شاک، تب و: سوزش با ادرار ادرار مکدر یک زن 02 ساله با شاک، درد شکم و: از دست رفتن سیکل قاعدگی خونریزی واژینال ( مهبلی ) یک مرد ۷1 ساله پس از تصادف با وسیله نقلیه موتوری با شاک، کبودی لگن خاصره و: • شکستگی استخوان ران انجام دادن: مدیریت ابتدا ارزیابی EDCBA را انجام دهید و برای شرایط تهدید کننده زندگی مداخله کنید. با دادن مایعات وریدی ( نارمل سلین یا رینگر لاکتات در بزرگسالان و کودکان با وضعیت تغذیه طبیعی( شروع کنید. سپس برای رفع علت احتمالی تلاش کنید. به سرعت دو ورید را با کنول بزرگ باز کنید، مایعات وریدی را شروع کنید و پاسخ را ارزیابی کنید. در صورت نیاز با بولوس های اضافی تکرار کنید. [به مهارت ها مراجعه کنید] اگر نمی توانید وریدی قرار دهید، فورا ًبا کمک کننده ای تماس بگیرید که می تواند یک تیوب یا NG تیوب )تیوب ای که از بینی به معده می رود( یا روش تزریق داخلی استخوانی )سوزنی که مستقیما ً در استخوان قرار می گیرد( قرار دهد. ببینید آیا مریض میتواند در این مدت با خیال راحت مایعات خوراکی مصرف کند یا خیر. احتیاط! برای افراد مبتلا به سوءتغذیه شدید یا کم خونی شدید، یا هر کسی که علایم اضافه بار حجمی دارد، از پروتوکول مایع ذیل پیروی نکنید. از پروتوکول تنظیم شده استفاده کنید [به مهارت ها مراجعه کنید] قلوومبول معم:1 لدومعلمدلم 611 اگر خونریزی واژینال ( مهبلی ) پس از ولادت به عنوان اسباب شاک مشکوک باشد: همه مریضان نیاز به رجعت دهی / انتقال سریع به یک مرکز طبی پیشرفته ولادی دارند. در جریان حمل و نقل مهم است که سعی کنید خونریزی را متوقف کنید. هم اکسیتوسین عضلی و هم وریدی بدهید. این یک دوز تطبیق کننده است. پس از این دوزها، اکسیتوسین وریدی را تا یک ساعت پس از قطع خونریزی ادامه دهید. [به مهارت ها مراجعه کنید] اگر رحم به طور کامل منقبض نشده باشد )در لمس سخت احساس نمی شود(، اغلب خونریزی اتفاق می افتد. بنآ مساژ رحم انجام دهید. [به مهارت ها مراجعه کنید] تا زمانی که رحم سخت شود. برای جلوگیری از خونریزی باید از اکسیتوسین و ماساژ رحم استفاده کنید. اگرپلاسنتا بیرون شد، آن را در یک ظرف جمع کنید و نزد مریض نگه دارید تا به داکتر متخصص نسایی ولادی اجازه دهید آن را بررسی کند. از نظر خارجی برای پارگی عجان یا واژن بررسی کنید. اگر پیدا شد، با گاز استریل فشار مستقیم وارد کنید و پاها را کنار هم قرار دهید. حتی اگر خونریزی متوقف شود، این مریضان همچنان نیاز به رجعت/ انتقال سریع به یک متخصص نسایی ولادی دارند )شکل را ببینید(. او ار اس SRO از طریق تیوب هضمی بینی آغاز کنید آیا مایعات وریدی در نزدیکی قابل دسترس است؟ آیا مایعات وریدی فورا قابل دسترس است؟ پس از بولوس فورا بررسی کنید آیا زرق وریدی انکشاف نموده است؟ مایعات را از طریق دهن ادامه دهید. مایعات را از طریق دهن یا ورید طبق استطباب شروع کنید. آیا پرفیوژن انکشاف نموده است؟ او ار اس SRO را از طریق زرق وریدی دوباره تیوب هضمی ادامه دهید. بلی بلی بلی بلی نخیر نخیر نخیر نخیر ارزیابی مجدد فوری بعد از زرق وریدی کنید 03 دقیقی> 03 دقیقی> 03 دقیقی> مایعات وریدی آغاز کنید توصیه مایعات در شاک )عدم سوء تغذی، اضافه بار یا کمخونی شدید( دوز وقایوی او آر اس 02-01 gk /lm او آر اس ای وی بولس اولیه بزرگسالان 1L نارمل سالین یا رینگر لکتات ای وی بولس اطفال 02-01 gk/lm نارمل سالین یا رینگر لکتات فورا انتقال دهید. egahrromeh mutraptsop rof egassam eniretU 71 egap مساژ بالای رحم به خاطر خونریزی های بعد از زایمان کتاب دستور عملیات اشتراک کننده گان 711 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE به یاد داشته باشید... مایع فقط مشکل فوری اروا را برطرف می کند. مریضان مبتلا به شاک نیاز به رجعت / انتقال سریع به واحدی دارند که قادر به عملکرد باعلل شاک و ارائه مدیریت پیشرفته از جمله انتقال خون باشد. به یاد داشته باشید... ارزیابی وضعیت مایعات بدن حیاتی است. برای مریضانی که اروای ناکافی و اضافه بار مایعات دارند بسیار مشکل که این چنین مریضان را تداوی کرد. مریضان مبتلا به سوء تغذی، کم خونی شدید و مایعات اضافی در ریه ها به دلیل نارسایی قلبی، کبدی یا کلیوی می توانند به این روش مراجعه کنند. این مریضان همچنان به مایعات نیاز دارند، اما مایعات باید با احتیاط و به خصوص در کودکان مبتلا به سوءتغذیه طبق پروتوکول خاصی داده شود. [به مهارت ها مراجعه کنید] خونریزی بعد از ولادت 1. مریض را فورا ًبه متخصص نسائی و ولادی انتقال دهید! 2. برای کنترل خونریزی در هنگام آمادگی و انتقال مریض کوشش کنید. 3. معاینه کنید: 4. فورا ًانتقال دهید: آیا خونریزی شدید بعد از ولادت وجود دارد؟ آیا پلاسنتا (حین ولادت) خارج شده است؟ آیا هنوز خونریزی موجود است؟ آیا پارگی قسمت های پرینه یا ناحیه پایین تر مهبلی موجود است؟ رحم را تا هنگام سخت شدن مساژ کنید ادویه اوکسیتوسین را عضلی زرق کنید. به مریض مایعات وریدی و اوکسیتوسین وریدی بدهید. مثانه مریض را تخلیه نمائید. مساژ نمودن رحم را ادامه دهید وقتی که رحم سخت شد، پلاسنتا به احتمال زیاد خارج خواهد شد. پلاسنتا را جمع آوری نموده نزد مریض نکهدارید. الی حد اقل یک ساعت بعد از توقف خونریزی به تجویز اوکسیتوسین ادامه دهید. با گازپت معقم فشار وارد کنید. پاهای مریض را با هم نزدیک کنید. به مساژ دادن رحم ادامه دهید تا سخت شود. به تزریق اوکسیتوسین ادامه دید. به تجویز مایعات وریدی با اوکسیتوسین ادامه دهید. ورید دوم را باز کنید. بلی بلی نخیر نخیر بلی قلوومبول معم:1 لدومعلمدلم 811 انجام دادن: مدیریت شرایط خاص همیشه ابتدا EDCBA را اجرا کنید. مریضان شاک به اکسیجن نیاز دارند. در تمام اشکال شاک، مدیریت اولیه، تجویز مایعات وریدی مناسب برای سن و شرایط است. شرایط خاص ذیل نیاز به ملاحظات بیشتری دارد. حالت ملاحظات مدیریت سوختگی مانعه جلد را مختل می کند و میتواند باعث از دست دادن مایعات قابل توجهی شود که میتواند منجر به شاک شود. این مریضان نیاز به جایگزین مایعات متفاوتی دارند. [به مهارت ها مراجعه کنید] سوختگی اگر نگران کتواسیدوز دیابیتیک هستید، با مایعات وریدی تداوی کنید. [به مهارت ها مراجعه کنید] یک فرد مبتلا به کتواسیدوز دیابیتیک به شدت مریض است و نیاز به انتقال سریع به مرکزی دارد که در آن انفوزیون وریدی و نظارت دقیق وجود دارد. شکر بلند مایعات بدهید و انتی بیوتیک را شروع کنید. [به مهارت ها مراجعه کنید] اگر به اسهال عفونی )مانند کولرا( مشکوک هستید، از دستکش، پیش بند و اقدامات احتیاطی مربوط به جداسازی استفاده کنید و آن را به نمایندگی صحت عامه محلی گزارش دهید. اگر علایم اروا ضعیف با مایعات بهبود نیافت، رجعت/ انتقال سریع را در نظر بگیرید. تب مایعات وریدی بدهید و برای مدیریت مداوم به مرکزی که میتواند مراقبت از ستون فقرات را ارائه دهد مراجعه کنید. [به مهارت ها مراجعه کنید] واقعات مربوط به ستون فقرات خونریزی معده مایعات وریدی را شروع کنید و برای تطبیق خون رجعت بدهید. [به مهارت ها مراجعه کنید] یا روده مایعات وریدی بدهید و برای انتقال خون و مراقبت های زایمان مراجعه کنید. [به مهارت ها مراجعه کنید] حاملگی خارج رحمی اکسیتوسین ومایعات وریدی بدهید و برای رجعت سریع به مرکز صحی با قابلیت انتقال خون و مراقبت های زایمان برنامه ریزی کنید. مایعات وریدی بدهید و رحم را ماساژ دهید تا سخت شود. [به مهارت ها مراجعه کنید] اکسیتوسین بدهید. [به مهارت ها مراجعه کنید] اگر پلاسنتا زایمان کرده است، آن را در یک ظرف شیشه ای و یا پلاستیکی جمع کنید و برای بررسی توسط کمک کننده پیشرفته نزد مریض نگه دارید. پارگی عجان و واژن را بررسی کنید و فشار مستقیم وارد کنید. خونریزی پس از زایمان • برای کاهش آنی فشار فورا رفع فشار سوزنی را انجام داده و اکسیجن و مایعات بدهید. [به مهارت ها مراجعه کنید] هر مریضی که رفع فشار با سوزن شده است، نیاز به انتقال/رجعت دهی سریع به مرکزی دارد که می تواند یک تیوب قفس سینه قرار دهد. نوموتوراکس تنشی مایعات وریدی بدهید تا به پر شدن قلب در برابر فشار وارده برساختمان در کیسه قلب کمک کند. [به مهارت ها مراجعه کنید] برای انتقال/رجعت سریع به ارائه دهنده ای که میتواند مایع پریکارد را تخلیه کند، برنامه ریزی کنید تامپوناد پریکارد کتاب دستور عملیات اشتراک کننده گان 911 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE حالت ملاحظات مدیریت در صورت لزوم اسپرین بدهید. ورید مریض را باز کنید و مایعات بدهید و مریض را مرتبا ًارزیابی کنید. [به مهارت ها مراجعه کنید] در حالی که اکسیجن دیگر در همه مریضان مبتلا به حمله قلبی توصیه نمی شود، در ابتدا باید در مریضان مبتلا به شاک یا مشکل در تنفس، حتی زمانی که علت مشکوک حمله قلبی است، تجویز شود. برای رجعت دهی/انتقال سریع به کمک کننده و یا مرکز پیشرفته برنامه ریزی کنید. مشکوک به حمله قلبی مایعات وریدی را آهسته تر بدهید، ریه ها را مرتبا ًاز نظر selkcarC )بیش از حد مایع( بررسی کنید. در صورت ایجاد اضافه بار مایعات )مشکل در تنفس، selkcarC در ریه ها، افزایش تعداد تنفس، افزایش ضربان قلب( مایعات وریدی را متوقف کنید. [به مهارت ها مراجعه کنید] برای رجعت دهی/انتقال سریع به یک ارائه دهنده پیشرفته برنامه ریزی کنید. نارسایی قلبی ادرینالین عضلی بدهید [به مهارت ها مراجعه کنید]. این مریضان همچنین به دسترسی وریدی و مایعات نیاز خواهند داشت زیرا وضعیت آنها میتواند به سرعت پس از از بین رفتن ادرینالین بدتر شود. در صورت از بین رفتن اثرات، می توانید دوز دوم را تجویز کنید. [به مهارت ها مراجعه کنید] اگر طرق هوایی پندیدگی شده یا در تنفس مشکل وجود دارد، مریضان ممکن است نیاز به انتقال سریع داشته باشند. عکس العمل حساسیتی شدید خونریزی را متوقف کنید، مایعات وریدی بدهید و ارزیابی کامل صدمه و یا تروما انجام دهید. [به مهارت ها مراجعه کنید] برای انتقال خون و مدیریت جراحی مداوم مراجعه کنید. آسیب های ناشی از تروما و یا مشکوک بودن به ضیاع آنی خون سوال شماره 4 کتاب تمرین: شاک با استفاده از بخش کتاب تمرین بالا، فهرستی از کارهایی که برای مدیریت این مریض انجام می دهید را فهرست کنید. پسر 6 ساله ای را با تب آورده اند. او در شاک است و سوء تغذی به نظر نمی رسد. مرکز شما امکانات باز کردن ورید را دارند. 1. 2. 3. مرد جوانی پس از تصادف با موتورسیکلت مراجعه میکند. او بریدگی بزرگی در دستش دارد که خونریزی دارد مقدار زیاد خون ضایع کرده است. وقتی او را معاینه می کنید در شاک است. 1. 2. 3. زن 03 ساله ای را پس از خوردن تصادفی میگو وارد می کنند. او یک الرژی شناخته شده به صدف دارد، بدنش پوشیده از دانه های جلدی سرخ رنگ و خارش دار است و در شاک است. 1. 2. 3. قلوومبول معم:1 لدومعلمدلم 021 ملاحظات خاص در کودکان شاک میتواند به سرعت در کودکان رخ دهد و تهدید کننده زندگی است. کودکان سطح بدن نسبتا بزرگتری دارند )در مقایسه با حجم بدنشان( و بنابراین احتمال دارد که سریعتر دچار کم آبی شوند. نوزادان و کودکان خردسال بطور خاص در معرض خطر هستند، زیرا نمی توانند تشخیص دهند که چه زمانی تشنه هستند و نمی توانند بیشتر بنوشند. ارزیابی شاک در کودکان: تعریف کلینیکی شاک در کودکان متفاوت است. دستورالعمل های OHW در سال 6102 برای مراقبت از کودکان بدحال از وجود سه ویژگی کلینیکی استفاده می کند: اندام های سرد، پر شدن مجدد عروق شعریه بیش از 3 ثانیه و نبض ضعیف و سریع. همچنین علایم مهم دیگری از اروا ضعیف وجود دارد، از جمله فشار خون پایین، تنفس سریع، تغییر وضعیت ذهنی و کاهش ادرار )همیشه از والدین بپرسید که کودک چقدر ادرار می کند(. [به مهارت ها مراجعه کنید] علایم دیهایدریشن در کودکان قرار ذیل است: دهان و لب های بسیار خشک بی حالی )خواب آلودگی بیش از حد و کندی پاسخ(، کودک تعاملی نیست چشم های فرورفته مقدار کمی ادرار تیره )در مورد تعداد پوشک نوزادان بپرسید( فونتانیل های فرو رفته در نوزادان زیر 1 سال پر شدن مجدد مویرگ ها با تاخیر )پر کردن مجدد مویرگ ها معمولی کمتر از 3 ثانیه است( نیشگون )ُچندی( گرفتن غیر نارمل جلد [به مهارت ها مراجعه کنید] رنگ پریدگی )کم خونی تداوی کم آبی بدن را دشوارتر می کند [به مهارت ها مراجعه کنید]( معاینه جلد غیر نورمال در اطفال علل شایع شاک و کم آبی در کودکان عبارتند از: استفراغ و اسهال: گاستروانتریت باعث شروع ناگهانی استفراغ و اسهال همراه با مقداری درد شکم و تب می شود. مقدار زیاد اسهال آبگین ممکن است نشان دهنده کولرا باشد و باید به مقامات صحت عامه گزارش شود. استفراغ بدون اسهال: استفراغ بدون اسهال یا تب ممکن است ن شان دهنده افزایش فشار روی مغز )صدمه، تومور، پندیدگی مغز( یا انسداد )بندش( روده باشد. معاینه کودک از نظر علایم صدمه مهم است. استفراغ همراه با تب ممکن است نشان دهنده انتان باشد. انتان طاقت فرسا: تب میتواند باعث کم آبی کودکان به سرعت شود. علاوه بر این، انتان شدید میتواند باعث گشاد شدن عروق خونی و بدتر شدن شاک شود. dlihc a ni hcnip niks lamronbA 43 egap کتاب دستور عملیات اشتراک کننده گان 121 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE ملاحظات مدیریت خاص سوءتغذی: کودکان سوءتغذی در معرض خطر شکر خون پایین هستند و علاوه بر مایعات به شکر نیز نیاز خواهند داشت. در صورت وجود مایعات تخصصی بدهید. [به مهارت ها مراجعه کنید] مایعات وریدی کمتری را آهسته تر بدهید و هر 5 دقیقه یک بار ریه ها را از نظر selkcarC )بیش از حد مایع( بررسی کنید. در صورت ایجاد اضافه بار مایعات )selkcarC در ریه ها، افزایش تعداد تنفس، افزایش ضربان قلب( مایعات وریدی را متوقف کنید. به محض بهبود علایم اروا ضعیف، مایعات خوراکی را جایگزین کنید. این مریضان نیاز به رجعت دهی / انتقال سریع به یک مرکز طبی پیشرفته در یک مرکز با قابلیت انتقال خون دارند. سوال شماره ۵ کتاب تمرین: شاک با استفاده از بخش کتاب تمرین بالا، علایم کم آبی شدید در کودکان را فهرست کنید. 1. 2. 3. 4. ۵. 6. ۷. 8. ملاحظات مرحله بعدی(دیسپوزیشن) در مواظبت افراد مبتلا به شاک می توانند بدتر شوند و به سرعت بمیرند. آنها باید بسیار دقیق نظارت شوند. علاوه بر این، همان مریضی هایی که باعث ایجاد شاک می شوند، با توانائی بدن در مدیریت مایعات تداخل می کنند، بنابراین این مریضان باید از نظر علایم مشکل در تنفس بسیار دقیق تحت نظر باشند. قلوومبول معم:1 لدومعلمدلم 221 مریضان مبتلا به شاک ممکن است گیج و مضطرب باشند. اطمینان حاصل کنید که آنها در طول انتقال ایمن و محفوظ هستند. مریضان مبتلا به شاک اغلب برای انتقال خون یا جراحی عمومی یا زایمان منتقل می شوند. همیشه مستقیما ًبا تسهیلات دریافت کننده ارتباط برقرار کنید تا مطمئن شوید که این منابع واقعا ًدر زمان انتقال در دسترس هستند. سناریوهای قضیه ها به رهبری استاد رهنما یا تسهیل کننده این سناریوها در گروپ های کوچک کار خواهد شد. یک شرکت کننده به عنوان پیشوا و یا رهنما شناخته میشود و ارزیابی میشود در حالی که بقیه گروپ پاسخ ها را در کتاب تمرین می نویسند. برای تکمیل یک سناریوی مسایل، شرکت کنندگان باید یافته های حیاتی و مدیریت مورد نیاز را شناسایی کرده و یافته های خویش را در یک جمله برای رجعت دهی خلاصه کنند که شامل، دریافت های ارزیابی و مداخلات میباشد. هنگام ارزیابی باید از کارت سریع برای این سناریوها استفاده کنید. مورد شماره 1: شاک بزرگسالان یک مرد 84 ساله با سابقه سوءمصرف الکول توسط همسرش برای ارزیابی ضعیفی وی آورده شده است. همسرش بیان می کند که او از 2 روز گذشته مدفوع بسیار تیره داشته و اکنون نمیتواند بایستد. 1. در عملکرد اولیه خود چه کاری باید انجام دهید؟ 2. از روش EDCBA برای ارزیابی و مدیریت این مریض استفاده کنید. از تسهیل کننده در مورد یافته های کلینیکی به وسیله چشم، گوش و لمس را بپرسید. در صورت نیاز از کارت های سریع برای رهنمایی استفاده کنید. مداخلات برای انجام: آیا نیاز مداخله است؟یافته ها ارزیابی نخیر بلی طرق تنفسی نخیربلیتنفس نخیربلیدوران خون نخیربلیناتوانی نخیربلیدر معرض قرار گرفتن کتاب دستور عملیات اشتراک کننده گان 321 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE 3. یک جمله کوتاه برای رجعت دهی مریض بنویسید. مورد شماره 2: شاک اطفال مریض دختری 4 ساله است که توسط مادرش آورده شده است. او در 3 روز گذشته تقریبا ًدائما ًاسهال داشته و هر بار که می خواهد چیزی بنوشد استفراغ می کند. مادر فکر می کند ممکن است تب نیز داشته باشد. او هیچ نشانه ای از سوء تغذی ندارد. 1. در عملکرد اولیه خود چه کاری باید انجام دهید؟ 2. برای ارزیابی و مدیریت این مریض از روش EDCBA استفاده کنید. از تسهیل کننده در مورد یافته های کلینیکی به وسیله چشم، گوش و لمس را بپرسید. در صورت نیاز از کارت سریع برای مرجع استفاده کنید. مداخلات برای انجام: آیا نیاز مداخله است؟یافته ها ارزیابی نخیر بلی طرق تنفسی نخیربلیتنفس نخیربلیدوران خون نخیربلیناتوانی نخیربلیدر معرض قرار گرفتن 3. یک جمله کوتاه برای رجعت دهی مریض بنیسید. قلوومبول معم:1 لدومعلمدلم 421 سوالات چند گزینه ای به سوالات زیر پاسخ دهید. پرسش و پاسخ در جلسه مورد بحث قرار خواهد گرفت. 1. پسر 7 ساله ای در 4 روز گذشته دچار بی حالی، استفراغ و اسهال شده است. علایم حیاتی وی عبارتند از: فشار خون 08/04 میلی متر ستون سیماب، ضربان قلب 041 ضربه در دقیقه، تعداد تنفس 81 تنفس در دقیقه. هنگامی که شما می خواهید چیزی را از طریق دهان بدهید، مریض استفراغ می کند. عاجلترین مدیریت شما چیست؟ A. زرقیات وریدی را شروع کنید و مایعات بدهید B. تلاش برای ادامه مایعات فمی نمایید C. یک تیوب بینی معده )GN( قرار داده و از طریق آن مایعات بدهید D. انتقال سریع به شفاخانه مجهز تر 2. شما در حال مراقبت از یک مرد 82 ساله هستید که از ناحیه شکم مورد اصابت مرمی قرار گرفته است. او بی حال است و علایم حیاتی به شرح زیر است: فشار خون 08/04 میلی متر ستون سیماب، ضربان قلب 031 ضربه در دقیقه، تعداد تنفس 02 تنفس در دقیقه. خونریزی شدید ناشی از شلیک مرمی وجود دارد و شکم سخت و حساس است. اولین مداخله ای که باید به این مریض بدهید چیست؟ A. مایعات وریدی B. تدادن مایعات از طریق مجرای بین العضمی C. جراحی D. ادرینالین 3. کودکی که با چشم های فرورفته، مقدار کمی ادرار تیره، غشاهای مخاطی خشک و آزمایش غیرطبیعی نیشگون )ُچندی( گرفتن جلد مراجعه می کند، به احتمال زیاد از موارد زیر رنج می برد: A. سینه و بغل / نمونیا B. جرحه در سر C. ضیاع مایعات بدن D. شکر پایین 4. مردی 06 ساله بیان می کند که در هفته گذشته دچار ضعف و سرچرخی بوده است. علایم حیاتی وی عبارتند از: فشار خون 09/05 میلی متر ستون سیماب، ضربان قلب 521 ضربه در دقیقه، تعداد تنفس 61 تنفس در دقیقه. جلدش خنک و رنگ پریده است. او می گوید که مدفوعش از 2 روز گذشته سیاه بوده است. شایع ترین دلیل شاک او چیست؟ A. خونریزی بطنی / درد بطن کتاب دستور عملیات اشتراک کننده گان 521 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE B. ضربه جسمی درشکم C. ضیاع مایعات بدن D. انتان شدید 5. شما در حال ارزیابی یک جوان 32 ساله هستید که از ناحیه قفس سینه مورد اصابت چاقو قرار گرفته است. شما قفس سینه را در معرض دید قرار می دهید تا یک زخم چاقو در قفس سینه سمت راست با خونریزی جزئی پیدا کنید. او از مشکل شدید در تنفس شکایت دارد و صدای ریه در سمت راست وجود ندارد. رگهای گردنش گشاد شده و جلدش خنک و عرق کرده است. علایم حیاتی وی عبارتند از: فشار خون 68/65 میلی متر ستون سیماب، ضربان قلب 631 ضربه در دقیقه، تعداد تنفس 82 تنفس در دقیقه. قدم بعدی شما چیست؟ A. قرار دادن تیوب قفس سینه B. رفع فشار با سوزن C. تزریق خون D. تزریق مایعات وریدی را شروع کنید قلوومبول معم:1 لدومعلمدلم 621 یادداشت کتاب دستور عملیات اشتراک کننده گان 721 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE مودل 5: عملکرد باوضعیت شعوری تغییر یافته اهداف باتکمیل نمودن این مودل باید بتوانید تا: یافته های تاریخچه کلیدی را که حاکی از علل مختلف تغییر وضعیت ذهنی است، بشناسید.. 1 یافته های فیزیکی کلیدی را که دلالت بر علل مختلف تغییر وضعیت ذهنی دارند، بشناسند.. 2 علل پرخطر تغییر وضعیت روانی در بزرگسالان و کودکان را فهرست کنید. . 3 اقدامات حیاتی برای علل پرخطر تغییر وضعیت روانی انجام دهید. . 4 مهارت های ضروری سنجش شعور در مریضانیکه از ناحیه سر صدمه میبینند. ارزیابی UPVA وضعیت ریکوری تجویز آکسیجن قرار دادن کنول وریدی احیای مایعات وریدی مدیریت مارگزیدگی بی حرکت ساختن ستون فقرات اصطلاحات کلیدی تعریف را با استفاده از واژه نامه در پشت کتاب تمرین بنویسید. وضعیت ذهنی تغیر یافته: کوما: قلووم5عم:1 لدومعل تبدضمدبل رمBمدددمدلدوم 821 گیجی/ کنفیوژن: تشنج/ کنولژن: سیانوز یا کبودی : هذیان/دیلرییم: جنون: دیابیتیک کیتو اسیدوزس: اکلمپسیا: مسمومیت ها : ویروس اچ ای وی )VIH(: پایین بودن گلوکوز: کمبود آکسیجن: عملیه بلع: مراقبت به نحوه کانگرو: سوراخ بزرگ وریدی: سطح شعور: آشنایی محیط ماحول noitatneirO: سایکوزس sisohcysP: ربیس یا گزیده شدن توسط سگ دیوانه: اختلاج: ستروک یا کم رسی خون و اکسیجن به دماغ: کتاب دستور عملیات اشتراک کننده گان 921 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE مرور عمومی وضعیت ذهنی تغییر یافته )SMA( اصطلاحی است که برای طیف وسیعی از علایم استفاده می شود، از تغییرات ناگهانی یا تدریجی در رفتار گرفته تا سردرگمی، گیچی و کوما. تغییرات در وضعیت ذهنی و/یا سطح هوشیاری ممکن است به دلیل شرایطی باشد که بر مغز تأثیر می گذارد )مانند کمبود اکسیجن یا گلوکوز؛ یا شاکی که باعث عدم اروا میشود( یا مشکلاتی در خود مغز )مانند انتان، التهاب یا آسیب(. . در حالی که مشکلات مزمن روان درمانی و زوال عقل میتواند باعث تغییر در وضعیت روانی شود، تغییر وضعیت روانی اغلب نشانه مریضی شدید است و سایر علل تهدید کننده زندگی همیشه باید در نظر گرفته شوند. وجود هذیان - یک حالت گیجی که به سرعت در حال تغییر است با بی قراری، از دست دادن تمرکز و ناتوانی در تعامل مناسب - همیشه نیاز به ارزیابی کامل دارد. در صورت امکان همیشه از خانواده/دوستان در مورد وضعیت روانی اولیه سوال کنید. هدف از ارزیابی اولیه شناسایی سریع اسباب برگشت پذیر تغییر وضعیت شعوری و شناسایی شرایط خطرناکی است که نیاز به انتقال به مرکز طبی مجهز دارند. هدف مدیریت حاد اطمینان از رسیدن خون، اکسیجن و گلوکوز به مغز است. و برای محافظت از مغز در برابر آسیب های اضافی. این مودل شما را در موارد زیر راهنمایی می کند: عناصر کلیدی EDCBA بپرسید: یافته های تاریخچه کلیدی )سابقه ELPMAS( بررسی: یافته های بررسی ثانوی علل احتمالی انجام دادن: مدیریت ملاحظات خاص در کودکان پیگیری و رسیدگی به ملاحظات به یاد داشته باشید ... همیشه با روش EDCBA شروع کنید و در صورت نیاز مداخله کنید. سپس یک تاریخچه ELPMAS انجام دهید. سپس یک بررسی متوسطه انجام دهید. قلووم5عم:1 لدومعل تبدضمدبل رمBمدددمدلدوم 031 EDCBA: عناصر کلیدی برای تغییر وضعیت شعوری برای فردی با وضعیت ذهنی تغییر یافته، موارد زیر عناصر کلیدی هستند که باید در روش EDCBA در نظر گرفته شوند. طرق هوایی افراد مصاب تغییر وضعیت ذهنی ممکن است نتوانند از مجاری تنفسی خود محافظت کنند و ممکن است در معرض خطر خفگی در اثر استفراغ باشند. نفس گرفتن هایپوکسیا )کمبود اکسیجن( میتواند دلیل تغییر وضعیت ذهنی باشد. هر نشانه ای از مشکل تنفسی یا سیانوز )رنگ آبی جلد( را جستجو کنید. تنفس غیر نارمل میتواند نشان دهنده کتواسیدوز دیابیتیک یا مسمومیت باشد. دوران خون کمبود خونرسانی به مغز میتواند باعث تغییر وضعیت ذهنی شود. علایم شاک )فشار خون پایین، افزایش ضربان قلب، تاخیر در پر شدن مجدد مویرگ ها( را جستجو کرده و مدیریت کنید. ناتوانی/ معلولین UPVA یا SCG )در صدمه( را بررسی کنید. به تعقیب گلوکوز غیر نارمل باشید )هایپوگلیسمی یا هایپرگلیسمی میتواند باعث تغییر وضعیت ذهنی شود(. حدقه های خیلی کوچک، مصرف بیش از حد مواد افیونی یا مسمومیت را پیشنهاد می کنند )ضد عفونی را در نظر بگیرید(. حدقه های بسیار گشاد شده مصرف ادویهی محرک را پیشنهاد می کنند. حدقه های نابرابر نشان دهنده افزایش فشار بر مغز است. اگر مریض میتواند دستورات را پیروی کند، قدرت و حسیت را در چهره، بازوها و پاها بررسی کنید. ضعیفی یا از دست دادن حسیت در یک طرف حاکی از وجود کتله، خونریزی یا مسدود شدن رگ های خونی در مغز )سکته مغزی( است، اگرچه هایپوگلیسمی نیز میتواند به این شکل ظاهر شود. تغییر وضعیت ذهنی همراه با ضعف عمومی عضلی ممکن است نشان دهنده عدم تعادل نمک )الکترولیت( در خون باشد. به تعقیب حرکات تکراری غیر نارمل یا تکان دادن در یک یا هر دو طرف بدن )تشنج/اختلاج( باشید – این ممکن است به دلیل تومور، خونریزی، انتان مغزی، هایپوگلیسمی یا عدم تعادل نمک )الکترولیت( باشد. کتاب دستور عملیات اشتراک کننده گان 131 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE برهنه ساختن مریض به یاد داشته باشید که مریضان با وضعیت ذهنی تغییر یافته ممکن است شرح حال خود را به طور دقیق گزارش نکنند. کل بدن را از نظر انتان، دانه های جلدی، و هرگونه شواهدی از ضربه، گزیدن یا نیش بررسی کنید. علایم سوزن روی بازوها ممکن است نمایان گر استفاده از ادویه باشد. بپرسید: یافته های کلیدی تاریخچه برای مریضان با وضعیت ذهنی تغییر یافته از روش ELPMAS برای گرفتن تاریخچه از مریض و/یا خانواده استفاده کنید. گرفتن تاریخچه از اطرافیان، دوستان یا خانواده بسیار مهم است، زیرا ممکن است گرفتن تاریخچه دقیق از یک مریض گیج دشوار باشد. به عنوان مثال، یک فرد مبتلا به هایپوگلیسمی ممکن است بیش از حد سردرگم باشد که نمیتواند سابقه دیابت را به شما بگوید. اگر سابقه یک وضعیت EDCBA را مشخص کرد، برای مدیریت آن، فورا ًبه EDCBA برگردید. S: اعراض و علایم وضعیت فعلی چگونه با وضعیت روانی معمول مقایسه می شود؟ همیشه در صورت امکان از خانواده/دوستان در مورد وضعیت روانی اولیه سوال کنید. آیا تنفس مشکل دارد؟ تغییر وضعیت ذهنی مرتبط با مشکل در تنفس ممکن است نشان دهنده کمبود اکسیجن به مغز باشد. آیا سردردی وجود دارد؟ سردردی با تغییر وضعیت ذهنی میتواند نشان دهنده انتان، تومور یا خونریزی باشد. آیا استفراق/اسهال وجود دارد؟ استفراغ بدون اسهال میتواند نشانه افزایش فشار در مغز باشد. هر منبع کم آبی بدن، از جمله استفراغ و اسهال، ممکن است باعث تغییر وضعیت ذهنی ناشی از اروا ضعیف شود. استفراغ و اسهال نیز میتواند باعث هایپوگلیسمی شود که منجر به تغییر وضعیت ذهنی می شود. آیا سرچرخی یا ضعف وجود داشته است؟ اینها ممکن است نشانه های اروا ضعیف )کمبود خون اکسیجن دار( به مغز باشد. علایم از چه زمانی شروع شد؟ می آیند و می روند؟ آن ها چقدر دوام می آورند؟ آیا آنها در طول زمان تغییر کرده اند؟ قلووم5عم:1 لدومعل تبدضمدبل رمBمدددمدلدوم 231 شروع سریع تغییر وضعیت ذهنی ممکن است نشان دهنده انتان، التهاب، خونریزی یا قرار گرفتن در معرض مواد مخدر/سمی باشد. شروع تدریجی تر )طی هفته ها یا ماه ها( ممکن است نشان دهنده وجود و یا noiseL اشغال کننده فضا در مغز باشد، مانند تومور یا خونریزی آهسته در مغز. تغییر وضعیت ذهنی که با فواصل طبیعی بین دوره ها می آید و می رود، ممکن است دلایل دیگری مانند تشنج/اختلاج یا مریضی روانی را نشان دهد. آیا اخیرا ًتب وجود داشته است؟ هر فردی که وضعیت ذهنی و تب تغییر یافته دارد ممکن است انتان داشته باشد. انتان های مغزی اغلب با تغییر وضعیت ذهنی و تب ظاهر می شوند. در کودکان کوچک و افراد مسن، هر گونه انتان جدی مانند انتان ادرار، ریه یا خون میتواند باعث تغییر وضعیت ذهنی شود. همچنین قرار گرفتن در معرض طولانی مدت در فضای باز و یا بیرونی، مسمومیت ها و ادویه ها را در نظر بگیرید زیرا ممکن است با تب نیز همراه باشند. تب بسیار بالا از هر منبعی ممکن است باعث تغییر وضعیت ذهنی شود. آیا ضعف، ناتوانی یا مشکل در راه رفتن وجود دارد؟ تغییر وضعیت ذهنی با ضعف یا از دست دادن حس در یک ناحیه از بدن، یا مشکلات راه رفتن و تعادل، نشان می دهد که تغییر وضعیت ذهنی ناشی از یک علت در خود مغز است، مانند سکته مغزی یا تومور. آیا گردن درد یا شخی گردن وجود دارد؟ مایعی که در اطراف مغز دوران می کند در اطراف نخاع نیز دوران می کند، به این معنی که هر گونه خونریزی، التهاب یا انتان در مغز )مننژیت، آنسفالیت( نیز میتواند باعث درد و سختی گردن شود. آیا سابقه اخیر صدمه یا به زمین افتادن وجود دارد؟ خونریزی در داخل یا اطراف مغز میتواند باعث تغییر وضعیت ذهنی چند روز پس از آسیب شود. به یاد داشته باشید که مصرف کنندگان مزمن الکول و افراد مسن بیشتر مستعد خونریزی مغزی هستند و ممکن است افتادن را به خاطر نداشته باشند. همیشه خونریزی آهسته در اطراف مغز را به عنوان یک علت در نظر بگیرید، حتی چند روز پس از افتادن، و صدمه های غیرمعمول را در مریضی که بدون علت شناخته شده تغییر یافته است، در نظر بگیرید. آیا اخیرا ًافسردگی یا تغییری در رفتار وجود داشته است؟ مصرف مواد مخدر و الکول یا مشکلات روانی میتواند به صورت تغییر وضعیت ذهنی ظاهر شود. همیشه احتمال اقدام به خودکشی با مسمومیت را در نظر بگیرید. آیا فرد دیگری از همان خانواده یا همان محل علایم دارد؟ مسمومیت با گاز، مانند مسمومیت با کاربن مونوکساید، میتواند باعث تغییر وضعیت ذهنی در افراد مختلف شود. مسمومیت با کاربن مونوکساید معمولا در آب و هوای سرد زمانی که افراد از گرمایش داخلی استفاده می کنند دیده می شود. کتاب دستور عملیات اشتراک کننده گان 331 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE A : الرژی یا حساسیت آیا الرژی یا تماس اخیر با یک آلرژن شناخته شده وجود دارد؟ عکس العمل های حساسیتی شدید )عکس العمل شدید( ممکن است با تغییر وضعیت ذهنی به دلیل سطح پایین اکسیجن خون یا دوران خون ضعیف در مغز در نتیجه شاک ظاهر شود. M: ادویه در حال حاضر دوای مصرف می کنید؟ بسیاری از ادویه جات رایج می توانند باعث تغییر وضعیت ذهنی به عنوان یک عارضه جانبی شوند، از جمله ادویه جاتی تشنج / اختلاج، درد و خواب. در مورد ادویه جاتی جدید و دوزهای تغییر یافته بپرسید و تداخلات ادویه یی را در نظر بگیرید. اگر فرد نتواند مکالمه کند، باید فهرست ادویه جات آن جمع آوری شود و می تواند سرنخ هایی برای مریضی بنیادی )مانند تشنج، مریضی کبد، دیابت( ارائه دهد. ادویه جاتی مخدر )مانند مورفین، پتیدین و هیروئین( می توانند باعث تغییر وضعیت ذهنی شوند. P: تاریخچه طبی گذشته سابقه دیابت داشته است؟ در هر مریض مبتلا به دیابت و تغییر وضعیت ذهنی، مشکوک به حالت اظطراری دیابت یا شکر خون پایین ناشی از ادویه است. افزایش اخیر در تخلیه ادرار، افزایش تشنگی و تنفس سریع یا عمیق حاکی از حالت اظطراری دیابت یا شکر خون )کتواسیدوز دیابیتیک( است. سابقه مریضی قلبی داشته است ؟ حمله قلبی میتواند باعث کاهش دوران خون و آکسیجن به مغز شود که منجر به گیچی می شود. افراد مبتلا به مریضی قلبی نیز در معرض خطر سکته مغزی هستند. سابقه سکته مغزی داشته است ؟ تغییر وضعیت ذهنی در مریض با سابقه سکته مغزی ممکن است نشان دهنده سکته مغزی یا خونریزی اضافی در مغز باشد. حتما از افرادی که مریض را می شناسند در مورد وضعیت روانی و عصبی معمول او سوال کنید. علایم سکته قدیمی ممکن است با هر نوع مریضی شدید عود کند. سابقه فشار خون بالا داشته است ؟ فشار خون بالا خطر خونریزی در داخل و اطراف مغز )مانند سکته( را افزایش می دهد. سابقه تشنج/اختلاج داشته است ؟ تغییر وضعیت روانی در مریض با سابقه تشنج/اختلاج ممکن است نشان دهد که مریض دچار تشنج شده یا در قلووم5عم:1 لدومعل تبدضمدبل رمBمدددمدلدوم 431 حال بهبودی است. اگر سابقه مرگی )اختلال تشنج اولیه/اختلاج( وجود دارد، در مورد ادویه جاتی معمولی و تغییرات اخیر دوز یا دوز فراموش شده سوال کنید. با تشنجی که شاهد آن بوده اند ، در مورد ضربه خوردن یا ضربه به سر بپرسید. همیشه بپرسید که آیا تشنج در مقایسه با قبل یکسان بوده یا متفاوت است. به یاد داشته باشید که بهبود وضعیت روانی طبیعی پس از تشنج معمولا ًفقط نیم ساعت تا حداکثر چند ساعت طول می کشد، اگرچه مریضان ممکن است برای مدت طولانی تری احساس خستگی کنند. تغییر وضعیت ذهنی طولانی تر دلیل دیگری را نشان می دهد. سابقه انتان VIH داشته است ؟ تغییر وضعیت ذهنی در فرد مبتلا به VIH ممکن است نشان دهنده انتان در داخل یا اطراف مغز باشد )مننژیت، آنسفالیت(. سابقه توبرکلوز داشته است ؟ توبرکلوز میتواند مغز را آلوده کرده و باعث تغییر وضعیت ذهنی شود. سابقه نارسایی کبد یا کلیه داشته است ؟ نارسایی کبد یا کلیه میتواند باعث ایجاد مشکلاتی در پاکسازی سموم و مواد اضافی از خون شود که میتواند منجر به تغییر وضعیت ذهنی شود. سابقه مصرف زیاد الکول داشته است ؟ مسمومیت با الکول و ترک الکول میتواند با تغییر وضعیت ذهنی ظاهر شود. افرادی که سابقه مصرف زیاد الکول دارند نیز در معرض خطر بالایی برای آسیب سر )و ممکن است زمین خوردن را به خاطر نداشته باشند( و هایپوگلایسیمی دارند، که هر دو میتوانند باعث تغییر وضعیت ذهنی شوند. استفاده سْو از مواد مخدر؟ سؤ استفاده چندین نوع ادیه باعث تغییر وضعیت ذهنی می شوند، از جمله محرک ها، آرام بخش ها و مواد افیونی. سابقه بارداری داشته است ؟ فشار خون بالا در دوران بارداری میتواند منجر به اکلامپسیاا )یا تشنج/اختلاج و فشار خون بالا( در دوران بارداری شود. L: آخرین مصرف خوراکی آخرین بار چی زمانی غذا خورده یا نوشیدند؟ سطح پایین گلوکوز خون و کم شدن مایعات بدن میتواند باعث تغییر وضعیت ذهنی شود. کتاب دستور عملیات اشتراک کننده گان 531 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE E: واقعات مرتبط به مریضی اخیرا صدمه یا اثر ضربه رخ داده است؟ هم آسیب به سر و هم اروا ضعیف ناشی از از دست دادن خون می توانند باعث تغییر وضعیت ذهنی شوند. سفر اخیر به مناطقی که ممکن است انواع خاصی از انتان ها شایع تر باشند، داشته اید؟ انتان های خاصی که می توانند باعث تغییر وضعیت ذهنی شوند ممکن است در مناطق خاصی شایع تر باشند. مالاریا در بسیاری از زمینه ها یک عامل کلیدی است. مواجه های اخیر: تماس با یک فرد مریض، نیش زدن و یا دهن انداختن توسط حیوانات، قرار گرفتن در معرض مواد کیمیاوی، محیط های گرم یا سرد و غیره؟ تماس های مریض ممکن است علت عفونی را نشان دهد. قرار گرفتن در معرض مواد کیمیاوی )مانند حشره کش ها( یا نیش ممکن است نشان دهنده مسمومیت باشد. تغییر وضعیت ذهنی میتواند ناشی از حرارت بسیار پایین و بسیار زیاد بدن باشد. مصرف اخیر الکول یا مواد مخدر؟ هم مسمومیت با الکول و هم ترک الکول می توانند باعث تغییر وضعیت ذهنی شوند. متا آمفتامین ها و کوکائین ممکن است باعث تحریک شدید شوند، در حالی که هروئین )و سایر مواد افیونی( ممکن است باعث بی حالی و کما شوند. همچنین به بخش «سابقه طبی گذشته» در بالا مراجعه کنید. سوال شماره 1 کتاب تمرین: وضعیت ذهنی تغییر یافته با استفاده از بخش کتاب تمرین بالا، هفت سؤال در مورد اعراض و علایم را لست کنید که هنگام گرفتن یک تاریخچه ELPMAS در مورد آنها می پرسید. 1. 2. 3. 4. ۵. 6. ۷. قلووم5عم:1 لدومعل تبدضمدبل رمBمدددمدلدوم 631 بررسی کنید: یافته های بررسی ثانوی در وضعیت ذهنی تغییر یافته فردی با وضعیت ذهنی تغییر یافته ممکن است نتواند به سؤالات پاسخ دهد و سرنخ هایی از علت آن تنها در طول معاینه فیزیکی یافت می شود. همیشه ابتدا EDCBA را ارزیابی کنید. عملکرد اولیه EDCBA شرایط تهدید کننده زندگی را شناسایی و مدیریت می کند. معاینه ثانوی به تعقیب تغییراتی در وضعیت مریض یا علل کمتر آشکاری است که ممکن است در طول EDCBA از قلم افتاده باشد. اگر معاینه ثانوی یک وضعیت EDCBA را شناسایی کرد، برای مدیریت آن، فورا ًبه EDCBA برگردید. مصؤنیت را بررسی کنید. رفتار تحریک آمیز و خشونت آمیز یک مصؤنیت رایج است. شناسایی و تداوی علت زمینه ای در صورت امکان بسیار مهم است و در عین حال مصؤنیت مریض و کمک کننده را در اولویت قرار می دهد. آرامش خود را حفظ کنید و به عنوان یک تیم کار کنید. مطمئن شوید که فضا از سلاح های احتمالی در امان است و مطمئن شوید که مریض بین شما و دروازه قرار ندارد. از ایجاد احساس خطر در مریض خودداری کنید. خیلی نزدیک ننشینید و با صدایی آرام، نرم و دلسوز صحبت کنید. به طور مداوم آنچه را که اتفاق می افتد توضیح دهید. بسیاری از مریضان پرخاشگر هنگام مواجهه با یک تیم همکاری می کنند، بنابراین کمک بخواهید و در صورت لزوم به صورت گروهی به مریض نزدیک شوید. علایم حیاتی از جمله حرارت بدن و گلوکوز را بررسی کنید و تشوشات را تداوی کنید. زودتر برای کمک تماس بگیرید و رجعت دهی / انتقال را به یک مرکز طبی پیشرفته ترتیب دهید. سطح هوشیاری را با مقیاس UPVA بررسی و نظارت کنید: A هوشیار V به صدا پاسخ می دهد P به درد پاسخ می دهد U پاسخگو نیست UPVA توانمندی فرد در پاسخ به محرک ها را آزمایش می کند. فردی که نشه نیست و هیچ مریضی یا آسیبی روی مغزش اثر نمی گذارد، معمولا ًبدون اینکه از او خواسته شود، شعور دارد. مریضانی که فقط در صورت تحریک صدا یا درد به آنها پاسخ می دهند، نیاز به ارزیابی بیشتر سیستم عصبی دارند. [به مهارت ها مراجعه کنید] در تروما مقیاس کومای گلاسکو را بررسی کنید: مقیاس کوما گلاسکو را بررسی و نظارت کنید. [به مهارت ها مراجعه کنید] سطح گلوکوز خون را بررسی کنید: هایپوگلیسمیا میتواند باعث تغییر وضعیت ذهنی شود. کتواسیدوز دیابیتیک میتواند با هایپرگلیسمیا و تغییر وضعیت ذهنی ظاهر شود. کتاب دستور عملیات اشتراک کننده گان 731 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE حدقه های چشم را بررسی کنید: حدقه های بسیار کوچک و تنفس آهسته نشان دهنده مصرف بیش از حد مواد افیونی است. حدقه های بسیار بزرگ )گشاد شده( مصرف ادویه جات محرک را پیشنهاد می کنند. حدقه های نابرابر نشان دهنده افزایش فشار روی مغز است. سطح هوشیاری و آگاهی ها را معاینه کنید: اگر مریض شعور دارد و به صدا پاسخ می دهد، سؤالات ساده بپرسید )مثًلا: نام شما چیست؟ کجا هستید؟ ساعت چند است؟ چه روزی از هفته است؟(. صدمه یا اثر ضربه را معاینه کنید: هر مریض با وضعیت ذهنی تغییر یافته و سابقه یا شواهدی از صدمه باید به عنوان آسیب احتمالی سر در نظر گرفته شود - حتی اگر صدمه چند روز قبل از آن اتفاق افتاده باشد. کبودی اطراف چشم ها، پشت گوش ها یا نشت مایع شفاف از بینی یا گوش نشان دهنده آسیب سر همراه با شکستگی جمجمه است. درجه حرارت بدن را معاینه کنید: تب باید در مورد یک علت انتانی نگرانی ایجاد کند و تب با شخی گردن نشان دهنده انتان در داخل یا اطراف مغز است. مسمومیت ها، مصرف بیش از حد ادویه جات، ترک الکول و تغییرات در هورمون های بدن نیز می توانند همراه با تب ظاهر شوند. )aimrehtopyH( یا حرارت پایین بدن ممکن است نشان دهنده انتان، سطوح پایین هورمون بدن )به عنوان مثال، تیروئید( یا قرار گرفتن در معرض محیط های مرطوب یا سرد باشد. شخی گردن را معاینه کنید: )به خاطر داشته باشید، اگر به صدمه مشکوک هستید، گردن را حرکت ندهید(: سختی گردن نشان دهنده انتان )مننژیت( یا خونریزی در اطراف مغز است. اگر مشکوک به انتان هستید، هر فردی که با مریض در تماس است باید از ماسک استفاده کند. قدرت و حس را معاینه کنید: اگر مریض میتواند دستورات را انجام دهد، قدرت و احساس را در چهره، بازوها و پاها آزمایش کنید. ضعف یا از دست دادن حس در یک طرف حاکی از وجود کتله، خونریزی یا مسدود شدن رگ های خونی در مغز )سکته مغزی( است، اگرچه هایپوگلیسمی نیز می تواند به این شکل ظاهر شود. تغییر وضعیت ذهنی همراه با ضعف عمومی عضلی ممکن است نشان دهنده عدم تعادل نمک )الکترولیت( در خون باشد. علایم کم شدن مایعات بدن را معاینه کنید: کم آبی میتواند باعث تغییر وضعیت ذهنی شود. خشکی دهان و نیشگون )ُچندی( گرفتن غیر نارمل جلد را بررسی کنید. کم آبی بدن همچنین ممکن است نشان دهنده کتواسیدوز دیابیتیک باشد. شکم را معاینه کنید: جس کنید اگر کبد بزرگ و یا بطن حساس است. یک کبد قابل لمس یا حساس نشان دهنده مریضی کبدی است. قلووم5عم:1 لدومعل تبدضمدبل رمBمدددمدلدوم 831 جلد را معاینه کنید: جلد سرد، رنگ پریده و مرطوب نشان دهنده شاک یا هایپوگلیسمی است. زردی جلد )یرقان( نشان دهنده مریضی کبدی است. کبودی نشان دهنده ضربه است. خال های جلدی میتواند نشان دهنده انتان سیستمیک باشد. نیش و خراشیدگی را بررسی کنید. نظارت بر تغییرات در وضعیت روانی: افرادی که در ابتدا سردرگم هستند و بدون تداوی به سرعت به حالت عادی باز می گردند، ممکن است دچار تشنج/اختلاج یا ضربه به سر شده باشند. افراد با وضعیت ذهنی تغییر یافته نیاز به نظارت دقیق دارند تا مطمئن شوید که دوباره بدتر نمی شوند. )این میتواند در مریضانی که شکر خون پایین یا ضربه به سر دارند اتفاق بیفتد(. سوال شماره 2 کتاب تمرین: وضعیت ذهنی تغییر یافته با استفاده از بخش کتاب تمرین بالا، پنج یافته معاینه ثانوی را که باید در یک مریض با وضعیت ذهنی تغییریافته بررسی کنید، لست کنید. 1. 2. 3. 4. ۵. کتاب دستور عملیات اشتراک کننده گان 931 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE علل احتمالی تغییر وضعیت شعوری علل به سرعت قابل برگشت حالت اعراض و علایم احساس گرمی )عرق کردن( تشنج/اختلاج گلوکوز خون < 5.3 L/lomm سابقه دیابت، مالاریا یا مریضی شدید به ویژه در کودکان وضعیت ذهنی به سرعت با گلوکوز بهبود می یابد هایپوگلایسیمیا علایم اروا ضعیف نیشگون )ُچندی( گرفتن غیر نارمل جلد کاهش توانائی نوشیدن مایعات، یا از دست دادن مایعات غشاهای مخاطی خشک دیهایدریشن شدید قرار گرفتن طولانی مدت در معرض گرما و آفتاب حرارت بدن بالا، جلد بسیار گرم ممکن است عرق کند یا خیر گرمازدگی نفس تنگی سطوح پایین آکسیجن خون سیانوز یا کبودی کمبود آکسیجن انتان حالت اعراض و علایم تب تست سریع مالاریا یا اسمیر مثبت منطقه که ملاریا در آن موجود باشد. مالاریا دماغی تب شخی گردن دانه های جلدی درد چشم با نگاه کردن به نور/حساسیت به نور سردردی اپیدمی یا قرار گرفتن در معرض انتان شناخته شده سابقه انتان VIH یا توبرکلوز التهاب/انتان اطراف مغز (مننژیت، آنسفالیت، آبسه مغزی، خونریزی) تب ضربان قلب سریع تنفس سریع ممکن است فشار خون پایین داشته باشد علایم انتان: انتان قابل مشاهده در جلد، سرفه و کرکل در یک ناحیه از ریه ها )اغلب با تنفس سریع(، سوزش همراه با ادرار یا ادرار مکدر یا تیره همراه با تب انتان شدید حالت اعراض و علایم تحریک یا اضطراب ترس از نوشیدن )هیدروفوبیا( ریزش آب دهان ضعیفی تاریخچه حیوان گزیدگی ربیس (ویروس سگ دیوانه) قلووم5عم:1 لدومعل تبدضمدبل رمBمدددمدلدوم 041 میتابولیک حالت اعراض و علایم سابقه دیابت تنفس سریع یا عمیق تکرر ادرار نفس بوی شیرین گلوکوز بالا در خون یا ادرار ضیاع مایعات بدن دیابیتیک کیتو اسیدوزس توکسیک حالت اعراض و علایم مصرف شناخته شده الکول یا مواد مخدر علایم تزریق، ادویه جاتی که روی مریضان یافت می شود الکول – نفس بوی الکول می دهد، صورت سرخ شده است مستی حاد )نشه( ترک )تشنج، گیجی، ضربان سریع )aidracyhcaT( استفاده مزمن )مشکلات تعادل، سردرگمی( مواد افیونی: مستی حاد )بی حالی، حدقه های بسیار کوچک و تنفس آهسته( قطع مصرف )بی قراری، تعرق، اسهال، استفراغ( سایر ادویه جات ممکن است باعث بزرگ شدن حدقه چشم، بیقراری، تعرق، تب شوند مسمومیت یا ترک الکول یا مواد مخدر تاریخچه قرار گرفتن در معرض حدقه های بسیار کوچک اسهال استفراغ تعرق بیش از حد مسمومیت با حشره کش ها تاریخچه مارگزیدگی آثار گزش در محیطی با مارهای سمی اذیما )پندیدگی( آبله کردن جلد کبودی پایین بودنفشار خون فلج تشنج خونریزی از زخم مار گزیده گی عکس العمل دوایی ادویه جاتی جدید یا تغییر اخیر در مقدار تجویز شده یا مشکل دوز سابقه مطابق با قرار گرفتن در معرض احتمالی مصاب شدن افراد متعدد با علایم آن سردرد مسمومیت با گاز کتاب دستور عملیات اشتراک کننده گان 141 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE علل دیگر حالت اعراض و علایم سابقه شناخته شده تشنج/اختلاج زبان گاز گرفته عدم کنترول ادرار بهبود تدریجی در طی چند دقیقه یا چند ساعت اگر مریض حامله است، اکلامپسیاا را در نظر بگیرید تشنج / اختلاج سردردی تشنج/اختلاج تهوع، استفراغ حدقه های غیر متناظر ضعف در یک طرف بدن یا مشکلات گفتاری افزایش فشار روی مغز (صدمه، تومور، خونریزی یا پندیدگی مغز) سابقه سوء استفاده الکول یا مریضی کبدی بزرگ شدن شکم با بازوهای نازک، رنگ زرد در جلد و چشم )یرقان(، یا هایپوکلایسیمی مریضی کبد فشار خون بالا اذیما )پندیدگی( یا پندیدگی در پاها کاهش یا عدم ادرار در صورت شدید بودن مریضی کلیوی از دست دادن بینایی و حافظه، استفراغ، سردرد سابقه صدمهی اخیر پارگی جلد سر و/یا سوشکل جمجمه کبودی در سر )به ویژه در اطراف چشم یا پشت گوش( خون یا مایع شفاف که از بینی یا گوش می آید غیر متناظر بودن حدقه ها یا ضعف در یک طرف بدن تشنج/اختلاج ضربه به سر ملاحظات اضافی در کودکان حالت اعراض و علایم در کودکان کوچکتر شایع است سابقه مصرف ادویه جات یا مواد یافت شده در اطراف کودک مصرف مواد کیمیاوی و سمی قلووم5عم:1 لدومعل تبدضمدبل رمBمدددمدلدوم 241 سوال شماره 3 کتاب تمرین: تغیر وضعیت ذهنی با استفاده از بخش کتاب تمرین بالا، علت احتمالی تغییر وضعیت روانی را از تاریخچه و یافته های فیزیکی زیر فهرست کنید. علت احتمالیتاریخچه و دریافت های فزیکی دختری ۵1 ساله با تغییر وضعیت روانی، تب و: شخی گردن درد چشم هنگام نگاه کردن به نور سردردی یک مرد ۵4 ساله با وضعیت ذهنی تغییر یافته، و تنفس عمیق و سریع و: تکرر ادرار نفس میوه مانند گلوکوز بالا در خون یا ادرار کم آبی بدن انجام دادن : مدیریت ابتدا ارزیابی EDCBA را انجام دهید و برای شرایط تهدید کننده زندگی مداخله کنید. توجه: اگر راه تنفسی باز است و شواهدی از صدمه وجود ندارد، مریض را در وضعیت ریکوری قرار دهید تا از ورود مایع یا استفراغ در ریه ها جلوگیری شود. [به مهارت ها مراجعه کنید] حالت ملاحظات مدیریت کمبود آکسیجن اکسیجن بدهید به تعقیب علت احتمالی باشید. [به مهارت ها مراجعه کنید] هایپوگلایسیمیا با گلوکوز تداوی کنید. [به مهارت ها مراجعه کنید] اگر نگران کتواسیدوز دیابیتیک هستید، با مایعات وریدی تداوی کنید. [به مهارت ها مراجعه کنید] وضعیت یک فرد مبتلا به دیابیتیک کتواسیدوز به شدت وخیم است و نیاز به انتقال سریع به مرکزی دارد که در آن انفوزیون وریدی و نظارت دقیق در دسترس است. هایپرگلیسمیا انتی بیوتیک را شروع کنید. انتان های شدید ممکن است نیاز به تداوی توسط یک مرکز طبی پیشرفته داشته باشد. شامل آزمایش و تداوی مالاریا در مناطق آندمیک باشد. مسمومیت را نیز در نظر بگیرید. تب بالا را با پاراستامول تداوی کنید. [به مهارت ها مراجعه کنید] برای افزایش شدید حرارت بدن، با آب خنک اسپری کنید، پکه کنید و مایعات وریدی بدهید. از لرزیدن جلوگیری کنید. تب (هیپرترمی) با تغییر وضعیت ذهنی (aimrehtopyH) به محیط گرم بروید، لباس های تر را بردارید، با پتو گرم کنید و مایعات گرم وریدی تجویز کنید. حرارت پایین بدن کتاب دستور عملیات اشتراک کننده گان 341 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE حالت ملاحظات مدیریت اگر ضربه ای وارد نشده، سر تخت را تا 03 درجه بالا ببرید. اگر مشکوک به صدمه باشد، از بیحرکتی ستون فقرات اطمینان حاصل کنید. [به مهارت ها مراجعه کنید] خونریزی یا سایر دلایل افزایش فشار داخل قحفی نالوگزان را تجویز کنید. [به مهارت ها مراجعه کنید] اثرات نالوگزان تقریبا ً1 ساعت طول می کشد. بیشتر اپیوئیدها دوام بیشتری دارند و مریضان ممکن است به تکرار دوز نالوگزان نیاز داشته باشند. این را هنگام برنامه ریزی مراقبت مداوم در نظر بگیرید و فرد را مرتبا ًارزیابی کنید. استفاده بیش از حد تریاک با بنزودیازپین تداوی کنید و فرد را از نزدیک تحت نظر بگیرید تا تنفس کند و حالت تنفسی را بررسی کنید. گلوکوز را چک کنید یا اگر قادر به بررسی نیستید گلوکوز بدهید. در صورت عدم شک به صدمه، مریض را در وضعیت بهبودی قرار دهید. [به مهارت ها مراجعه کنید] اگر مریض همچنان به تشنج ادامه میدهد یا بین حملات بیدار نمیشود، ترتیب انتقال سریع را به یک مرکز پیشرفته مهیا ساخته و طرق هوایی را کنترول کنید. تشنج / اختلاج فعال این میتواند اکلامپسیاا باشد. ترتیب انتقال/رجعت دهی سریع به یک واحد تخصصی و دادن مگنیزیم سولفات. مریض را از نظر علایم مسمومیت از نزدیک تحت نظر بگیرید. [به مهارت ها مراجعه کنید] اگر هر یک از این موارد رخ داد، از دادن دوز اضافی مگنیزیم خودداری کنید. حامله با تشنج/اختلاج فعال همیشه گلوکوز را چک کنید و در صورت نیاز گلوگوز بدهید. ترک کننده ها را با بنزودیازپین تداوی کنید. [به مهارت ها مراجعه کنید] طرق هوایی را به دقت کنترول کنید. ترک الکول سعی کنید سم را شناسایی کنید و برای تداوی های خاص به یک کمک کننده پیشرفته مراجعه کنید. در صورت مسمومیت با حشره کش، مطمئن شوید که مریض از سم پاک شده است و طرق هوایی را به دقت کنترول کنید زیرا ترشحات می توانند باعث انسداد )بندش( شوند. گزیدن مار باید همانطور که در بخش «مدیریت زخم» توضیح داده شده است، تداوی شود. مسمومیت تداوی خاصی برای ربیس وجود ندارد. ربیس در صورت بروز اعراض و علایم تقریبا ًهمیشه کشنده است. برای مدیریت زخم مشکوک ناشی از نیش حیوان، به صدمه مراجعه کنید. ربیس (وایرس سگ دیوانه) از مریض در برابر آسیب رساندن به خود یا دیگران محافظت کنید. اطمینان حاصل کنید که کارکنان یک مسیر خروجی صاف دارند )مریض را بین کارکنان و دروازه قرار ندهید(. سلاح های احتمالی و اشیاء ناامن را دور کنید. در صورت نیاز از همکاران، اعضای خانواده و امنیت تماس بگیرید. با لحن آرام، نرم و بدون تهدید صحبت کنید. توضیح دهید که در هر مرحله از مراقبت چه اتفاقی می افتد. مقابله و قضاوت نکنید. علل دیگر را در نظر بگیرید: گلوکوز و علایم حیاتی از جمله حرارت بدن و اشباع اکسیجن را بررسی کنید. حالات غیر نارمل را تحت نظر گرفته و تداوی کنید. برای رجعت دهی / حمل و نقل ایمن به مرکز طبی پیشرفته ترتیب دهید. مریض خشن یا بسیار آشفته مقیاس کومای گلاسکو را ارزیابی کنید، ستون فقرات را بی حرکت کنید و علایم افزایش فشار داخل قحفی را ارزیابی کنید. [به مهارت ها مراجعه کنید] صدمه قلووم5عم:1 لدومعل تبدضمدبل رمBمدددمدلدوم 441 ملاحظات خاص مدیریت تشنج های فعال EDCBA را ارزیابی کنید. باز بودن طرق هوایی را حفظ کنید – چیزی در دهان قرار ندهید. در صورت نگرانی از کمبود آکسیجن یا تشنج/اختلاج طولانی مدت اکسیجن بدهید. در صورت امکان مریض را در پهلو قرار دهید. از مریض در برابر آسیب بیشتر محافظت کنید. گلوکوز را چک کنید یا گلوکوز بدهید )اگر قادر به معاینه نیستید(. یک بنزودیازپین بدهید. در صورت بارداری و تشنج، مگنیزیم سلفیت بدهید. در صورت عدم پاسخ، دوز دیگری از بنزودیازپین بدهید )در صورت نیاز سه بار تکرار کنید( و فشار خون پایین و تنفس آهسته را کنترول کنید. اگر مریض در فاصله بین تشنج/اختلاج از خواب بیدار نشد، این وضعیت را تهدید کننده زندگی در نظر بگیرید. ترتیب انتقال/ رجعت دهی سریع به یک مرکز طبی پیشرفته را بدهید. اگر تشنج/اختلاج متوقف شد، مریض را در وضعیت بهبودی قرار دهید و از نزدیک نظارت کنید. سوال 4 کتاب تمرین: وضعیت ذهنی تغییر یافته با استفاده از بخش کتاب تمرین بالا، لیستی را که برای مدیریت این مریضان انجام می دهید را فهرست کنید. مدیریتحالت یک کودک 3 ساله با تغییر وضعیت ذهنی و گلوکوز 1.خون 2 میلی مول در لیتر مراجعه می کند. یک زن ۵2 ساله با حرکات تند وارد می شود و شما 1.مشکوک به تشنج یا اختلاج فعال هستید. 2. 3. مردی 0۵ ساله به تعقیب سقوط از پشت بام به داخل خانه آورده شد. او سردردی دارد و وضعیت ذهنی او تغییر یافته است. 1. 2. کتاب دستور عملیات اشتراک کننده گان 541 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE ملاحظات خاص در کودکان کودکان با وضعیت ذهنی تغییر یافته ممکن است علایم به ظاهر خفیف مانند خواب بیش از حد معمول یا کمتر تعاملی داشته باشند. ابتدا EDCBA را مدیریت کنید و سپس دلایل تغییر وضعیت ذهنی را جستجو و مدیریت کنید. به یاد داشته باشید که کودکان بسیار مریض یا آسیب دیده ممکن است علایم حیاتی طبیعی داشته باشند تا زمانی که به سرعت وخیم شوند. هایپوگلایسیمی اغلب در کودکان شدیدا ًمریض رخ می دهد و یکی از علل شایع تغییر وضعیت روانی در کودکان است. در هر کودکی که وضعیت ذهنی تغییر یافته دارد، شکر خون را چک کنید )یا اگر قادر به بررسی آن نیستید، گلوکوز بدهید(. کمبود آکسیجن میتواند در نتیجه بسیاری از شرایط، از جمله انتان های تنفسی و شاک رخ دهد. کمبود آکسیجن هنگام تولد در نوزادان مورد توجه است. حرارت بلند بدن (aimrehtrepyH) با تغییر وضعیت ذهنی نشان دهنده انتان است، اما میتواند با قرار گرفتن در معرض حرارت زیاد، ورزش، تشنج/اختلاج، عدم تعادل هورمونی و بعضی ادویه جات و تسمم نیز دیده شود. (aimrehtopyH) یا حرارت پایین بدن با تغییر وضعیت ذهنی نیز میتواند نشان دهنده انتان باشد، به ویژه در نوزادان، اما میتواند به دلیل مسمومیت با ادویه، قرار گرفتن در معرض سرما یا عدم تعادل هورمونی باشد. نوزادان خردسال بیشتر تحت تأثیر تغییرات دما هستند. کودک را با استفاده از پتو و کلاه برای جلوگیری از اتلاف گرما و استفاده از تماس جلد با جلد )که «مراقبت کانگورویی» نیز نامیده میشود( با یکی از اعضای خانواده در 42 ساعت در روز گرم نگه دارید. تشنج/اختلاج میتواند تنها به دلیل تب باشد، اما )مانند بزرگسالان( همچنین میتواند نشان دهنده انتان، هایپوگلایسیمی یا هیپوناترمی )کاهش سدیم( باشد. مصرف انتی بیوتیک در مریضان مشکوک به انتان باکتریایی جدی را به تاخیر نیندازید. همیشه صدمه و یا تروما را در نظر بگیرید. انتان در داخل یا اطراف مغز میتواند باعث تغییر وضعیت ذهنی شود. به تعقیب فونتانل برآمده یا پندیدگی )در یک کودک زیر سن 1 سال، باشید( و یا به تعقیب دانه های سرخ جلدی در پاها و پایین شکم باشید که میتواند نشان دهنده انتان یا افزایش فشار روی مغز باشد. مصرف انتی بیوتیک در کودکان مشکوک به انتان باکتریایی جدی را به تاخیر نیندازید. اروا ضعیف میتواند باعث تغییر وضعیت ذهنی شود. کودکان ممکن است خیلی سریع دچار کم آبی شوند. علایم کم آبی بدن را بررسی کنید: نیشگون )ُچندی( گرفتن غیرطبیعی جلد، خشکی غشاهای مخاطی )قسمت صورتی و داخلی دهان(، تحریک پذیری، فونتانل فرورفته یا فشرده )در کودک زیر 1 سال(، پر کردن آهسته عروق شعریه )بیش از 3 ثانیه(، سردی اندام ها، ضربان سریع قلب و فشار خون پایین. مایعات وریدی بدهید و مرتبا ارزیابی مجدد کنید. [به مهارت ها مراجعه کنید] ellenatnof gnigluB ellenatnof talF 13 egap فوتانیل وسیع فوتانیل برامده قلووم5عم:1 لدومعل تبدضمدبل رمBمدددمدلدوم 641 مالاریا ممکن است در کودکان شدیدتر از بزرگسالان باشد. کودکان مبتلا به مالاریا شدید ممکن است با کم خونی شدید، تشنج/اختلاج، کوما و رهایپوگلایسیمی ظاهر شوند. مصرف مواد کیمیاوی یا ادویه در کودکان رایج است. سعی کنید سم را شناسایی کنید )با والدین صحبت کنید( و سعی کنید از بسته عکس بگیرید. برای مدیریت فورا ًبا مرکز صحی پیشرفته مشورت کنید. بلع مواد سمی بدون شاهد را در کودکان زیر 6 سال (مخصوصا ً1 تا 3 سال) در نظر بگیرید: در مورد اعراض و علایم وابسته به ماده مصرف شده سوال کنید. یک تاریخچه کامل از خانواده بگیرید. بوتل های ماده یا ادویهی بلعیده شده را بررسی کنید. تعیین کنید چه زمانی اتفاق افتاده است. اطمینان حاصل کنید که هیچ کودک دیگری درگیر نبوده است. علایم سوختگی داخل یا اطراف دهان را بررسی کنید استریدور )صداهای با صدای بلند( را بررسی کنید که حاکی از بلعیدن مواد شیمیایی است که باعث سوختگی یا آسیب رساندن به طرق هوایی و ایجاد پندیدگی می شود. کودکانی که ادویه جات یا مواد شیمیایی مصرف می کنند باید به دقت تحت نظر باشند و ممکن است برای مدیریت بیشتر به یک واحد مجهز انتقال شوند. سوال ۵ کتاب تمرین: وضعیت ذهنی تغییر یافته با استفاده از بخش کتاب تمرین بالا، به سؤالات زیر در مورد وضعیت ذهنی تغییر یافته در کودکان پاسخ دهید: انتان مغزی کودک را چگونه ارزیابی می کنید؟ چرا هایپوگلایسیمی در کودکان شدیدا ًمریض اتفاق می افتد؟ تشنج / اختلاج در کودکان خردسال میتواند نشانه چه باشد؟ کتاب دستور عملیات اشتراک کننده گان 741 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE ملاحظات مرحله بعدی (دیسپوزیشن ) در مواظبت مراحل بعدی انتقال به علت تغییر وضعیت ذهنی بستگی دارد. علل تغییر وضعیت روانی که به سرعت قابل اصلاح نیستند یا ممکن است پس از از بین رفتن تاثیر ادویه جات عود کنند، نیاز به مدیریت در شفاخانه دارند. هر مریض با وضعیت ذهنی تغییر یافته باید از نظر مشکلات طرق هوایی، به دقت تحت نظر باشد. رجعت دهی/انتقال به یک مرکز طبی با قابلیت های پیشرفته طرق هوایی را در نظر بگیرید. اگر علت بنیادی پایین بودن گلوکوز خون شناسایی و تداوی نشود، مریضان مبتلا به هایپوگلایسیمی که با گلوکوز بهبود یافته اند ممکن است دوباره به گلوکوز خون پایین مبتلا شوند و ممکن است به تکرار تداوی نیاز داشته باشند. این مریضان نیاز به نظارت دقیق دارند. اثرات نالوکسون )عامل معکوس کننده مواد افیونی( فقط تقریبا ً1 ساعت باقی می ماند. بسیاری از ادویه جاتی اپیوئیدی اثر طولانی تری دارند و ممکن است برای معکوس کردن اثرات مواد افیونی به دوزهای بیشتری از نالوگزان نیاز داشته باشند. هر مریض تحت تداوی با نالوگزان باید به دقت تحت نظر باشد. اطمینان حاصل کنید که عرضه کننده خدمات صحی بعدی می داند که به مریض نالوگزان داده شده است و ممکن است به دوزهای اضافی نیاز داشته باشد. سناریوهای قضیه ها تحت رهبری تسهیلگر و یا استاد رهنما این سناریوها در گروپ های کوچک کار خواهد شد. یک شرکت کننده به عنوان رهنما شناخته میشود و مورد ارزیابی قرار می گیرد، در حالی که بقیه گروپ پاسخ ها را در کتاب تمرین می نویسند. برای تکمیل یک سناریوی موردی، گروپ باید یافته های حیاتی و مدیریت مورد نیاز را شناسایی کند و خلاصه ای یک خطی برای رجعت دهی، شامل دریافت های ارزیابی و مداخلات میباشد. هنگام ارزیابی باید از کارت سریع برای این سناریوها استفاده کنید. مورد شماره 1: بزرگسال با وضعیت ذهنی تغییر یافته مرد 24 ساله ای را پس از اینکه در یک ملی بس در حال افتیده پیدا کردند، به داخل آوردند. وقتی اطرافیان به سمت او رفتند او بیدار بود اما بسیار گیج بود. آنها او را نمی شناسند، اما چون خیلی گیج است او را برای مراقبت نزد شما آوردند. 1. در عملکرد اولیه خود چه کاری باید انجام دهید؟ 2. از روش EDCBA برای ارزیابی و مدیریت این مریض استفاده کنید. از تسهیل کننده در مورد یافته های کلینیکی به وسیله چشم،گوش و لمس را بپرسید. در صورت لزوم از کارت های سریع برای رجعت استفاده کنید. قلووم5عم:1 لدومعل تبدضمدبل رمBمدددمدلدوم 841 مداخلات برای انجام: آیا نیاز مداخله است؟یافته ها ارزیابی نخیر بلی طرق تنفسی نخیربلیتنفس نخیربلیدوران خون نخیربلیناتوانی نخیربلیدر معرض قرار گرفتن 3. یک جمله را برای خلاصه کردن این مریض برای رجعت دهی نوشته کنید. مورد شماره 2: مریض کودک با وضعیت ذهنی تغییر یافته مادری پس از اینکه امروز دو بار طفل او تشنج / اختلاج داشت، فرزند 3 ساله خود را برای ارزیابی نزد شما می آورد. کودک در چند کمپل پیچیده شده است. این مادر بیان می کند که کودک در 2 روز گذشته به طور فزاینده ای گیج شده و تب های بالایی داشته است. 1. در عملکرد اولیه خود چه کاری باید انجام دهید؟ 2. از روش EDCBA برای ارزیابی و مدیریت این مریض استفاده کنید. از تسهیل کننده در مورد یافته های کلینیکی به وسیله چشم، گوش و لمس بپرسید. در صورت لزوم از کارت سریع برای مرجع استفاده کنید. مداخلات برای انجام: آیا نیاز مداخله است؟یافته ها ارزیابی نخیر بلی طرق تنفسی نخیربلیتنفس نخیربلیدوران خون نخیربلیناتوانی نخیربلیدر معرض قرار گرفتن کتاب دستور عملیات اشتراک کننده گان 941 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE 3. یک جمله را برای خلاصه کردن این مریض برای رجعت دهی نوشته کنید. سوالات چند گزینه ای به سوالات زیر پاسخ دهید. پرسش و پاسخ در جلسه مورد بحث قرار خواهد گرفت. 1. شما در حال ارزیابی EDCBA روی پسر 4 ساله ای هستید که تب و سرفه دارد. او به شما پاسخ نمی دهد که نامش را صدا بزنید، اما اگر کف پایش را نیشگون )ُچندی( بگیرید، ناله می کند. سطح او در مقیاس UPVA چقدر است؟ A. هشدار B. کلامی C. درد D. پاسخگو نیست 2. یک مرد 73 ساله توسط همسرش با تب و گیجی وارد می شود. او می گوید از زمان شروع تب از 3 روز پیش، او بسیار گیج شده است. هیچ ضربه ای وارد نشده است. در معاینه متوجه می شوید که گردن او شخ شده است. علت احتمالی تغییر وضعیت روانی او چیست؟ A. نومونیا )سینه وبغل( B. انتان اطراف مغز C. سکته مغزی D. مصرف مواد مخدر 3. مردی 64 ساله برای چک کردن فشار خون وارد می شود. علایم حیاتی وی عبارتند از: فشار خون 061/09، ضربان قلب 021، تعداد تنفس 81 و گلوکوز خون 5 میلی مول در لیتر. در حالی که شما او را معاینه می کنید تشنج / اختلاج دارد. چه تداویی باید انجام دهید؟ A. بنزودیازپین B. گلوکوز C. انتی بیوتیک ها D. نالوگزان 4. یک زن باردار در هفته 63 تشنج / اختلاج دارد. او اخیرا ًسابقه فشار خون بالا نیز دارد. چه تداویی باید انجام دهید؟ A. مگنیزیم سلفایت B. گلوکوز C. نیتروگلیسیرین D. هیچی، تشنج/اختلاج به خودی خود متوقف می شود قلووم5عم:1 لدومعل تبدضمدبل رمBمدددمدلدوم 051 5. شما در حال ارزیابی یک نوزاد 6 ماهه هستید و یک فونتانل فرورفته پیدا می کنید. این یافته معاینه فیزیکی چه چیزی را نشان می دهد؟ A. انتان در مغز B. کم آبی بدن C. نومونیا یا سینه و بغل D. رهایپوگلایسیمی 151 یادداشت
351 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE کولبمو ول م:1 دل م1دتر1 مکللدهمگلن مراقبت های اولیه عاجل سازمان جهانی صحت OHW (مهارتها)
کتاب دستور عملیات اشتراک کننده گان 551 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE فهرست مطالب: مهارت 1. بخش مهارت طرق هوایی: مودل EDCBA مرجع کتاب تمرین ............................................... ۷۵1 بخش مهارت طرق هوایی: مانورهای اساسی طرق هوایی................................................................................ 751 • باز کردن طرق هوایی: کج کردن سر بزرگسالان و لیفت چانه................................................................... 751 • باز کردن طرق هوایی: شیب سر و چانه برای کودکان................................................................................. 751 • باز کردن طرق هوایی: بلند کردن الاشه بزرگسالان و کودکان .................................................................. 851 بخش مهارت طرق هوایی: مانورهای اساسی طرق هوایی................................................................................ 951 بخش مهارت طرق هوایی: سکشن طرق هوایی............................................................................................... 161 بخش مهارت طرق هوایی: قرار دادن دستگاه اصلی طرق هوایی.................................................................. 161 ارزیابی بخش مهارت طرق هوایی.......................................................................................................................... 261 2. بخش های مهارت تنفس گرفتن ............................................................................................... ۵61 بخش مهارت تنفس گرفتن: معاینه فزیکی سیستم تنفسی........................................................................... 561 بخش مهارت های تنفسی: دادن اکسیجن تکمیلی ......................................................................................... 561 بخش مهارت های تنفسی: وینتلیشن یا تهویه ماسک بیگ والو EVLAV-GAB .................................. 661 بخش مهارت تنفس: رفع فشار عاجل توسط سوزن......................................................................................... 761 بخش مهارت تنفس: مدیریت نوموتوراکس باز )مکیدن زخم قفس سینه(.............................................. 861 بخش مهارت تنفس گرفتن: چگونه از یک بوتل پلاستیکی جداکننده بسازیم ........................................ 861 ارزیابی بخش مهارت های تنفسی ....................................................................................................................... 961 3. بخش های مهارت دوران خون.................................................................................................. 2۷1 بخش مهارت دوران خون: معاینه دوران خون .................................................................................................. 271 معاینه بخش مهارت دوران خون: کنترول خونریزی خارجی......................................................................... 271 • فشار مستقیم برای خونریزی خارجی.............................................................................................................. 271 • بسته بندی زخم عمیق برای خونریزی خارجی............................................................................................. 371 • تخنیک تورنیکیت برای خونریزی خارجی کنترول نشده ............................................................................ 371 مهارت دوران خون: ماساژ رحم برای خونریزی پس از ولادت........................................................................ 471 مهارت دوران خون: کنول زدن وریدی............................................................................................................... 671 • قرار دادن کنول وریدی )بزرگسال( .................................................................................................................. 671 • قرار دادن کانول وریدی )اطفال(....................................................................................................................... 771 مهارت دوران خون: مایعات وریدی – تنظیم حجم مایع برای شرایط خاص.............................................. 871 مهارت های کنترول دوران خون: مایعات وریدی – تجویز.............................................................................. 181 مهارت های مرتبط به ارزیابی دوران خون .......................................................................................................... 281 دود ضمقبلاطعمقول 651 4. بخش های مهارت معاینه عمومی بدن: ................................................................................... ۷81 بخش مهارتی معاینه فیزیکی سر تا پا: معاینه اعصاب..................................................................................... 781 • مقیاس کوما گلاسکو )SCG(............................................................................................................................. 781 • محاسبه نمره کوما گلاسکو )SCG( ................................................................................................................. 781 • اندازه گیری UPVA........................................................................................................................................... 781 بخش مهارتی ارزیابی معاینه فزیکی سر تا پا: ارزیابی ثانوی صدمه.............................................................. 881 ارزیابی بخش مهارت معاینه فیزیکی گسترده ................................................................................................... 881 ۵ . مهارت های مرتبط به بی حرکت کردن .................................................................................... 091 عملکرد بی حرکت ساختن ستون فقرات............................................................................................................. 091 بخش مهارت بی حرکتی: بی حرکتی ستون فقرات گردنی .............................................................................. 091 بخش مهارت بی حرکت کردن : LLOR GOL .............................................................................................. 191 بخش مهارت بی حرکتی: بی حرکتی کامل ستون فقرات................................................................................. 291 بخش مهارت بی حرکتی: طرز وضعیت دادن مریض باردار............................................................................ 291 بخش مهارت بی حرکتی: وضعیت ریکاوری ...................................................................................................... 391 بخش مهارت بی حرکتی: بی حرکتی شکستگی................................................................................................. 491 • غیر متحرک ساختن شکستگی ....................................................................................................................... 491 • بی حرکت ساختن شکستگی: باز...................................................................................................................... 591 بخش مهارت بی حرکتی: استفاده از بنداژ لگن خاصره .................................................................................. 591 ارزیابی بخش مهارت بی حرکتی.......................................................................................................................... 691 6 . بخش های مهارت مدیریت زخم .............................................................................................. 991 مدیریت زخم: مدیریت عمومی زخم..................................................................................................................... 991 مدیریت زخم: مدیریت سوختگی .......................................................................................................................... 991 • مدیریت سوختگی بزرگسالان: تعیین سطح کل بدن )ASBT( ............................................................... 002 • مدیریت سوختگی در اطفال: سطح تمام بدن را تعین کنید. .................................................................... 102 • مدیریت سوختگی: عمق سوختگی را تخمین کنید: .................................................................................... 102 مدیریت سوختگی: احیای مایعات در آسیب سوختگی..................................................................................... 102 مدیریت زخم: بنداژ و بی حرکت کردن گزیدن مار........................................................................................... 202 ارزیابی بخش مهارت مدیریت زخم ..................................................................................................................... 302 ۷. بحث مهارت تجویز و تطبیق ادویه........................................................................................... ۵02 8. بحث مهارت های انتقال و واگذاری ........................................................................................... 902 کتاب دستور عملیات اشتراک کننده گان 751 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE مهارت بخش های مهارتی به گونه ای طراحی شده اند که به شما امکان این را میدهد که مهارت های جدید را تمرین کرده و تکنیک های نجات جان را به نمایش بگذارید. به یاد داشته باشید... همیشه قبل از مراقبت از مریض و انجام هر مهارتی از تجهیزات حفاظتی مناسب استفاده کنید. 1 بخش مهارت طرق هوایی: مودل EDCBA مرجع کتاب تمرین بخش مهارت طرق هوایی: مانورهای اساسی طرق هوایی باز کردن طرق هوایی: کج کردن سر بزرگسالان و لیفت چانه برای مریضان با وضعیت ذهنی تغییر یافته که ممکن است قادر به محافظت از طرق هوایی نباشند، بدون تاریخچه صدمه استفاده شود: فرد را رو به بالا روی سطح هموار و سخت قرار دهید. با یک دست سر را به عقب خم کنید و با انگشتان خود چانه و یا زنخ را بالا بیاورید. برای این کار یک دست را روی پیشانی مریض قرار دهید و سپس دو انگشت دست دیگر را روی قسمت استخوانی الاشه قرار دهید. دستان خود را بچرخانید، چانه را به سمت بالا از قفس سینه خم کنید. اجسام خارجی را در صورت مشاهده بردارید. در صورت نیاز از سکشن برای خارج کردن مایعات یا ترشحات از طرق هوایی استفاده کنید. طرق هوایی را باز نگه دارید - اجازه ندهید سر به سمت عقب بیفتد زیرا این کار باعث بسته شدن طرق هوایی می شود. باز کردن طرق هوایی: شیب سر و چانه برای کودکان برای استفاده در مریضان با وضعیت ذهنی تغییر یافته که ممکن است قادر به محافظت از طرق هوایی نباشند، بدون سابقه صدمه: به یاد داشته باشید که سر کودکان در مقایسه با اندازه بدن بزرگتر از سر بزرگسالان است و راه های هوایی آنها نرم تر است و در صورت خم شدن گردن راحت تر مسدود می شود. در کودکان بزرگتر، طرق هوایی را می توان با کمی کج کردن سر به عقب باز کرد )شکل را ببینید(. نوزادان نسبت به اندازه بدنشان بزرگترین سر را دارند. سر آنها باید در وضعیت )بو کردن( قرار گیرد )شکل را ببینید(. دهان را بازرسی کنید و اجسام خارجی قابل مشاهده را بردارید. مراقب باشید جسم خارجی را به عمق طرق هوایی فشار ندهید. tfil-nihc dna tlit-daeh tludA 1 egap کج کردن سر بزرگسالان و بلند کردن چانه قول 851 برای خارج کردن مایعات یا ترشحات از طرق هوایی از سکشن استفاده کنید. سر را مانند زیر در موقعیتی نگه دارید تا طرق هوایی باز بماند. باز کردن طرق هوایی: بلند کردن الاشه بزرگسالان و کودکان هنگامی که مریض وضعیت ذهنی تغییر داده است و ممکن است نتواند از طرق هوایی محافظت کند و سابقه صدمه و یا تروما وجود دارد استفاده شود (شکستگی ستون فقرات گردنی ممکن است): از یک همکار بخواهید که ستون فقرات گردنی را در حین انجام پروسیجر بی حرکت کند. [به مهارت ها مراجعه کنید] انگشتان دست را پشت زاویه الاشه پایین )منحنی روی استخوان الاشه ( در دو طرف الاشه قرار دهید و به سمت بالا فشار دهید تا الاشه پایین حرکت کند. سر و گردن نباید حرکت کنند. دهان را معاینه کنید و اجسام خارجی را در صورت مشاهده خارج کنید. در صورت نیاز از سکشن برای خارج کردن مایعات یا ترشحات از طرق هوایی استفاده کنید. الاشه را در جای خود نگه دارید تا طرق هوایی باز بماند – اجازه ندهید الاشه عقب بیفتد زیرا این کار باعث بسته شدن طرق هوایی می شود. وضعیت نیوترل در کودکان بالا کردن الاشه در اطفال بالا کردن الاشه در بزرگ سالان نشیب سر و بالا کردن زنخ در کودکان )بدون تروما( )amuart on( nerdlihc ni tfil-nihc dna tlit-daeH 3 egap stnafni ni noitisop lartueN 2 egap 20_ deifidoM tsurht waj cirtaideP A_4 egap کتاب دستور عملیات اشتراک کننده گان 951 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE بخش مهارت طرق هوایی: مانورهای اساسی طرق هوایی مدیریت خفگی در یک کودک بالغ یا بزرگتر اگر مشکل تنفسی به طور ناگهانی در حین غذا خوردن رخ دهد، گلون فرد را ببندد، یا سرفه های بی صدا، سیانوز )جلد به رنگ آبی در می آید(، استریدور یا تنفس پر سر و صدا وجود داشته باشد، مشکوک باشید که جسم خارجی طرق هوایی را مسدود کرده است. در صورت امکان فرد را به صحبت کردن یا سرفه کردن تشویق کنید و ببینید آیا انسداد )بندش( برطرف شده است. اگر فرد با صدای بلند سرفه می کند و/یا قادر به تولید صدا است، مانورهای شرح داده شده در زیر را انجام ندهید. فردی که قادر به صحبت کردن یا سرفه نیست، دارای انسداد (بندش) کامل طرق هوایی است و نیاز به کمک فوری دارد: به شخص بگویید که قرار است کمکی ارائه کنید. پنج ضربه به شکم وارد کنید )برای اصلاحات برای زنان باردار به زیر مراجعه کنید(. – پشت فرد بایستید و فرد را به جلو خم کنید. با یک دست مشت کنید و آن را در مرکز شکم بین ناف )ناف( و قسمت پایینی سینه قرار دهید. دست دیگر خود را روی مشت خود قرار دهید. توجه: اگر مریض باردار است، پهلوی مشت خود را در مرکز قفس سینه قرار دهید و به شدت به سمت داخل بکشید. با استفاده از فشار های سریع و سخت پنج بار به داخل و بالا بکشید. این امر هوا را از ریه های مریض خارج می کند تا سعی کند انسداد )بندش( را «بیرون بزند”. اگر انسداد )بندش( ادامه پیدا کرد، از فرد بخواهید از ناحیه کمر خم شود و پنج ضربه به پشت وارد کند )با پاشنه دست به پشت بین تیغه های شانه در جهت سر ضربه بزنید(. ارزیابی مجدد تا زمانی که مریض صحبت کند، سرفه کند یا بیهوش شود، فشارهای شکم ی و به تعقیب آن ضربات به پشت را تکرار کنید. اگر فرد خفگی بیهوش شد، او را به صورت رو به بالا روی یک سطح سخت دراز بکشید. انجام تراست قفس سینه ممکن است انسداد )بندش( را برطرف کند. اگر یک سری از رانش های قفس سینه موفقیت آمیز نبود، با تنفس های دهن به دهن و فشردن قفس سینه بر اساس پروتوکول های RPC مربوطه ادامه دهید. ycnangerp etal ni gnikohc rof stsurht tsehC 6 egap tluda gnikohc rof stsurht lanimodbA 5 egap فشار روی صدر خانم حامله به علت خفک شدن فشار روی شکم بزرگسالان به خاطر خفه شدن طرق تنفسی قول 061 مدیریت خفگی در نوزاد یا کودک کوچک نوزاد را روی بازو یا ران خود به صورت رو به پایین و سرش را پایین تر از شکم قرار دهید. پنج ضربه به پشت بزنید )با کف دست، ضربه تند به پشت بین تیغه های شانه در جهت به سمت سر(. اگر انسداد )بندش( ادامه داشت، نوزاد را برگردانید. با دو انگشت، درست زیر خط نوک سینه در خط وسط سینه، پنج ضربه به سینه بدهید. اگـر انسـداد )بنـدش( ادامـه داشـت، دهـان نـوزاد را بـرای هـر گونـه انسـداد )بنـدش( قابـل مشـاهده کـه قابـل برداشـتن اسـت بررسـی کنیـد. )احتیـاط بـرای گاز گرفتـن.( در صورت لزوم، کل پروسه را تکرار کنید تا جسم خارجی خارج شود. stnafni ni gnikohc rof stsurht tsehC 7 egap stnafni ni gnikohc rof swolb kcaB 8 egap ضربه بر پشت اطفال از برای خفه شدن فشار بر صدر اطفال از باعث خفه شدن کتاب دستور عملیات اشتراک کننده گان 161 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE بخش مهارت طرق هوایی: سکشن طرق هوایی هدف از سکشن حذف هرگونه مایع یا ترشح از طرق هوایی علوی است. اگر فرد نتواند بدون کمک ترشحات را پاک کند، ممکن است برای باز نگه داشتن طرق هوایی، سکشن ضروری باشد. بررسی کنید که آیا جعبه سکشن یا دستگاه دستی شما کار می کند یا خیر. یک کتیتر سکشن سخت یا نرم را به انتهای تیوب سکشن وصل کنید. کاری که انجام می دهید را توضیح دهید. کتیتر سکشن را در پشت دهان قرار دهید )فقط تا جایی که می بینید(، سوراخ کناری کتیتر )نه نوک کتیتر( را بپوشانید تا سکشن ایجاد شود. سکشن نمایید فقط در حین بیرون کشیدن کتیتر و آزاد کردن سکشن در هنگام جلو بردن کتیتر )به جلو بردن کتیتر به داخل دهان در حین سکشن میتواند باعث آسیب شود(. این کار را برای سکشن تمام مایع دهان تکرار کنید. بیش از 01 ثانیه در یک زمان سکشن نکنید، مگر اینکه طرق هوایی کامًلا با مایع مسدود شده باشد. برای جلوگیری از صدمه به دهان، نهایت نوک سکشن را مستقیما ًروی انساج نرم قرار ندهید یا آن را فقط در یک مکان نگه دارید. فقط جوف دهان را سکشن کنید، بینی را سکشن نکنید. بخش مهارت طرق هوایی: قرار دادن دستگاه اصلی طرق هوایی قرار دادن طرق هوایی اوروفارنکس طرق هوایی اوروفارنکس تنها زمانی باید وارد شود که فرد بیهوش است. فرد آگاه APO را تحمل نمی کند و آن را بیرون می راند. اگر فرد مقاومت کرد، گرفتگی دهان یا استفراغ کرد، بلافاصله دستگاه را خارج کنید. در صورت وجود سابقه ضربه، همیشه از ستون فقرات گردنی محافظت کنید. اندازه مناسب APO را با اندازه گیری از نوک نرمی گوش تا گوشه دهان اندازه گیری کنید. دهان فرد را با دقت باز کنید تا انگشتان خود را بین دندان ها قرار ندهید )برای جلوگیری از گاز گرفتن تصادفی(. APO را طوری وارد کنید که قسمت منحنی آن به یک طرفین باشد و نوک آن به سمت گلون باشد. APO را به آرامی به داخل دهان فشار دهید و هنگامی که نمی توانید بیشتر فشار دهید، APO را 09 درجه بچرخانید، به طوری که نوک آن به سمت پایین گلو قرار گیرد و منحنی زبان را تعقیب کنید )نگاه کنید به شکل(. در صورت لزوم APO را تا نهایت مسیر به داخل فشار دهید تا فلنج )انتهای پهن و هموار( روی لب های فرد قرار گیرد. اگر مجبور به انجام این کار هستید، مطمئن شوید که نوک APO زبان را به سمت پایین فشار نمی دهد تا پشت گلو را مسدود کند. دوباره بررسی کنید تا مطمئن شوید که APO زبان را به پایین فشار نداده و طرق هوایی را مسدود نکرده است. در صورت موجودیت اکسیجن بدهید. noitresni )APO( yawria laegnyrahporO 01 egap تطبیق کردن آله دهانی حنجری قول 261 تطبیق طرق هوایی نازوفارنکس (APN). راه های هوایی نازوفارنکس )APN( در افرادی که نیمه هوشیار هستند یا در مواردی که احتمال گرفتگی راه های هوایی اوروفارنکس وجود دارد، بهتر قابل تحمل است. از APN در افراد مبتلا به تروما سر و صورت استفاده نکنید. مسیر بینی را از نظر هرگونه انسداد )بندش( آشکار طرق هوایی ارزیابی کنید. اندازه مناسب APN را برای تطبیق تعیین کنید. از نرمی سوراخ های بینی تا نرمی گوش اندازه گیری کنید. قطر APN باید از مجرای بینی فرد کوچکتر باشد. APN را به خوبی چرب کرده و آن را داخل سوراخ بینی قرار دهید و آن را در امتداد کف بینی به سمت گلو هدایت کنید تا جایی که قسمت پهن و هموار )فلنج( تیوب روی سوراخ بینی قرار گیرد. در صورت وجود اکسیجن بدهید. ارزیابی بخش مهارت طرق هوایی معیارهای علامت گذاری بخش مهارت مصؤونیت: تجهیزات مصوؤنیت فردی استفاده گردیده و یا شفاهی بیان گردد. مانور های اساسی طرق هوایی مهارت 1 - طرق هوایی را باز کنید: سر را با شیب و چانه بالا ببرید استطبابات پروسیجر را لست کنید - در حالات غیر تروما. سر را با یک دست روی پیشانی کج کنید و چانه را با انگشتان بلند کنید. بیان کنید که کودک باید در وضعیت خنثی و یا طبیعی )بوی کشیدن( قرار گیرد. اجسام خارجی را در صورت مشاهده بردارید. در صورت نیاز طرق هوایی را سکشن کنید. طرق هوایی را باز نگه دارید. اجازه ندهید سر به عقب بیفتد زیرا این کار باعث بسته شدن طرق هوایی می شود. نظریات: مهارت 2- باز کردن طرق هوایی: بلند کردن الاشه خنثی و یا طبیعی استفاده از بلند کردن الاشه در مقابل شیب سر و لیفت چانه )صدمه با آسیب احتمالی ستون فقرات گردنی( را فهرست کنید. از یک دستیار برای بی حرکت کردن ستون فقرات گردنی کمک بخواهید. noitresni )APN( yawria laegnyrahposaN 9 egap تطبیق آله بینی حنجری کتاب دستور عملیات اشتراک کننده گان 361 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE انگشتان دست را پشت زاویه الاشه پایین )منحنی روی استخوان الاشه ( در دو طرف الاشه قرار دهید و به سمت بالا فشار دهید تا الاشه پایین حرکت کند. توجه داشته باشید که سر و گردن نباید حرکت کنند. هر گونه جسم خارجی قابل مشاهده را بردارید. طرق هوایی را باز نگه دارید – اجازه ندهید الاشه عقب بیفتد زیرا این کار باعث بسته شدن طرق هوایی می شود. نظریات: مدیریت خفگی مهارت 3 - خفگی: بزرگسال و کودک بزرگتر قادر به ارائه استطبابات برای مانور فشارهای بطنی )فرد قادر به صحبت کردن یا سرفه نیست( باشد. به شخص بگویید که قرار است چه کاری انجام دهید. به پشت سر فرد ایستاده شود و فرد را به جلو خم کنید. با یک دست مشت کنید و آن را در مرکز شکم بین ناف و قسمت پایینی سینه قرار دهید. یک مشت را با دست دیگر خود بپوشانید. با استفاده از رانش های سریع، پنج بار به داخل و بالا بکشید. این امر هوا را از ریه های مریض خارج می کند تا سعی کند انسداد )بندش( را «بیرون بزند”. فرض کنید شخص مصاب هنوز در حال خفگی است: از او بخواهید از ناحیه کمر خم شود. پنج ضربه به پشت با پاشنه یک دست بین تیغه های شانه وارد کنید و به پشت در جهت به سمت سر ضربه بزنید. بیان کنید که مریض را مجددا ارزیابی خواهید کرد. فشار های شکم را تکرار کنید و سپس به عقب ضربه بزنید تا زمانی که مریض صحبت کند یا سرفه کند یا بیهوش شود. نحوه اصلاح این مورد را برای یک زن حامله بیان کنید: به جای فشار به شکم ، طرف مشت را در مرکز قفس سینه قرار دهید، مشت را با دست دیگر بپوشانید و به شدت به سمت داخل بکشید. نظریات: مهارت 4 - مدیریت خفگی نوزاد و کودک کوچک نوزاد را روی بازو یا ران خود در وضعیت رو به پایین قرار دهید و سرش پایین تر از شکم باشد. با کف یک دست پنج ضربه پشتی به پشت شیرخوار بین تیغه های شانه وارد کنید. اگر انسداد )بندش( ادامه داشت، نوزاد را برگردانید. با دو انگشت که درست زیر خط نوک سینه در وسط قفس سینه قرار دارد، پنج فشار به سینه بدهید. اگر انسداد )بندش( ادامه داشت، دهان شیرخوار را برای هر گونه انسدادی که قابل برداشتن است بررسی کنید. نظریات: قول 461 مهارت ۵ - سکشن طرق هوایی قوطی سکشن یا دستگاه دستی خود را بررسی کنید تا مطمئن شوید که کار می کند. یک کتیتر سکشن سخت )reuaknay( یا نرم را به اخیر تیوب سکشن وصل کنید. کتیتر سکشن را در پشت دهان قرار دهید )فقط تا جایی که می بینید( و سوراخ کناری کتیتر )نه نوک کتیتر( را بپوشانید. هنگام قرار دادن کتیتر در دهان، سکشن نکنید. سکشن فقط در حین بیرون کشیدن کتیتر. مدت زمان سکشن مریض را بیان کنید )هر بار بیش از 01 ثانیه مگر اینکه طرق هوایی کامًلا با مایع پوشانده شده باشد(. نیاز به حرکت مداوم کتیتر سکشن و عدم قرار دادن نوک سکشن در برابر انساج نرم را بیان کنید. نظریات: قرار دادن دستگاه اصلی طرق هوایی مهارت 6 - طرق هوایی اوروفارنکس (APO) استطبابات استفاده از طرق هوایی اوروفارنکس را ذکر کنید )فردی بیهوش است و رفلکس حالت تهوع ندارد(. اندازه APO مناسب را برای تطبیق تعیین کنید: )شرکت کننده باید نحوه انجام این کار را با صدای بلند توضیح دهد(. از نرمی گوش تا کنج دهان در آن طرف اندازه بگیرید. دهان را با دقت باز کنید تا انگشتان خود را بین دندان ها قرار ندهید )برای جلوگیری از گاز گرفتن تصادفی(. APO را طوری وارد کنید که قسمت منحنی آن به طرفین باشد و نوک آن به سمت رخسار باشد. هنگامی که APO تا جایی که می رود، اوروفارنکس را 09 درجه بچرخانید تا نوک آن به سمت پایین گلو باشد و منحنی از زبان پیروی کند. APO را تا انتهای مسیر به داخل فشار دهید تا فلنج )انتهای هموار( روی لب های فرد قرار گیرد. بررسی کنید تا مطمئن شوید که APO زبان را به سمت پایین فشار نداده تا طرق هوایی را مسدود کند. بیان کنید که در صورت قابل دسترس اکسیجن به شما داده خواهد شد. نظریات: مهارت ۷ - طرق هوایی نازوفارنکس (APN) استطبابات APN را فهرست کنید. )در فردی که نیمه هوشیار است یا ممکن است هنوز رفلکس دلبدی داشته باشد بهتر است(. بیان کنید که APN ها نباید در افرادی که تروما به سر و صورت دارند استفاده شود. مسیر بینی را برای هر گونه انسداد )بندش( واضح طرق هوایی ارزیابی کنید. نحوه تعیین اندازه مناسب APN برای درج را توضیح دهید: از قسمت خارجی سوراخ بینی تا انتهای نرمی گوش اندازه گیری کنید. قطر تیوب نباید از سوراخ بینی بزرگتر باشد. APN را چرب کنید نوک بینی را بالا بیاورید. APN روغن چرب کاری شده را داخل سوراخ بینی قرار دهید و به آرامی آن را در امتداد کف بینی فشار دهید تا زمانی که پایه گشاد شده )فلنج( روی سوراخ بینی قرار گیرد. بیان کنید که در صورت وجود آکسیجن به شما داده خواهد شد. شایستگی نشان داده شده است بلی نخیر اصلاح مورد نیاز است بلی نخیر امضای استاد رهنما: کتاب دستور عملیات اشتراک کننده گان 561 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE 2. بخش های مهارت تنفس گرفتن بخش مهارت تنفس گرفتن: معاینه فزیکی سیستم تنفسی تعداد تنفس را ارزیابی و شمارش کنید )طبیعی بین 01 تا 02 تنفس در دقیقه در یک بزرگسال است. برای مقادیر طبیعی کودکان به مودل EDCBA مراجعه کنید(.به تعقیب افزایش کار تنفس )تعداد شدن بینی، جمع شدن یا کشیدن قفس سینه( باشید. احساس بلند شدن قفس سینه و حساس شدن دیوار قفس سینه. قرع به دیوار قفس سینه: یک دست را روی قفس سینه قرار دهید و انگشتان را از هم جدا کنید )دست وسط باید بین اضلاع قرار گیرد(. با دست دیگر، روی انگشت وسط دست اول ضربه بزنید و به تغییرات صدا )میان خالی یا گنگ( گوش دهید. به صدای تنفسی گوش دهید: همیشه قفس سینه را در برهنه کنید. هرگز از طریق لباس گوش نکنید. مطمئن شوید که ستاتسکوپ )آله شنوایی صدای سینه( شما خیلی سرد نباشد. ستاتسکوپ خود را به آرامی روی دیوار قفس سینه قرار دهید. از مریض بخواهید که دهان خود را باز کند و یک نفس عمیق به داخل و خارج بکشد. به صداهای تنفس گوش دهید و سمت چپ را با راست مقایسه کنید. در ناحیه بالا، ناحیه میانی و ناحیه پایین گوش کنید و به جلوی سینه و پشت گوش دهید. صدای تنفس طبیعی مانند حرکت باد به داخل و خارج می شود، در حالی که تنفس غیرطبیعی مانند عبور هوا از آب، مچاله شدن کیسه های کاغذی یا عدم حرکت هوا است. )به مشکل در تنفس مراجعه کنید( به حجاب و محرمیت احترام بگذارید و در صورت امکان از قرار دادن ستاتسکوب مستقیم روی سینه ها خودداری کنید. بخش مهارت های تنفسی: دادن اکسیجن تکمیلی هنگامی که مریض دچار کمبود آکسیجن اعراض و علایم - تنفس سریع، اضطراب، تعریق زیاد، سیانوز یا درد قفس سینه است، باید آکسیجن مکمل داده شود. در صورت دسترس بودن، باید از یک پالس اکسیمتر برای اندازه گیری اشباع آکسیجن استفاده شود. اگر کمبود آکسیجن شدید به نظر نمی رسد، سطوح پایین تری از اکسیجن )24 تا 40 درصد اکسیجن( را می توان از طریق کنول بینی )شاخه های بینی( در اختیار کودکان و بزرگسالان قرار داد، اما در صورت نیاز به ماسک به دقت نظارت کنید. )به یاد داشته باشید، هوای معمولی تقریبا ً21٪ اکسیجن دارد( - کنولای بینی باید تقریبا ًنصف اندازه سوراخ بینی باشد. کنولا را در هر سوراخ بینی قرار دهید و مطمئن شوید که خیلی به عقب کشیده نشود یا روی انساج فشار نیاورد. تیوب را روی گونه ها محکم کنید یا تیوب را روی گوش ها حلقه کنید تا شاخک های بینی و تیوب هر دو در سمت قدامی بدن مریض قرار گیرند )هرگز سر را از طریق حلقه بالای تیوب قرار ندهید چون اگر مریض گیج و کم آکسیجن شد، آنها می توانند به طور تصادفی خود را خفه کنند(. آکسیجن با مقدار کم تجویز میشود: حداکثر 5 لیتر در دقیقه. اگر کمبود آکسیجن شدیدتر به نظر برسد )یا اگر علایم کمبود آکسیجن با حداکثر جریان آکسیجن از طریق کنولای بینی ادامه یابد(، ممکن است از یک ماسک ساده برای وجه استفاده شود. ماسک وجهی ساده معمولا ًبا سرعت جریان آکسیجن 6 تا 01 لیتر در دقیقه استفاده می شود و میتواند تقریبا ً04 تا 06 درصد آکسیجن را برای مریض تحویل میدهد. ماسک صورت روی صورت زده می شود تا از پوشاندن پل بینی اطمینان حاصل شود و تا حد امکان کمتر از کناره نشتی داشته باشد. ماسک باید زیر لب پایین قرار گیرد، اما از زنخ عبور نکند. بند الاستیک باید روی سر قرار داده شود تا ماسک محکم شود. برای مریضانی که به شدت کمبود آکسیجن به نظر می رسند یا هنوز علایم کمبود آکسیجن را با یک ماسک ساده صورت دارند، می توان آکسیجن را از طریق ماسک وجه خریطه دار تجویز کرد. اگر کیسه مخزن پر باشد، این آکسیجن نزدیک به 001٪ را فراهم می کند. برای تهیه ماسک صورت بدون تنفس مجدد، یک انگشت را روی دریچه بالای کیسه مخزن داخل ماسک قرار دهید تا کیسه پر از باد شود سپس ماسک وجه خریطه دار را به همان روش ماسک ساده وجه بزنید تا از نشتی کمتری که ممکن است اطمینان حاصل کنید. اطمینان حاصل کنید که اکسیژن به منبع مرکزی اکسیجن روی دیوار و یا سیلندر متصل است و سرعت جریان بین 10-15 لیتر در دقیقه به فشار در سیستم آکسیجن شما و سرعت و عمق تنفس مریض بستگی دارد. اگر مریض دچار کمبود اکسیجن آکسیجن است و یا هم کیسه ماسک خریطه دار بدون تنفس مجدد پر نمی شود، سرعت جریان آکسیجن را افزایش دهید. قول 661 هرگز قبل از اتصال به آکسیجن ماسک ماسک خریطه دار را روی وجه مریض نگذارید. یک ماسک واقعی خریطه دار اجازه ورود هوای بیرون را نمی دهد و اگر آکسیجنی در تیوب جریان نداشته باشد، میتواند مشکلات تنفسی و کمبود آکسیجن را بدتر کند. بخش مهارت های تنفسی: وینتلیشن یا تهویه ماسک بیگ والو EVLAV-GAB ارزیابی و مدیریت طرق هوایی و ارائه تهویه توسط آمبوبک )MVB( برای هر مریضی که تنفس نمی تواند یا به اندازه کافی نفس نمی کشد )بسیار آهسته نظر به سن یا خیلی سطحی(، هر مریض بیهوش با تنفس غیرطبیعی )آهسته، کم عمق، نفس نفس زدن یا پر سر و صدا( یا هر مریض با نبض که نفس نمی کشد )برای مریضان بدون نبض، پروتوکول های RPC مربوطه را تعقیب کنید(. احتیاط! از وینتلیشن/ تهویه بیش از حد تهاجمی )استفاده از ksam-evlav-gab خیلی سریع یا با فشار زیاد( اجتناب کنید زیرا به ریه ها آسیب می رساند. کودکان ریه های کوچکتری دارند که به ویژه شکننده هستند. هنگام تهویه کودک، به خصوص مراقب باشید که فقط فشار کافی برای بالا آمدن قفس سینه وارد شود و مطمئن شوید که زمان کافی بین تنفس برای زفیر )برای خروج هوا( در نظر گرفته شود. حجم زیاد هوا یا فشار زیاد ممکن است منجر به نوموتوراکس یا آسیب غیرقابل برگشت ریه شود. مراحل تهویه ksam-gaB : اگر، تهویه در دسترس دارید، تیوب MVB را وصل کنید و جریان را روی بالاترین درجه موجود تنظیم کنید. برای آماده سازی آکسیجن تهویه ksam-gaB را به تاخیر نیندازید. )آکسیجن را می توان بعدا ًوصل کرد.( ماسک را روی دهان و بینی مریض قرار دهید )اگر دو نفر در موجود است، یک نفر کیسه را فشار می دهد و دیگری ماسک را روی صورت مریض نگه می دارد و طرق هوایی را باز نگه می دارد( یک حلقه اطراف ماسک ایجاد کنید تا هوا به بیرون نشت نکند. دست یا دستان خود را در وضعیت “CE” قرار دهید - انگشت شست و انگشت اول شما باید یک “C” را در اطراف بالای ماسک ایجاد کنند و به طور یکنواخت به سمت پایین فشار دهید، سه انگشت آخر شما باید دقیقا ًزیر قسمت استخوانی الاشه برسد )به شکل ظاهری مانند “E”( و الاشه را به سمت بالا بکشید تا طرق هوایی باز شود. به کشیدن وجه به سمت ماسک )در نتیجه باز شدن طرق هوایی( و فشار دادن ماسک به سمت پایین روی صورت )ایجاد حلقه بدون درز( فکر کنید. اگر فشار زیادی به پایین بیاورید بدون اینکه صورت را به سمت ماسک بکشید، طرق هوایی را مسدود کرده و مریض را به مشکل مواجه میکنید. اگر در تهویه مشکل دارید، دست ها و ماسک را تغییر دهید و دوباره امتحان کنید. اگر مریض خودش تنفس میتواند، هنگامی که مریض نفس می کشد )در حین شهیق( با آمبو تنفس بدهید. هنگام زفیر مریض سعی نکنید نفس بکشید. rehtaerber-noN ksamecaf elpmiS sgnorp/alunnac lasaN 11 egap کنول بینی ماسک ساده چهرهوسیله عدم تنفس دوباره کتاب دستور عملیات اشتراک کننده گان 761 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE اگر پس از جابجایی ماسک همچنان قادر به تهویه فرد نیستید، احتمال انسداد )بندش( جسم خارجی یا نشت هوا را در نظر بگیرید. اگر دستگاه طرق هوایی فمی )اوروفارنکس( یا انفی )نازوفارنکس( را قبلا جابجا نکرده اید، استفاده نمایید )به مهارت ها مراجعه کنید(. کیسه را در یک دست بگیرید و آنقدر کیسه را فشار دهید تا قفس سینه بالا بیاید )به حدود یک سوم حجم آن برای بزرگسالان - مطمئن شوید که از آمبوبک با سایز مناسب استفاده میکنید: حجم یک کیسه بزرگسال باید حدود 2 لیتر باشد.( کیسه را به مدت 1 تا 2 ثانیه فشار دهید تا قفس سینه بلند شود )تنفس سریعتر میتواند باعث آسیب ریه شود(. هر 6 ثانیه یک تنفس )01 نفس در دقیقه( در بزرگسالان بدهید. یک نفس در هر 4 ثانیه )51 نفس در دقیقه( در کودکان بزرگتر. یا هر 3 ثانیه یک نفس )02 تنفس در دقیقه( در نوزادان.محتاط حجم تنفسی در کودکان باشید )به مهارت ها مراجعه کنید(. تنفس با حجم زیاد میتواند باعث نوموتوراکس شود. بعد از هر نفس، قبل از اینکه تنفسی دیگری بدهید، اجازه دهید قفس سینه در جای خود قرار گیرد. با هر نفس بالا و پایین رفتن یکنواخت قفس سینه را تماشا کنید. بخش مهارت تنفس: رفع فشار عاجل با سوزن رفع فشار با سوزن قفس سینه یک روش عاجل نجات برای نوموتوراکس فشاری مشکوک است )وجود هوا یا گاز در حفره بین ریه ها و دیوار قفس سینه که باعث فشار بیش از حد بر روی ریه مقابل، اوعیه بزرگ و قلب می شود(. مریضان می توانند بسیار زود در اثر نوموتوراکس فشاری بمیرند. این مریضان به تیوب صدری ebuT tsehC عاجل نیاز دارند، اما رفع فشار با سوزن عاجل فشار فوری را کاهش میدهد و زمان رجعت دهی/انتقال برای تیوب قفس سینه را میدهد. رفع فشار سوزنی عاجل فقط باید برای نوموتوراکس فشاری انجام شود. قفس سینه را در معرض دید قرار دهید و تنفس را ارزیابی کنید. در صورت وجود شاک و موارد زیر، نوموتوراکس تنشی شناسایی می شود: مشکل در تنفس عدم وجود صداهای ریوی در سمت آسیب دیده فشار خون پایین توسع وریدهای گردن تشدید بیش از حد صدا با قرع در سمت آسیب دیده دور شدن شزن از سمت آسیب دیده یک کنول وریدی با سوراخ بزرگ )ترجیحا ً41-61 گیچ( را در امتداد لبه بالایی ضلع سوم از طریق فضای ضلع دوم )بین ضلعی( در راستای خط میانی ترقوه در سمت آسیب دیده قرار دهید. در نوموتوراکس فشاری، هوای خارج شده با فشار بیرون میاید اکسیجن را با غلظت بالا بدهید )ماسک غیر تنفسی یا خریطه دار(. ورید را باز نموده و مایعات وریدی بدهید. فورا ًبه مرکز پیشرفته جهت تداوی قطعی رجعت و انتقال دهید. dlihC :MVB sredivorp owT :MVB redivorp enO :MVB 21 egap ماسک یک طریقه ماسک دو طریقه ییماسک تنفس اطفال قول 861 تیوب صدری باید در اسرع وقت پس از برداشتن فشار با سوزن )حتی در صورت عدم وجود هجوم هوا( یا برای هرگونه هموتوراکس مشکوک قرار داده شود. بخش مهارت تنفس: مدیریت نوموتوراکس باز (زخم مکنده زخم قفس سینه) نوموتوراکس باز یک زخم باز دیوار قفس سینه است که هنگام تنفس مریض هوا را به داخل می مکد. به طور معمول، هنگامی که دیوار قفس سینه منبسط می شود، هوا از طریق طرق هوایی به داخل ریه ها کشیده می شود )از طریق اثر خلاء(. اگر سوراخ دیگری در دیوار قفس سینه وجود داشته باشد )به دلیل تروما و یا صدمه( هوا نیز در آن سوراخ کشیده می شود، اما به جای رفتن به ریه ها، به فضای بین دیوار قفس سینه و ریه ها می رود و نوموتوراکس ایجاد می کند. یک پانسمان 3 طرفه برای جلوگیری از ورود هوای بیشتر در حین استنشاق قرار داده می شود، اما برای جلوگیری از ایجاد نوموتوراکس تنشی، هوا از نوموتوراکس در هنگام ذفیر خارج می شود. برای مدیریت زخم مکنده قفس )نوموتوراکس باز(: • آکسیجن با جریان بالا بدهید. زخم سینه را با گاز یا سایر پانسمان های غیر چسبنده مانند لفاف پلاستیکی بسته گاز بپوشانید. سه طرف پانسمان را بچسبانید و یک طرف آن را بدون چسب رها کنید تا به عنوان یک دریچه فلپ عمل کند. این مریضان باید در اسرع وقت به مرکزی منتقل شوند که بتوان تیوب صدری را در آن قرار داد. )تیوب قفس سینه را در ناحیه آسیب دیده قرار ندهید.( احتیاط! خطر چسبیدن پانسمان به دیوار قفس سینه با خون لخته شده وجود دارد. هنگامی که این اتفاق می افتد، هوا نمیتواند از حفره قفس سینه خارج شود و فشار میتواند ایجاد شود که منجر به نوموتوراکس تنشی می شود. در صورت بدتر شدن وضعیت تنفسی یا شواهدی از بدتر شدن اروا، پانسمان را به طور کامل خارج کنید. اگر مریض را نمی توان به طور مداوم مشاهده کرد، یک پانسمان سه طرفه نباید گذاشت. بخش مهارت تنفس گرفتن: چگونه از یک بوتل پلاستیکی اسپیسر بسازیم هدف از اسپیسر نگه داشتن ادویه )سالبوتامول( آزاد شده از یک انهیلر با دوز اندازه گیری شده است تا فرد وقت داشته باشد تا ادویه را به طور موثر استنشاق کند. )بدون تجربه و آموزش مناسب، استفاده موثر از یک استنشاقی با دوز اندازه گیری شده دشوار است و ادویه اغلب در دهان یا گلو از بین می رود(. با این حال، اسپیسرها باید از قبل ساخته شوند. برای ساخت اسپیسر تجویز سالبوتامول را به تاخیر نیندازید. noisserpmoced eldeeN 31 egap کاهش فشار سوزنی کتاب دستور عملیات اشتراک کننده گان 961 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE از یک بوتل پلاستیکی پاک 003-005 میلی لیتری استفاده کنید )با مواد شوینده بشویید و خوب خشک کنید(. درپوش دستگاه استنشاقی و یا انهیلر با دوز اندازه گیری شده را بردارید و شکل دهانه استنشاقی را روی پایه بوتل دقیقا ًدر مقابل دهانه بطری ترسیم کنید. یک دهانه در قاعده بوتل کمی کوچکتر از شکل ترسیم شده برش دهید. می توانید این را با قیچی یا کاغذ گیر گرم شده برش دهید. برای بررسی اندازه، دستگاه استنشاقی را داخل اسپیسر قرار دهید )انهیلر تنفسی باید محکم در دهانه قرار گیرد(. همیشه به خاطر داشته باشید که قبل از استفاده، اسپیسر را با پنج پاف آماده کنید تا فضای مرده را پاک کنید. ارزیابی بخش مهارت های تنفسی موفق: موفق: دومموفق: اولمعیارهای علامت گذاری بخش مهارت سوم مصؤونیت: مصوؤنیت فردی استفاده گردیده و یا شفاهی بیان گردد. مهارت 1- ارزیابی تنفس تعداد تنفس را ارزیابی و شمارش کنید. به تعقیب افزایش کار تنفس )گشاده شدن بینی، جمع شدن( باشید. احساس بلند شدن قفس سینه و حساس شدن دیوار قفس سینه. دیوار سینه را قرع کنید. به قفس سینه گوش دهید )اصغا کنید(. نظریات: مهارت 2 - تجویز مکمل آکسیجن استطباب آکسیجن )کمبود آکسیجن، که با تنفس سریع، اضطراب، تعریق بیش از حد، سیانوز )آبی رنگی جلد(، یا درد قفس سینه مشخص می شود را بیان کنید. توضیح دهید که چه زمانی باید از کنول بینی استفاده شود )کمبود آکسیجن خفیف(. استفاده از یک کنول بینی با شاخک بینی در هر سوراخ بینی را نشان دهید. تیوب را روی گونه یا به شکل روی گوش مریض محکم کنید. )شرکت کننده نباید سر مریض را از طریق حلقه بالای تیوب قرار دهد.( elttob citsalp a morf edam recapS 41 egap ساختار وسیله فاصله تنفس از بوتل پلاستیکی قول 071 بیان کنید که سرعت جریان آکسیجن نباید بیشتر از 5 لیتر در دقیقه باشد. اگر مریض همچنان علایم کمبود آکسیجن دارد، توضیح دهید که در مرحله بعد از کدام روش آکسیجن رسانی باید استفاده شود. )ماسک ساده( ماسک ساده صورت – ماسک را روی پل بینی و زیر لب پایین بزنید. از حداقل نشت هوا اطمینان حاصل کنید - قسمت الاستیکی را برای نگه داشتن در جای خود تنظیم کنید. توضیح دهید که سرعت جریان آکسیجن باید بین 6 تا 01 لیتر در دقیقه باشد. اگر مریض همچنان علایم کمبود آکسیجن دارد، توضیح دهید که در مرحله بعد از کدام روش آکسیجن رسانی باید استفاده شود. )ماسک صورت بدون تنفس مجدد و یا خریطه دار( برای تهیه ماسک صورت بدون تنفس مجدد، یک انگشت را روی دریچه بالای کیسه مخزن داخل ماسک قرار دهید تا کیسه پر از هوا شود. اطمینان حاصل کنید که کیسه مملو از هوا شده است. ماسک صورت بدون تنفس مجدد را روی پل بینی و زیر لب پایین بزنید. از حداقل نشت هوا اطمینان حاصل کنید - پلاستیک را برای نگه داشتن در جای خود تنظیم کنید. با در نظر گرفتن به تنفس مریض، آکسیجن را به 01-51 لیتر در دقیقه روشن کنید. ماسک بدون تنفس مجدد را تنظیم کنید و جریان را تنظیم کنید تا مطمئن شوید کیسه تا حدی پر شده است. نظریات: مهارت 3 – ونتلیشن /تهویه ماسک بیگ والو evlav-gab استطباب ونتلیشن /تهویه ماسک امبو بک evlav-gab را بیان کنید. بیان کنید که اگر آکسیجن در دسترس است، آن را به کیسه وصل کنید - اما MVB را برای آماده کردن آکسیجن به تاخیر نیندازید. از مطمین شوید که ماسک بخ خوبی روی صورت بسته شده است کافی ماسک صورت اطمینان حاصل کنید. اندازه صحیح تهویه را بیان کنید. هنگام تهویه کودک، احتیاطات مربوطه را بیان کنید. بیان کنید که تهویه بیش از حد میتواند به ریه ها آسیب برساند و باعث استفراغ شود. حجم صحیح تهویه را بیان یا نشان دهید. افزایش قفس سینه را ارزیابی کنید. اگر قفس سینه بالا نیامد، طرق هوایی را تغییر دهید. APO یا APN را در نظر بگیرید. نظریات: کتاب دستور عملیات اشتراک کننده گان 171 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE مهارت 4 - رفع فشار با سوزن عاجل استطباب این روش را بیان کنید. روش کار را برای بیمار توضیح دهید. قفس سینه را در معرض دید قرار دهید و جلد را تمیز کنید. مشخص کردن نقطه تطبیق: دومین فضای بین ضلعی )بین ضلع های 2 و 3( در خط میانی ترقوه. کنول وریدی 41-61گیچ را در محل مشخص شده قرار دهید. کنول را روی سوزن بکشید و سوزن را بردارید. برنامه انتقال مریض را جهت تطبیق تیوب صدری بیان کنید. اکسیجن بدهید و تعداد تنفس، علایم حیاتی و اشباع اکسیجن )در صورت دسترس بودن( را ارزیابی کنید. ورید را باز کنید و مایعات VI بدهید نظریات: مهارت ۵ - مدیریت نوموتوراکس باز (زخم مکنده قفس سینه) اکسیجن با جریان بالا بدهید. با گاز طبی بپوشانید. 3 طرف گاز را بچسبانید. نیاز به قرار دادن تیوب صدری را بیان کنید. خطر لخته شدن پانسمان که مانع خروج هوا می شود راشرح دهید. نظریات: نخیربلیشایستگی نشان داده شده است نخیربلیاصلاح مورد نیاز است امضای استاد رهنما: قول 271 3. بخش های مهارت دوران خون بخش مهارت دوران خون: معاینه دوران خون اضطراب، سردرگمی یا تغییر وضعیت ذهنی را معاینه کنید. احساس نبض، ارزیابی میزان و کیفیت )محدوده طبیعی 06 تا 001 ضربه در دقیقه در بزرگسالان است. برای مقادیر طبیعی کودکان به EDCBA مراجعه کنید(. پر کردن مجدد مویرگ ها را ارزیابی کنید )با فشار دادن ناخن، کف دست، یا کف پا و رها کردن برای دیدن مدت زمانی که طول می کشد تا رنگ به جلد برگردد )جریان خون برای بازگشت( بررسی شود. محدوده طبیعی کمتر از 3 ثانیه است. رنگ جلد را ارزیابی کنید و جلد را برای ارزیابی حرارت لمس کنید. سایر علایم حیاتی را اندازه گیری کنید: تعداد تنفس و فشار خون )مقادیر طبیعی بزرگسالان: RR 01-02 تنفس در دقیقه و فشار خون سیستولیک بیش از 09 میلی متر ستون سیماب. برای مقادیر طبیعی کودکان به EDCBA مراجعه کنید(. معاینه بخش مهارت دوران خون: کنترول خونریزی خارجی فشار مستقیم برای خونریزی خارجی زخم که عمیق است و خونریزی شدید دارد ممکن است بخودی خونریزی را متوقف نکند. واردکردن فشار مستقیم با یک پانسمان تمیز مانند گاز میتواند به کاهش یا توقف خونریزی کمک کند )شکل را ببینید(. دستکش بپوشید. از گاز یا پانسمان تمیز و غیر چسبنده دیگر استفاده کنید. از پانسمان های حجیم استفاده نکنید زیرا ممکن است فشار کافی در محل مناسب را دشوار کند. فشار محکم را تا حد امکان مستقیما ًروی منبع خونریزی وارد کنید، معمولا ًبا دو یا سه ضربه. اگر زخم روی اعضای دستان است، دستان را بالاتر از قلب قرار دهید. اگر پانسمان اول ملوث به خون شد، آن را جدا نکنید زیرا لخته های ایجاد شده را از بین می برد. در عوض یک پد دیگر اضافه کنید و فشار محکمی وارد کنید. هنگامی که خونریزی متوقف شد، یک بنداژ بپیچانید تا گاز/ پد را در جای خود نگه دارید. اگر خونریزی متوقف نشد، پانسمان عمقی زخم یا تورنیکت را در نظر بگیرید )به بخش بعدی مراجعه کنید(. dnuow a ot erusserp tcerid gniylppA 51 egap وارد کردن فشار مستقیم بالای زخم کتاب دستور عملیات اشتراک کننده گان 371 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE پانسمان زخم عمیق برای خونریزی خارجی اگر زخم عمیق است یا شکاف دارد و فشار ساده خونریزی را متوقف نمی کند، بسته بندی عمیق زخم ممکن است کمک کند. با این حال، بسته بندی زخم عمیق یک روش موقت برای متوقف کردن خونریزی است زیرا اگر بیش از 42 ساعت باقی بماند میتواند منجر به انتان شود. دستکش بپوشید. همیشه نبض، پر شدن مجدد عروق شعریه و حسیت را قبل و بعد از پانسمان یا اتل زدن هر زخم ارزیابی کنید. زخم را با حد اقل یک لیتر آب تمیز کاملا بشویید )در صورت امکان تحت فشار، بخش بعدی را ببینید(. از گاز یا مواد تمیز و فشرده دیگری برای پر کردن کامل فضای داخل زخم استفاده کنید. از گاز اضافی در بالای سطح زخم استفاده کنید و با دستکش خود یا بنداژ محکمی که در اطراف زخم/ اندام پیچیده شده است، فشار مستقیم وارد کنید. برای زخم های اندام که نیاز به بسته بندی دارند، از اتل استفاده کنید تا خطر خونریزی مجدد کاهش یابد. یک پانسمان زخم عمیق به دلیل خطر انتان نباید بیش از 42 ساعت در جای خود باقی بماند. اگر خونریزی متوقف نشد، تورنیکیت را در نظر بگیرید )به بخش بعدی مراجعه کنید(. تخنیک تورنیکیت برای خونریزی خارجی کنترول نشده از شما انتظار نمی رود که تخنیک تورنیکیت را انجام دهید، اما از شما انتظار می رود که بدانید برای چه شرایط تهدید کننده زندگی می توان از آن استفاده کرد، ملاحظات ویژه در مورد استفاده از تورنیکت و مراقبت مداوم از مریض. فقط در صورتی از این روش استفاده کنید که سایر اقدامات کنترول خونریزی ناموفق باشد و خونریزی تهدید کننده زندگی باشد. اگر یک تورنیکت را قرار میدهید، این احتمال وجود دارد که انساج تحت تورنیکت برای همیشه آسیب ببینند و حتی نیاز به قطع عضو داشته باشند. اگر قصد استفاده از تورنیکیت را دارید، فورا ًبرای کمک تماس بگیرید و برای رجعت دهی/انتقال به مرکز طبی که امکان جراحی وجود دارد برنامه ریزی کنید. در صورت وجود، از یک تورنیکیت نوماتیک )مانند کاف فشار خون( روی جلد پوشانده شده با پد استفاده کنید و تا زمانی که خونریزی متوقف شود هوا بدهید. اگر نه، از یک نوار ضخیم یا تکه پارچه یا کمربند )هرچه پهن تر، بهتر( روی جلد پوشانده با پد یا گاز استفاده کنید. تا حد امکانتورنیکت را نزدیک زخم قرار دهید، اما روی زخم یا شکستگی قرار ندهید. فشار کافی برای ناپدید شدن نبض های دیستال و خونریزی را مجددآ ارزیابی کنید. اگر خونریزی متوقف شد و پانسمان از قبل موجود بود در حالت خود بگذارید در غیر آن زخم را پانسمان کنید و و برای انتقال/ انتقال به یک مرکز طبی مراقبت جراحی آماده کنید. اگر خونریزی متوقف نشد، فشار تورنیکیت را افزایش دهید تا خونریزی عمده متوقف شود. زمان دقیق استفاده از تورنیکت را در ثبت کنید و آن را روی جلد مریض یا خود تورنیکت بنویسید. در اسرع وقت ، هر دو ساعت برای 01 دقیقه تورنیکیت را باز کنید )و هرگز بیش از 2 ساعت( پس از قرار دادن آتورنیکیت با مراقبت کننده پیشرفته مشورت کنید. تورنیکیت باید هر 2 ساعت یکبار به مدت حداقل 01 دقیقه رها شود. در این مدت به ناحیه خونریزی فشار مستقیم دهید. تورنیکیت را مجددا ًوارد نکنید، مگر اینکه شواهدی از ادامه خونریزی فعال باشد. محل قرارگیری تورنیکت: تورنیکت ها فقط باید روی اندام ها قرار گیرند و باید بالاتر از سطح خونریزی قرار گیرند. به دلیل ارتباط بین استخوان ها و رگ های خونی، تورنیکت های روی بازو یا پا اغلب مؤثرتر از تورنیکت هایی هستند که زیر آرنج یا زانو قرار می گیرند. مطمئن شوید که تورنیکت به وضوح قابل مشاهده است. به یاد داشته باشید که تورنیکیت باید به عنوان آخرین راه حل قرار گیرد. اگر یک تورنیکت قرار دهید، خون رسانی به اندام را قطع می کنید، بنابراین این کار را فقط برای خونریزی های تهدید کننده زندگی انجام دهید. هنگامی که استفاده از تورنیکیت کامًلا ضروری است، از یک نوار پهن و در عین حال فشرده استفاده کنید. قول 471 مهارت دوران خون: ماساژ رحم برای خونریزی پس از ولادت با هر زایمان مقداری خونریزی رخ می دهد. پس از زایمان، رحم باید منقبض شود، که عروق را فشرده می کند و خونریزی را محدود می کند. عدم انقباض رحم مهمترین علت خونریزی غیرطبیعی پس از ولادت )خونریزی پس از زایمان( است. برای کمک تماس بگیرید، برای رجعت دهی/انتقال سریع ترتیب دهید، ماساژ رحم را شروع کنید و فورا اکسیتوسین بدهید خونریزی پس از زایمان 1. ترتیب و انتقال فوری به یک کمک کننده واجد شرایط ولادی 2. تلاش برای کنترل خونریزی در هنگام تنظیم و در حین انتقال. 3. معاینه کنید: 4. فورا انتقال دهید خونریزی شدید بعد ولادت؟ آیا پلاسنتا تخلیه شده است؟ هنوز خونریزی است؟ آیا پارگی پرینه یا پایین واژن وجود دارد؟ رحم را ماساژ دهید تا سخت شود. اکسی توسین عضلی بدهید. مایعات وریدی و اکسی توسین وریدی بدهید. مثانه را خالی کنید ماساژ رحم را ادامه دهید. هنگامی که رحم سخت است، پلاسنتا احتمالا ًزایمان می کند. پلاسنتا را جمع آوری کنید و نزد بیمار نگه دارید. اکسی توسین را ادامه دهید. اکسی توسین را حداقل 1 ساعت پس از قطع خونریزی ادامه دهید. با گاز استریل فشار وارد کنید، پاها را کنار هم قرار دهید. هنوز خونریزی دارید؟ ماساژ رحم را تا سخت شدن ادامه دهید. اکسی توسین را ادامه دهید. مایعات وریدی را با اکسی توسین ادامه دهید. ورید دومی را باز کنید بلی بلی نخیر نخیر بلی کتاب دستور عملیات اشتراک کننده گان 571 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE انجام ماساژ رحم برای خونریزی پس از ولادت به خانم باردار توضیح دهید که چه خواهید کرد و چرا. هدف فشرده کردن رحم بین دست و ساختارهای استخوانی پشت رحم )مانند ساکروم/کمر( است. دست خود را روی شکم زن بگذارید. از طریق دیوار شکم ، رحم را لمس کنید و آن را با دست خود محکم بگیرید. این اطمینان حاصل می کند که در هنگام ماساژ زیر دست شما باقی می ماند. به سادگی رحم را فشار ندهید، بلکه اطمینان حاصل کنید که در حین ماساژ با حرکات دایره ای، فشار قوی به پشت مریض وارد می کنید. رحم را ماساژ دهید تا خیلی سخت شود. هنگام انقباض باید مانند یک سنگ 01 سانتی متری در قسمت پایین شکم باشد. تا زمانی که رحم منقبض نشده است )سخت( ماساژ را متوقف نکنید. مطمئن شوید که رحم پس از توقف ماساژ رحم شل )نرم( نمی شود. اگر آرام شد، ماساژ را از سر بگیرید. به طور مداوم خونریزی واژینال ) مهبلی ( را دوباره ارزیابی کنید. علایم حیاتی را مکرر انجام دهید. egahrromeh mutraptsop rof egassam eniretU 71 egap مساژ بالای رحم به خاطر خونریزی های بعد از زایمان قول 671 مهارت دوران خون: کنول زدن وریدی قرار دادن کنول وریدی (بزرگسال) قرار دادن کنول وریدی یک مهارت ضروری برای تداوی شاک است. اگر یک فرد بالغ هر گونه اعراض و علایم شاک را نشان داد، دو کنول با سوراخ بزرگ )41 یا 61 گیج( وارد کنید. کنولا، مایعات وریدی مورد ضرورت، تورنیکیت، دستکش، پانسمان برای پوشاندن کنولا و سواب الکولی را آماده کنید. دستکش بپوشید. یک باند یا دستکش الاستیک را در اطراف بازو قرار دهید تا به عنوان یک گیره موقت برای کمک به پر شدن وریدها عمل کند )این "تورنیکیت" با مورد بالا متفاوت است و نباید آنقدر سخت باشد که جریان خون شریانی را قطع کند(. از قرار دادن کانول وریدی در هر بازویی که ممکن است فیستول برای تداوی مریضی کلیوی داشته باشد، خود داری کنید. به تعقیب وریدی باشید که هموار است. از اوعیه ای که نبض دارند اجتناب کنید. اگر فردی در شاک باشد، پیدا کردن رگ ممکن است دشوار باشد. در این مورد، یک ورید در حفره پیش کوبیتال )جایی که آرنج خم میشود، به شکل پایین نگاه کنید( جستجو کنید. از الکول یا سایر پاک کننده های مناسب جلد برای پاک کردن جلد اطراف ورید که قصد استفاده از آن را دارید استفاده کنید. کانول را از طریق جلدی که صدمه دیده یا عفونی به نظر می رسد وارد نکنید. کنولا را آماده کنید. آماده سازی ممکن است بسته به منابع محلی و انواع کنولا متفاوت باشد. به مریض بگویید که چه کار می کنید. پوشش ایمنی روی کنول را بردارید )تنها چیزی که باید وارد شود سوزن با کنول پلاستیکی است(. سوزن را مستقیما ًبالا و در راستای ورید تا حد امکان هموار و موازی با جلد وارد کنید. هنگام ورود به ورید مراقب فلاش بک )فلش خون در کنولا( باشید. اگر خون دارای خاصیت فورانی منظم است، احتمالا ًبه شریان برخورد کرده اید و باید سوزن/کتیتر را بردارید و حداقل به مدت 5 تا 10 دقیقه به محل فشار محکمی وارد کنید. پس از مشاهده مقدار خون، سوزن را چند میلی متر جلوتر وارد کنید، سپس کنول پلاستیکی را روی سوزن به طور کامل وارد رگ مریض کنید. )وقتی شروع به حرکت کنول پلاستیکی می کنید، اجازه ندهید سوزن به سمت جلو حرکت کند.( کنول را در جای خود نگه دارید، به قاعده کنول فشار وارد کنید )برای مسدود کردن آن و توقف جریان خون( و سوزن را بیرون بکشید و کنول را در ورید قرار دهید. در صورت نیاز، خون را بردارید تا برای آزمایشات لابراتواری ارسال شود. تورنیکت وریدی را بردارید و یک مقدار نارمل سلین را وارد کنول کنید. در انتهای کنول یک کلاهک بگذارید، کنول را به خوبی محکم کنید و محل را پانسمان کنید. تاریخ درج کنول در را ثبت کنید. مطمئن شوید که سوزن در بکس مصئوون xob ytefas قرار داده شده است. روزانه محل کانول وریدی را برای علایم انتان مانند سرخی جلد، درد و پندیدگی بررسی کنید. اطمینان حاصل کنید که کنول هنوز در ورید است و در جلد کنار ورید قرار ندارد و اجازه نمی دهد مایع زیر جلد تزریق شود و باعث درد و پندیدگی شود. در صورت هر گونه نشانه ای از پندیدگی یا انتان، کنول وریدی را بردارید و مجددا ارزیابی کنید. assof latibucetna ni VI 61 egap تطبیق وریدی در جوف آرنج کتاب دستور عملیات اشتراک کننده گان 771 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE قرار دادن کانول وریدی (اطفال) ابتدا سعی کنید کانولا را در دست کودک قرار دهید. محل های دیگری که می توان برای قرار دادن کانول استفاده کرد عبارتند از: وریدهای جلد سر وریدهای خارجی گردن niev raluguJ وریدهای ناحیه قدامی آرنج وریدهای فمورال یا ران هنگام آماده شدن برای کنول زدن وریدی در کودکان، از دستیار یا والدین دیگری بخواهید که بازوی کودک را ثابت نگه دارد. یک کانول گیج 12 یا 32 آماده کنید. هنگام قرار دادن کانولا در پشت دست، دست را خم نگه دارید تا مانع از بازگشت وریدی شود و وریدها نمایان شوند. در صورت نیاز یک «تورنیکت وریدی» )مانند بالا( قرار دهید. اگر از تورنیکت وریدی استفاده می کنید، حتما فراموش نکنید که آن را بردارید. کانول را با استفاده از همان تکنیکی که در بزرگسالان استفاده می شود وارد کنید. مجددا ًمطمئن شوید که خون به آرامی از کتیتر جریان می یابد و پمپ نمی کند. پس از قرار دادن، در صورت نیاز برای بررسی لابراتواری، خون را خارج کنید. تورنیکیت را بردارید و پس از قرار دادن کانولا را با مقدار کمی نارمل سلین شستشو دهید. کانولا را به خوبی محکم کنید. بچه ها سعی می کنند کانولا را خارج کنند و پانسمان ها را باز کنند. از قرار دادن یک تکه نوار پلاسترکه در اطراف بند دست و پا قرار می گیرد خودداری کنید زیرا ممکن است جریان خون را محدود کند. اگر وریدی در نزدیکی مفصل )دست، حفره جلویی، ناحیه فمورال( قرار گرفته است، مفصل را اتل کنید تا از خم شدن آن جلوگیری کنید و از جریان مایع وریدی به داخل آن جلوگیری کنید، و به آرامی محل وریدی را با پانسمان های حجیم پانسمان کنید تا از کشیدن پانسمان چسبنده زیر کودک جلوگیری شود. ورید جمجمه ورید خارجی جکیولر ورید انتی کیوبیتل وریدی های سطحی خارجی دست ورید های ران ورید های بجولک ورید ها در اطفال قول 871 موقعیت های وریدی را روزانه برای علایم انتان مانند سرخی جلد، درد و پندیدگی بررسی کنید. اطمینان حاصل کنید که کانول هنوز در ورید است و در جلد کنار ورید قرار نمی گیرد تا اجازه دهد مایع به جلد تزریق شود و باعث درد، پندیدگی و منبع انتان دیگری شود. در صورت هر گونه علامت انتان، کانول وریدی را بردارید و مجددا ارزیابی کنید. مهارت دوران خون: مایعات وریدی – تنظیم حجم مایع برای شرایط خاص شاک باید با مایعات وریدی تداوی شود. حجم مایعات باید برای مریضان با سه وضعیت تنظیم شود: سوء تغذی، کم خونی شدید و اضافه بار مایعات. هنگام تجویز مایع وریدی به هر مریض، به تعقیب علایم جدید یا بدتر شدن اضافه بار مایع باشید: مشکل در تنفس، selkcarc در ریه ها، افزایش تعداد تنفس یا افزایش ضربان قلب. در صورت وجود هر یک از این علایم، مایعات وریدی را متوقف کنید و برای رجعت دهی فوری به یک مرکز و یا کمک کننده پیشرفته برنامه ریزی کنید. شناخت شرایط نیاز به تنظیم مایع وریدی در مریضان مبتلا به شاک - اضافه بار مایعات، سوء تغذی و کم خونی شدید. 1. آیا اضافه بار مایع وجود دارد؟ در بعضی از مریضان، مانند مریضان مبتلا به نارسایی قلبی یا کلیوی، ممکن است مایع اضافی در انساج )به عنوان مثال، در ریه ها یا نسج های نرم پاها( وجود داشته باشد. این مریضان حتی زمانی که اروا ضعیفی دارند )زیرا مایع اضافی در رگ های خونی وجود ندارد( ممکن است «بیش از حد» مشبوع از مایعات شوند. این مریضان در صورت شاک همچنان به مایع وریدی نیاز دارند، اما مایع وریدی باید با نظارت دقیق آهسته تر تطبیق شود تا مشکلات اضافه باری مایع بدتر نشود. dlihc a ni VI na gniruceS 02 egap dnah s'dlihc llams a ni VI gnitresnI 91 egap بی حرکت ساختن کانول وریدی در اطفال تطبیق کانول وریدی در دست طفل کتاب دستور عملیات اشتراک کننده گان 971 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE بررسی کنید: علایم اضافه بار مایعات مشکل در تنفس همراه با شنیدن صدای خش خش یا کراکل در معاینه قفس سینه اذیمای اطراف سفلی )معمولا ًدر پاها( مریض قادر به دراز کشیدن نیست وریدهای گردن متوسع شده اگر علایم اضافه بار مایعات یا daolrevO وجود دارد، باید مایعات را تنظیم کنید: مقدار کمی مایعات ممکن است داده شود )052-005 میلی لیتر بصورت بولوس در بزرگسالان( سرعت انفیوژ مایعات را کاهش دهید در صورت تشدید علایم اضافه بار مایعات )افزایش تعداد تنفس یا ضربان قلب، مشکل جدید یا بدتر شدن تنفس و افزایش کرکل در قفس سینه( از نزدیک نظارت کنید. در صورت بروز هر یک از این علایم، مایعات وریدی را قطع کنید. به یاد داشته باشید: مهم است که تطبیق مایعات را به آرامی شروع کنید تا بتوانید برای علایم اولیه اضافه بار مایعات را تشخیص ودر صورت نیاز تطبیق آنرا در زمان مناسب متوقف کنید. اگر هنگام بروز این علایم اولیه، مایع وریدی را قطع نکنید، مایع وریدی بیش از حد می تواند باعث پر شدن ریه های مریض و ایجاد مشکل شدید در تنفس یا حتی مرگ شود. 2. آیا مریض کم خونی شدید دارد؟ در مریضان مبتلا به کم خونی شدید، مایع وریدی میتواند خون را رقیق کرده و ظرفیت آن را برای حمل آکسیجن به سطوح خطرناک کاهش دهد. علاوه بر این، مریضان مبتلا به کم خونی شدید با تجویز مایع وریدی، علایم اضافه بار مایعات را سریعتر نشان می دهند. به یاد داشته باشید: فقط در صورت وجود نشانه های شاک باید به فردی که کم خونی شدید دارد مایعات وریدی بدهید )شکل را ببینید(. بررسی کنید: علایم کم خونی شدید رنگ پریدگی شدید در کف دست ها )در مقایسه با کف دست خود( یا غشاهای مخاطی. تنفس سریع یا ضربان قلب سریع گیجی یا بی قراری ممکن است علایم نارسایی قلبی/ اضافه بار مایعات نیز داشته باشد اگر این علایم کم خونی شدید وجود دارد، باید مایعات را تنظیم کنید: سرعت تزریق مایعات را کاهش دهید نظارت دقیق داشته باشید و تطبیق مایعات وریدی را در صورت بدتر شدن وضعیت مریض متوقف کنید. رجعت دهی/انتقال سریع مریض به مرکزی با قابلیت انتقال خون. 3. آیا مریض دچار سوءتغذیه شدید است؟ مایع وریدی میتواند باعث تورم تهدید کننده زندگی و نارسایی قلبی در مریضان مبتلا به سوء تغذی شود و باید با دقت زیاد تنظیم شود. مریضانی که سوءتغذیه دارند نیز در معرض خطر بسیار بالای هایپوگلایسیمی هستند. قول 081 بررسی کنید: علایم سوء تغذی علایم کودک مبتلا به گرسنگی شدید ، فاقگی یا ضایعات قابل مشاهده: کودک مبتلا به ضایعات شدید فقط لاغر به نظر نمی رسد، بلکه به طور واضح استخوانی مشاهده شده وجلد بدن بیش از حد بزرگ به نظر میرسد. بازوها، پاها و باسن ممکن است نازک باشند و سر ممکن است به دلیل ضایعات بدن بدن نسبتا ًبزرگ به نظر برسد. اذیما هر دو پا: کفش یا جوراب را بردارید و هر دو پا را از نظراذیما ارزیابی کنید. بالای پا را به آرامی با شست خود چند ثانیه فشار دهید تا ببینید آیا فرورفتگی در انساج باقی مانده است یا خیر. به یاد داشته باشید که طفل مصاب سؤ تغذی شدید لاغر به نظر نمیرسد اگر اذیمای شدید داشته باشد. اگر این علایم سوء تغذی شدید وجود دارد، باید مایعات را تنظیم کنید. [تجویز مایعات در حالت شاک )کودکی با سوء تغذی شدید( را برای انتخاب دقیق مایعات و میزان مصرف رجوع کنید] اگر مریض بتواند آن را تحمل کند، مایع خوراکی ترجیح داده می شود. افزودن دکستروز: از مایعات حاوی دکستروز استفاده کنید یا یک دوز دکستروز را با مایعات وریدی بدهید. سرعت تزریق مایعات را کاهش دهید به دقت نظارت کنید و مایعات را برای هرگونه نشانه اضافه بار مایعات متوقف کنید در اسرع وقت به تجویز مایعات از طریق فمی بروید ارزیابی اذیما (پندیدگی) دو طرفه در سوء تغذی شدید در کودکان: ضایعات شدید قابل مشاهده در کودک: از انگشت شست خود برای فشار دادن به آرامی به مدت چند ثانیه بالای هر پا استفاده کنید - اگر وقتی انگشت شست خود را بلند می کنید، کودک دچار اذیما )پندیدگی( می شود. روی پای دیگر تکرار کنید )شکل را ببینید( جلد بدن خیلی بزرگ به نظر می رسد هیچ چربی روی جلد کودک وجود ندارد خطوط اضلاع دیده می شود ضیاع شدید عضلات بازوها، پاها و باسن ممکن است به دلیل ضایعات بدن، سر نسبتا ً بزرگ به نظر برسد )شکل را ببینید( dlihc a ni gnitsaw ereves elbisiV 32 egap noitirtunlam htiw nerdlihc ni amede gnittip rof gnissessA 22 egap معاینه پندیدگی پاه ها در اطفال سوء تغذی ضایعات شدید قابل مشاهده در کودک کتاب دستور عملیات اشتراک کننده گان 181 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE مهارت های کنترول دوران خون: تجویز مایعات وریدی تجویز مایعات برای شاک در بزرگسالان محلول نارمل سلین یا s’regniR detatcaL را به کانولا وصل کنید. در بزرگسالان 1 لیتر در کمتر از 03 دقیقه تجویز شود. پاسخ مریض به تجویز مایعات را بلافاصله بعد از انفیوژن بولوس مایع ارزیابی کنید. اروا )پرکردن مجدد مویرگی، وضعیت ذهنی، تخلیه ادرار( را ارزیابی کنید و ضربان نبض و فشار خون را بررسی کنید. در صورت بهبود، ضربان نبض باید کاهش یابد و فشار خون باید افزایش یابد. وضعیت روانی نیز ممکن است بهبود یابد. بررسی اضافه بار مایعات )به علایم بالا مراجعه کنید(. اگر مریض همچنان در شاک است و شواهدی از اضافه بار مایعات وجود ندارد، 1 لیتر بولوس دیگر بدهید. اگر مریض بعد از تجویز 2 لیتر مایعات وریدی هنوز هم در شاک است، خونریزی دوامدار )خارجی و داخلی( یا آسیب نخاعی مجددا ًارزیابی کنید و با مرکز طبی پیشرفته تماس بگیرید. اگر شواهدی از سوء تغذی شدید، کم خونی شدید یا اضافه بار مایعات وجود داشته باشد: مریضان مبتلا به شاک هنوز به مایعات وریدی نیاز دارند، اما ارزیابی مجدد مکرر از نظر علایم بدتر شدن اضافه بار بسیار مهم است. برای مریضان کهن سالیکه در معرض خطر بالای اضافه بار مایعات هستند، ابتدا با 005 میلی لیتر مایع وریدی بولوس کنید، سپس مجددا ارزیابی کنید. اگر نشانه ای از اضافه بار مایعات یا مایع در ریه ها وجود نداشت، 005 میلی لیتر اضافی بدهید. تجویز مایعات برای شاک در کودکان با توجه به شواهد اخیر مبنی بر اینکه مایعات بولوس میتواند نتایج را در بعضی از کودکان بدتر کند، مقدار مناسب مایع برای کودکان وخیم بحث برانگیز است. علاوه بر این، معیارهای مرتبط برای اروا ضعیف و شاک ممکن است نظر به هر حالت متفاوت باشد. دستورالعمل های OHW در سال 6102 برای مراقبت از کودکان وخیم )به بخش منابع OHW مراجعه کنید( از وجود سه ویژگی کلینیکی برای تعریف شاک نیاز به مایعات بولوس استفاده می کند: نهایات سرد، پر کردن مجدد مویرگ ها بیش از 3 ثانیه، و نبض ضعیف و سریع. برای کودکان مبتلا به اروا ضعیف که به دلیل از دست دادن مایعات است، مانند کسانی که خونریزی، سوختگی یا اسهال/استفراغ شدید دارند، مایعات بولوس نیز توصیه می شود. برای سایر کودکانی که شواهدی از اروا ضعیف دارند، مقادیر کمتر مایعات که آهسته تر داده می شود ممکن است بی خطرتر باشد. تیم های صحی هر کشور باید هنگام تطبیق توصیه ها با شرایط ملی، تظاهرات کلینیکی کودک، ظرفیت تیم کمک کننده برای تشخیص علایم اضافه بار مایعات، و در دسترس بودن تجهیزات نظارتی و پشتیبانی را در نظر بگیرند. نحوه تجویز مایعات وریدی به کودکانیکه مبتلا به سوء تغذی شدید، کم خونی شدید و یا اضافه بار مایعات وریدی نیستند: کنول وریدی را همانطور که در بالا توضیح داده شد وارد کنید. کودک را وزن کنید یا از والدین وزن اخیر بخواهید. نارمل سلین یا رینگر لاکتات بدهید: 01 تا 02 میلی لیتر به ازای هر کیلوگرم وزن بدن در مدت 03 دقیقه. پس از اولین انفوزیون کودک را دوباره معاینه کنید. در صورت عدم بهبود، 01 میلی لیتر به ازای هر کیلوگرم وزن بدن را در مدت 03 دقیقه تکرار کنید. برای کمک تماس بگیرید و برای رجعت دهی به یک کمک کننده و مرکز پیشرفته با ظرفیت انتقال خون برنامه ریزی کنید. تجویز مایعات وریدی به کودکانیکه مبتلا به شاک و سوء تغذی هستند. کودکانی که در شاک هستند و دچار سوءتغذیه شدید هستند، به مایعات تخصصی )در صورت دسترس بودن( با سرعت های مختلف تزریق نیاز دارند. کودکانی که دچار سوءتغذیه شدید و شاک هستند در خطر بسیار بالایی از هایپوگلایسیمی قرار دارند و علاوه بر مایعات به گلوکوز نیز نیاز خواهند داشت. [به ادویه جات مراجعه کنید] اگر کودک میتواند مایعات را مصرف کند، به او محلولات احیای خوراکی با laMoSeR بدهید )مگر اینکه کودک به دلیل کولرا در شاک باشد، از SRO استفاده کنید(. اگر کودک بی حال، بیهوش است یا قادر به مصرف مایعات خوراکی نیست، مایعات وریدی بدهید. احتیاط! تزریق داخل وریدی مایعات میتواند در کودکان دچار سوءتغذیه خطرناک باشد. در حین مصرف مایعات به هر نحوی، باید هر 5 دقیقه یکبار علایم خطر زیر را بررسی کنید: بدتر شدن تنفس یا ایجاد مشکل جدید تنفسی، افزایش تعداد تنفس بیش از پنج بار در دقیقه یا افزایش ضربان قلب بیش از 51 ضربه در دقیقه. در صورت بروز هرگونه علامت خطر، مصرف مایعات را قطع کنید. قول 281 ورید مریض را طوریکه قبلا ذکر شد باز کنید. کودک را وزن کنید. 01-51میلی لیتر مایع وریدی در مقابل هر فی کیلوگرم وزن بدن ، را در مدت 1 ساعت تجویز کنید . اگر مایعات تخصصی در دسترس باشد ، یکی از موارد زیل را با توجه به دسترس بودن اش ، تطبیق کنید: رینگر لاکتات با 5% گلوکوز )دکستروز( محلول htgnertS flaH s’worraD با 5% گلوکوز )دکستروز( – 54.0% نارمل سلین با 5% گلوکوز )دکستروز(. اگر مایعات حاوی دکستروز ندارید، یکی از موارد زیر را بدهید: رینگر لاکتات و دوز خوراکی یا وریدی جداگانه دکستروز می دهد [به ادویه جات مراجعه کنید] نارمل سلین و یک دوز خوراکی یا وریدی جداگانه دکستروز بدهید. [به ادویه جات مراجعه کنید] بعد از 5 تا 01 دقیقه اول انفوزیون و سپس هر 5 دقیقه یکبار کودک را مجددا ارزیابی کنید: اگر کودک در طول پروسه احیاء مایعات بدتر شود )افزایش مشکل در تنفس، تعداد تنفس 5 در دقیقه و ضربان نبض 51 در دقیقه افزایش می یابد یا ترق ریه ایجاد میشود(: مایعات را قطع کنید. برای کمک تماس بگیرید و برای رجعت دهی به یک مرکز پیشرفته پیشرفته برنامه ریزی کنید. اگر بعد از اولین انفوزیون بهبودی حاصل نشد: برای کمک تماس بگیرید. برای رجعت دهی به یک مرکز پیشرفته با قابلیت اتتقال خون برنامه ریزی کنید. مایع را با 4 میلی لیتر در کیلوگرم در مدت 1 ساعت در حالی که منتظر انتقال به مرکز پیشرفته هستید، بدهید. اگر کودک علایمی از بهبود را نشان داد (بهبود دوباره پر کردن مویرگی، تعداد نبض کمتر و تعداد تنفس): با) laMoSeR محلول آبرسانی خوراکی کم سدیم( 01 میلی لیتر در هر کیلوگرم در ساعت به مدت حداکثر 01 ساعت به تجویز مایعات فمی یا نازوگستریک GN تغییر دهید. انتقال به مرکز سوء تغذی. ملاحظات ویژه: کودکان مبتلا به کم خونی شدید و اروا ضعیف نیاز به رجعت دهی فوری به یک کمک کننده و مرکز پیشرفته با ظرفیت انتقال خون دارند. به کودکانی که نیاز به مایعات وریدی دارند، اما در آنها مایعات بولوس تجویز نشده است، باید مایعات نگهدارنده داده شود. برای اطلاع از میزان توصیه شده مایعات نگهدارنده در کودکان به سایت انتشارات بهداشت کودک /tni.ohw.www( OHW dlihc/stnemucod/tnecseloda_dlihc_lanretam/( مراجعه کنید. مهارت های مرتبط به ارزیابی دوران خون موفق سومموفق دومموفق اولمعیارهای نشانی شده بخش مهارت مصئونیت: تجهیزات مصئونیت فردی را استفاده کنید و یا شفاهی بیان کنید مهارت 1 - دوران خون را ارزیابی کنید به تعقیب اضطراب، سرگیچی و تغیر وضعیت ذهنی باشید با معاینه نبض سرعت و کیفیت آنرا کنترول کنید. بازگشت مجدد اوعیه را ارزیابی کنید: بیش از 3 ثانیه نشان دهنده اروا ضعیف است رنگ و حرارت جلد را ارزیابی کنید کتاب دستور عملیات اشتراک کننده گان 381 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE برای اندازه گیری سایر علایم حیاتی: تعداد تنفس و فشار خون، به صورت شفاهی گزارش دهید. نظریات مهارت 2 - کنترول خونریزی: فشار مستقیم دستکش بپوشید: با استفاده از گاز و یا دیگر مواد پانسمانی تمیز و غیر چسپنده بروی زخم فشار وارد کنید. تا حد امکان مستقیما ًبه منبع خونریزی فشار قوی وارد کنید، معمولا ًبا دو یا سه انگشت نشان دهید که چگونه یک اندام با زخم را بالاتر از قلب قرار دهید متوجه باشید که پانسمان اولی را حذف نکنید پانسمان دوم را با فشار محکم در زمانی که زخم همچنان به خونریزی ادامه می دهد اعمال کنید نظریات: مهارت 3 - کنترول خونریزی: پانسمان عمیق زخم دستکش بپوشید زخم عمیق و یا زخم باز نیاز با پانسمان عمیق با اعمال فشار دارد. نبض، پر شدن مجدد عروق شعریه و حسیت را پس از پانسمان یا اتل زدن هر زخمی ارزیابی می کند قبل از پانسمان زخم را با یک لیتر اب پاک شستشو کنید.. با استفاده از گاز یا کدام مواد پانسمانی پاک دیگر، شکاف زخم را پر یا پاک کنید. گاز اضافی را در بالای سطح زخم قرار دهید و با دستکش خود یا بنداژی که به طور محکم در اطراف زخم یا اندام پیچیده شده فشار مستقیم وارد کنید. اگر زخم روی نهایات است و نیاز به پانسمان دارد، برای کاهش خطر خونریزی مجدد، از اتل استفاده کنید. نبض، پر شدن مجدد عروق شعریه ها و احساس را پس از پانسمان یا اتل زدن هر زخمی ارزیابی می کند بیان کنید که یک پانسمان زخم عمیبق به دلیل خطر انتان نباید بیش از 42 ساعت در جای خود باقی بماند نظریات: قول 481 مهارت 4 - کنترول خونریزی: تورنیکیت خونریزی شدید و دوامدار استطباب استفاده از تورنیکیت است. در صورت که قصد دارید از کاف فشار خون یا نوار ضخیم یا تکه پارچه یا کمربند )هرچه پهن تر، بهتر( پس از پوشاندن جلد با تکه و یا گاز جلد استفاده کنند. مکان مناسب برای تورنیکه را مشخص می کند باید تورنیکیت را تا زمانی که نبض های دیستال ناپدید شوند، محکم کنید. سپس خونریزی را دوباره ارزیابی کنید تا ببینید آیا متوقف شده است یا خیر به یاد داشته باشید که تورنیکیت را در محلش ثابت کنید. به یاد داشته باشید که تورنیکیت را هر دو ساعت یکبار برای ده دقیقه برای به جریان انداختن مجدد خون سست کنید. به خاطر داشته باشید که زمان بستن تورنیکیت را یادااشت کنید. از یاد نبرید که استفاده تورنکیت به مدت بیشتر از 2ساعت باید به مشورت مراجع معتبر طبی صورت گیرد نظریات: مهارت ۵ – ماساژ رحم برای خونریزی پس از زایمان به یاد داشته باشید که درخواست کمک نموده و پروسه انتقال و تحویل دهی مریض را شروع کنید استطباب انجام ماساژ رحم را بدانید. نیاز به تهیه اکسیتوسین و مایع وریدی را بفهمید متوجه باشید که هدف فشردن رحم بین دست و ساختمانهای استخوانی پشت رحم است نشان دهید که چگونه رحم را از طریق جدار بطن درزیر دست خود نگه میدارید نحوه اعمال فشار قوی به پشت مریض را در حین ماساژ با حرکات دایره ای نشان می دهد بیان کنید که ماساژ نباید تا زمان انقباض رحم متوقف شود )احساس سختی می کند( متوجه باشید که رحم پس از توقف ماساژ رحم نباید شل شود )نرم(. اگر چنین شد، ماساژ رحم را از سر بگیرید از یاد نبرید که باید به طور مداوم خونریزی واژینال ) مهبلی ( را مجددا ًارزیابی کند و علایم حیاتی مکرر را انجام دهد نظریات: مهارت 6 - قرار دادن کانول وریدی تجهیزات را آماده کنید: دستکش، کانول VI، ست سیروم، مایعات، تورنیکت VI، سواب الکول به بیمار بگویید که در حال انجام چه کاری هستید کتاب دستور عملیات اشتراک کننده گان 581 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE تورنیکیت VI را روی اندام قرار دهید یک ورید مستقیم را شناسایی کنید جلد روی رگ را تمیز کنید پوش محافظتی کانول را بردارید و کانول را وارد کنید، کانول را هموار و در راستای رگ نگه دارید. وقنی خون در کانول جریان کرد سوزن را کمی به جلو ببرید و سپس کانول را روی سوزن به داخل ورید بکشید این را در جای خود نگه دارید و سوزن را در حالی که بر نهایی یا نوک کانول فشار می آورید خارج کنید از یاد نبرید که روزانه ناحیه کانول وریدی را برای ارزیابی سرخی یا علایم انتان بررسی کنند نظریات: مهارت ۷ - تشخیص شرایطی که نیاز به تنظیم مجدد مایع وریدی دارند ملاحظات ویژه برای احیای مایعات را بیان کنید: سوء تغذی / کم خونی شدید / اضافه بار مایعات نحوه ارزیابی اضافه بار مایعات را بیان کنید: مشکل در تنفس همراه با خش خش یا کراکل در معاینه قفس سینه، پندیدگی پایین بدن )معمولا ًدر پاها(، ناتوانی در دراز کشیدن به دلیل تنگی نفس، توسع رگهای گردن. راه های تنظیم مایعات در مریضان شاک با اضافه بار مایعات را بیان کنید: مقدار کمی مایعات )052-005 میلی لیتر بولوس در بزرگسالان( سرعت مایعات را کاهش دهید از نظر علایم بدتر شدن اضافه بار مایعات به دقت نظارت کنید نحوه ارزیابی علایم کم خونی شدید را به صورت شفاهی بیان کنید راه های تنظیم مایعات در مریضان مبتلا به کم خونی شدید را بیان کنید: سرعت تطبیق مایعات را کاهش دهید برای علایم اضافه بار مایعات به دقت نظارت کنید نیاز به رجعت دهی/انتقال سریع به مرکزی که قادر به انتقال خون باشد را بیان کنید نحوه ارزیابی تحلیل عضلی در سوء تغذی شدید را به صورت شفاهی بیان کنید نحوه ارزیابی اذیما )پندیدگی( دو طرفه در پا را نشان دهید راه های تنظیم مایعات در مریضان مبتلا به سوء تغذی شدید را بیان کنید: در صورت امکان مایعات فمی بدهید دکستروز را به مایعات وریدی اضافه کنید یا با مایعات وریدی دکستروز بدهید سرعت مایعات را کاهش دهید برای علایم اضافه بار مایعات به دقت نظارت کنید نظریات: قول 681 مهارت 8 – احیای مایع وریدی برای شاک به خاطر داشته باشید که تطبیق مایعات وریدی در مریضان مبتلا به سوء تغذی و یا کم خونی شدید باید به احتیاط صورت گیرد. تجویز مایعات برای بزرگسالان باید به صورت نارمل سلین یا رینگر لاکتات باشد تجویز مایعات برای حالت شاک در بزرگسالان باید 1 لیتر در کمتر از 03 دقیقه داده شود اروا را ارزیابی کنید، اگر هنوز مریض در شاک است، 1 لیتر بولوس دیگر در کمتر از 03 دقیقه بدهید متوجه باشید که اگر بعد ازتطبیق 2 لیتر مایعات وریدی همچنان در شاک هستید، مشکوک بهخونریزی دوامدار باشید و برای رجعت دهی به مراقبت های سطح بالاتر برنامه ریزی کنید. در صورت وجود سوءتغذیه شدید، کم خونی شدید یا اضافه بار مایعات، میکانیزم را برای اصلاح مایعات برای بزرگسالان ارائه دهید: مایع را در بولوس های کوچکتر بدهید و مرتبا ًبرای علایم بدتر شدن اضافه بار مایعات ارزیابی کنید. علایم اضافه بار مایعات عبارتند از: مایع در ریه ها و مشکل در تنفس اذیما )پندیدگی( مریض نمیتواند هموار دراز بکشد وریدهای گردن متوسع شده برای کودک در شاک )بدون سوء تغذی شدید، کم خونی یا اضافه بار(: وزن کودک را بدست آورید 01 تا 02 میلی لیتر/کیلوگرم نارمل سلین یا رینگر لاکتات در مدت 03 دقیقه بدهید. بعد از بولوس مجددا ًارزیابی کنید، در صورت عدم بهبود، بولوس را تکرار کنید اگر شاک ادامه داشت، انتقال دهید برای کودک در شاک )با سوء تغذی شدید، کم خونی یا اضافه بار(: کودک را وزن کنید مطلع باشید که این کودکان به مایعات وریدی تخصصی نیاز دارند - رینگر لاکتات با 5% گلوکوز محلول htgnertS flaH s’worraD با 5% گلوکوز 54.0% )نیم( نارمل سلین با 5% گلوکوز 01-۵1 gk/Lm مایع وریدی را در مدت 1 ساعت به بدن بدهید در حین دریافت مایعات، کودک را هر 5 تا 01 دقیقه دوباره ارزیابی کنید در صورت عدم بهبود، انتقال را بیان کنید در صورت بروز علایم اضافه بار مایعات، برای قطع مایع وریدی در هر مریض به صورت شفاهی صحبت کنید نظریات: نخیربلیشایستگی نشان داده شده است نخیربلیاصلاح مورد نیاز است امضای استاد رهنما: کتاب دستور عملیات اشتراک کننده گان 781 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE 4. بخش های مهار ت معاینه عمومی بدن: بخش مهارتی معاینه فیزیکی گسترده یا وسیع بدن: معاینه اعصاب مقیاس کوما گلاسکو (SCG) SCG یک مقیاس 51 درجه ای برای ارزیابی و نظارت بر افراد مبتلا به آسیب سر است. فرد از نظر باز شدن چشم، پاسخ کلامی و حرکتی مورد ارزیابی قرار می گیرد و برای بالاترین سطح عملکرد در هر ناحیه نمره می گیرد. مجموع نمرات برای تعیین امتیاز کلی استفاده میشود. هر چه نمره کمتر باشد، آسیب سر ممکن است شدیدتر باشد. لطفا توجه داشته باشید که کمترین نمره ای که یک مریض میتواند دریافت کند 3 است. آسیب شدید سر - SCG 8 یا کمتر آسیب متوسط سر - SCG 9-21 آسیب سر خفیف - SCG 31-51 محاسبه نمره کوما گلاسکو (SCG) امتیاز کوما گلاسکو )SCG( نمرهپاسخعملکرد 4خود به خود باز میکندچشم )4( 3با فرمان باز میکند 2به تحریک درد باز میکند 1هیج 5نارملکلامی )5( 4صحبت های گیج کننده 3کلمات نامناسب 2صداهای نامناسب 1هیچ 6فرمان را اطاعت می کندتحرک )6( 5درد را تعیین موقعیت می کند 4اندام ها را به طور معمول به درد خم می کند 3اندام ها را به طور غیر نارمل به درد خم می کند 2اندام ها را تا حد درد بسط می دهد 1هیچ اندازه گیری UPVA مقیاس UPVA یک ارزیابی ساده است که میتواند با ارزیابی پاسخ به تنبهات، نشانه ای از سطح هوشیاری به شما بدهد. مقیاس UPVA به ویژه برای کودکان و نوزادان مفید است. A = هوشیار: افرادی که کامًلا بیدار هستند و تعاملی دارند )حتی اگر کامًلا جهت گیر نباشند( هوشیار هستند. V = صدا: کسانی که کاملا هوشیار نیستند )ممکن است چشمانشان بسته باشد یا خواب آلود به نظر برسد(، اما بدون تماس کردن به صدا پاسخ می دهند )پاسخ ممکن است کلمات، ناله یا حرکت باشد(. P = درد: کسانی که به صدا پاسخ نمی دهند، اما به درد عکس العمل نشان می دهند: مالش سخت قفس سینه )استرنوم( در بزرگسالان، نیشگون یا چندی گرفتن کف پا در کودکان، یا نیشگون گرفتن به پل بینی در موارد مشکوک به آسیب نخاعی. پاسخ ممکن است کلمات، ناله یا حرکت باشد. قول 881 U = پاسخگو نیست. کسانی که هیچ حرکت یا پاسخ کلامی به تنبهات دردناک نمی دهند، عکس العملی نشان نمی دهند. برای هر مریضی که در مرحله P یا U در مقیاس UPVA است، توقف کرده و به EDCBA برگردید زیرا ممکن است برای محافظت از طرق هوایی نیاز به مداخله سریع باشد. بخش معاینه فزیکی وسیع و ارزیابی ثانوی تروما بررسی ثانوی )ارزیابی سر تا پا( از یک فرد آسیب دیده تنها زمانی انجام می شود که EDCBA تکمیل شده باشد و عوارض تهدید کننده زندگی برطرف شده باشند. هدف از ارزیابی سر تا پا شناسایی تمام آسیب ها، برنامه ریزی مدیریت مداوم و برنامه ریزی وضعیت مناسب است. اگر وضعیت فرد در طول ارزیابی سر تا پا بدتر شد، فورا EDCBA را متوقف کرده و مجددا ارزیابی کنید. مطمئن شوید که لباس ها را درآورده اید اما فرد را با روپوش، ملحفه یا پتو گرم نگه دارید. برای این جلسه از بخش کتاب تمرین در مورد بررسی ثانوی از مودل AMUART استفاده کنید. ارزیابی بخش مهارت معاینه فیزیکی وسیع موفق سومموفق دومموفق اولمعیارهای علامت گذاری بخش مهارت مصئونیت: از تجهیزات فردی استفاده شود و یا شفاهی بیان گردد ارزیابی صدمهی سر تا پا مهارت 1 - معایته TNEEH به جلد سر، صورت، چشم ها و در دهان، بینی، گوش ها نگاه کنید به صداهای استریدور با وصف جوشیدن آب یا سایر صداهای طرق هوایی گوش دهید متوجه حرکات غیرطبیعی استخوان های صورت یا الاشه ، لق شدن دندان ها یا کرپیتوس را احساس کنید. نظریات: مهارت 2 - معاینه گردن به دنبال جراحات گردن،تروما، هماتوم ویا وریدهای متوسع عنق باشید احساس وجود هوا در انساج یا درد/تغییر شکل ستون فقرات گردنی کاهش توانائی در حرکت گردن یا درد را بررسی کنید نظریات: مهارت 3 - معاینه قفس سینه به تعقیب کبودی، حرکت ناهموار قفس سینه و یا سوختگی باشید به صداهای تنفسی، صداهای خفه شده قلب گوش دهید با جس تماس به دنبال کریپیتیشن باشید. نظریات: کتاب دستور عملیات اشتراک کننده گان 981 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE مهارت 4 - معاینه شکم به تعقیب اتنفاخ بطن، زخم، کبودی، سوختگی باشید بدنبال حساسیت بعداز فشار بالای بطن، شخی و یا موقعیت درد باشید نظریات: مهارت ۵ – معاینه لگن خاصره و دستگاه بولی تناسلی به تعقیب کبودی، پارگی، خون، نعوذ طولانی، رنگ ادرار باشید متوجه بی ثباتی و حساسیت در لگن خاصره یا حوصله باشید. نظریات: مهارت 6 - معاینه نهایات به تعقیب پندیدگی، کبودی، تغییر شکل یا شکستگی باز، زخم و اندام کم رنگ باشید. متوجه احساس نبض، اندام سرد، حساسیت، اجزای محافظه عضلی سفت/ دردناک باشید نظریات: مهارت ۷ – معاینه ستون فقرات/کمر مریض را با کمک دیگران توسط روش لاگ رول بچرخانید به تعقیب کبودی یا تغییر شکل باشید بدنبال حساسیت، تغییر شکل در ستون فقرات و کتف باشید نظریات: مهارت 8 - معاینه جلد به تعقیب کبودی، ساییدگی، پارگی، سوختگی باشید نظریات: نخیربلیشایستگی نشان داده شده است نخیربلیاصلاح مورد نیاز است امضای استاد رهنما: قول 091 ۵ . مهارت های مرتبط به بی حرکت کردن عملکرد بی حرکتی ستون فقرات دو نوع بی حرکت ساختن ستون فقرات وجود دارد: ستون فقرات گردنی و ستون فقرات صدری سینه/کمر. هردوی اینها با هم بی حرکت ساختن کامل ستون فقرات نامیده می شوند. بی حرکتی استخوان ها را تثبیت می کند تا از آسیب بیشتر به ستون فقرات جلوگیری شود. بیحرکتی ستون فقرات را برای هر فردی با سابقه پولی تروما که بیهوش است انجام دهید. یا کسی که هوشیار است و درد گردن، حساسیت ستون فقرات، بی حسی یا ضعیفی دارد. به یاد داشته باشید، مریضان تثبیت شده نمی توانند به طور طبیعی حرکت کنند و در معرض خطر انسداد )بندش( طرق هوایی )توسط ترشحات یا استفراغ( و ایجاد زخم بستر هستند. بنآ از نزدیک تحت مراقبت داشته باشید. بخش مهارت بی حرکتی: بی حرکت ساختن ستون فقرات گردنی برای بی حرکت کردن ستون فقرات گردنی: مریض را هموار به پشت و رو به بالا روی یک سطح هموار مانند تخت نگه دارید. به مریض بگویید که چه کار می کنید. سر مریض را در موازی با ستون فقرات با دو دست در دو طرف سر نگه دارید. از حرکت گردن مریض با مواد قابل دسترس در محل )پیچاندن دستمال، روزنامه، کیسه ریگ، یا کیسه های مایعات وریدی( یا گردن بند در صورت وجود جلوگیری کنید. این ها را می توان با چسب پلاستر روی سر محکم کرد اما هرگز نباید روی بستر مریض محکم شود. )اگر مریض استفراغ کند، نمی توانید او را بچرخانید و در صورت از بین رفتن، چسب پلاستر میتواند باعث آسیب به ستون فقرات گردن شود.( اگر مریض استفراغ کرد، از تکنیک llor-gol استفاده کنید )به زیر مراجعه کنید( تا کل مریض را به پهلوی خود بچرخانید و سر را در راستای بدن نگه دارید. همیشه یک نفر را در کنار مریض نگه دارید تا طرق هوایی را زیر نظر داشته باشد. به یاد داشته باشید، مریضی که درد/آسیب شدید در جای دیگر بدن دارد ممکن است نتواند درد گردن را احساس کند، حتی اگر دچار شکستگی باشد. یک میکانیسم نگران کننده باید باعث شک شود در این مریضان. کتاب دستور عملیات اشتراک کننده گان 191 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE بخش مهارت بی حرکت کردن : LLOR GOL برای جابجایی هر مریض تثبیت شده یا هر فردی که مشکوک به آسیب ستون فقرات است )مثًلا اگر مصدوم استفراغ میکند یا نیاز به انتقال دارد(، از تکنیک llor-gol استفاده کنید )شکل را ببینید(: کمک بخواهید. در حالت ایده آل، یک نفر طرف سر داشته باشید که گردن را بگیرد، یک یا دو نفر برای نگه داشتن بدن و یک نفر برای پاها. کمک کننده در سر باید سر، گردن و بالاتنه را در موازی با بقیه ستون فقرات نگه دارد. کمک کننده باید ساعد خود را محکم در کنار سر قرار دهد و با دست هایی که شانه ها را گرفته باشد، سر و گردن را در یک خط با بقیه ستون فقرات نگه دارد. هم سطح بودن بدن را هنگام دور دادن مصدوم حفظ کنید. فردی که سر و گردن را کنترول می کند، تیم را رهبری می کند و می گوید: «1-2-3 رول» تا زمان بندی چرخش را برای همه دستیاران راهنمایی کند. با هم کار کنید، مریض را به پهلو دور بدهید و ستون فقرات را در یک خط نگه دارید. در طول رول، شخصی که کنترول سر و گردن را انجام می دهد باید اطمینان حاصل کند که ستون فقرات گردنی با بقیه ستون فقرات هم سطح است. افرادی که بدن را می چرخانند باید اطمینان حاصل کنند که بقیه ستون فقرات تا حد امکان در یک خط مستقیم باقی می ماند. هنگامی که مریض به یک طرف قرار داده می شود، کمک کننده میتواند پشت را معاینه کند، تخته ثابت نگهدارنده ستون فقرات را بگذارد یا بردارد و/یا زخم های کمر را در صورت نیاز مراقبت کند. برای اینکه مریض را دوباره در حاالت استجاع ظهری قرار دهید، شخصی که سر و گردن را کنترول می کند از دستور «1-2-3 llor» برای اطمینان از حرکت هماهنگ استفاده می کند. همیشه یک بک بورد را در اسرع وقت با استفاده از تکنیک llor-gol بردارید. زمان روی تخته ثابت نگهدارنده ستون فقرات خطر ابتلا به زخم بستر را افزایش می دهد. نواحی فشار را مرتبا ًبا استفاده از llor goL بررسی کنید. llor gol rof gniraperP 42 egap آماده کردن مریض به شیوه لاگ رول قول 291 بخش مهارت بی حرکتی: بی حرکتی کامل ستون فقرات برای بی حرکت کردن ستون فقرات سینه ای و کمری )به بخش قبلی برای بیحرکتی ستون فقرات گردنی مراجعه کنید(: ستون فقرات گردنی را مانند بخش قبل بی حرکت کنید. فرد را روی یک سطح هموار نگه دارید و دستور دهید که هموار بخوابد و حرکت نکند. برای حمل و نقل، چوب را روی یک سطح هموار )مانند تخته پشتی( قرار دهید تا از حرکت ستون فقرات جلوگیری شود. تخته پشتی را به تخت نچسبانید، زیرا در صورت نیاز نمی توانید رول را وارد کنید )به بالا مراجعه کنید(. قبل از بی حرکت کردن، مطمئن شوید که هیچ شیشه یا زباله ای در پشت یا زیر کمر مریض وجود ندارد. برای بررسی از لاگ رول llorgol استفاده کنید. مریضان بی حرکت باید به طور منظم برای جلوگیری از زخم های نقطه فشار بررسی شوند. اگر فرد استفراغ میکند، از تکنیک لاگ رول llor-gol استفاده کنید تا فرد را به پهلو قرار دهید تا استفراغ وارد طرق هوایی نشود. تخته ستون فقرات فقط باید برای جابجایی مریضان استفاده شود. گذاشتن مریضان روی تخته های ستون فقرات برای مدت طولانی میتواند باعث ایجاد زخم فشاری شود. مریضان را به محض ورود به مرکز از تخته ها خارج کنید و می توان آنها را به حالت استجاع ظهری قرار. بخش مهارت بی حرکتی: وضعیت دهی خانم حامله اگر مریض بالای 02 هفته حمل دارد و نیاز به بی حرکتی ستون فقرات دارد، ستون فقرات را مانند بالا بی حرکت کنید. سپس بالشتک را در زیر کنار تخته نزدیک پشت و باسن قرار دهید تا مریض به سمت چپ کج شود. این به جلوگیری از فشرده شدن ورید اجوف سفلی توسط رحم محمل کمک می کند که میتواند بازگشت خون به قلب را کاهش دهد. tneitap a gnivom rof noitazilibommi lanipS 52 egap آماده کردن مریض به شیوه لاگ رول کتاب دستور عملیات اشتراک کننده گان 391 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE بخش مهارت بی حرکتی: وضیعت ریکاوری اگر مریض بیهوش یا نیمه هوشیار است و اگر صدمه وجود ندارد، مریض را روی پهلوی چپ قرار دهید. با خم کردن پای بالایی به جلو، مریض را تثبیت کنید. بازوی چپ باید هموار باشد و سر مریض روی بازو قرار گیرد تا سر را بالا بیاورد و دهان را به سمت پایین قرار دهد. این موقعیت باعث می شود که استفراغ و سایر ترشحات با خطر کمتر انسداد )بندش( طرق تنفسی از دهان خارج شوند. به این موقعیت ریکاوری می گویند )شکل را ببینید(. noitisop yrevoceR 62 egap آماده کردن مریض به شیوه ریکوری قول 491 بخش مهارت بی حرکتی: بی حرکتی شکستگی غیر متحرک ساختن شکستگی از اتل ها برای بی حرکت کردن اطراف های مشکوک به شکستگی، جلوگیری از درد ناشی از حرکت استخوان های شکسته و به حداقل رساندن خونریزی و آسیب بیشتر استفاده می شود. همیشه اروا نهایات را فراتر از شکستگی با ارزیابی نبض ها و زمان پر شدن مجدد مویرگی ارزیابی و ثبت کنید. همیشه نبض ها، پر شدن مجدد مویرگ ها و حسیت را قبل و بعد از پانسمان یا اتل گذاری هر زخم، ارزیابی کنید. در صورت عدم اروا )سردی اندام، رنگ پریدگی، بدون نبض، آهسته یا عدم پر شدن مجدد مویرگ ها(، ارجاع مجدد )کاهش( سریع اندام برای بازگرداندن دوران خون مورد نیاز است. اگر پس از تنظیم مجدد طرف هنوز اروا وجود ندارد، اتل را ببندید و برای رجعت دهی/انتقال سریع به یک واحد متخصص برنامه ریزی کنید. اگر نمی توانید طرف را دوباره راسته یا ارجاع کنید، سریعا ًبه یک مرکز صحی پیشرفته رجعت دهی دهید. هدف از مدیریت شکستگی: بازگرداندن دوران خون تداوی و کاهش درد از صدمات و خونریزی بیشتر جلوگیری کنید قطعات استخوانی را مجددا ًارجاع کنید تا التیام و پیوند انجام شود و عملکرد طبیعی بازیابی شود مواد اتل گذاشتن عبارتند از: پخته برای محافظت از جلد و ایجاد پندیدگی اتل از پیش ساخته شده یا منابع محلی استفاده شود بنداژ برای محکم کردن اسپلینت نوار چسب )گچ( قبل از استفاده از اتل، به فرد بگویید که چه کاری انجام می دهید و درد را تسکین دهید. لباس ها را درآورید تا آسیب را به وضوح ببینید. تمام جواهرات را بردارید. نبضان، پر شدن مجدد مویرگ ها، احساس و حرکت اطراف را بررسی کنید. این را قبل و بعد از استفاده از اسپلینت متوجه باشید. اندازه اسپلینت را طوری تنظیم کنید که مفصل بالا و پایین محل شکستگی را بی حرکت کند. اگر طرف به طور مشهود تغییر شکل داده است و نبض های فراتر از شکستگی ضعیف یا وجود ندارد، ابتدا شکستگی را قبل از استفاده از اسپلینت هموار کنید )راست کنید(. اگر عضو دارای نبض خوبی است، مجددا ًاقدام به راست کردن آن نکنید. مفصل را در موقعیت مورد نظر قرار دهید و اگر انگشتان دست و پا صدمه دیده باشد، بین انگشتان پا و انگشتان دست پد قرار دهید. اگر گاز جورابی در دسترس است، آن را روی عضو بدون چین و چروک قرار دهید تا از صدمه جلد جلوگیری شود. سمتی از اتل را که در تماس با جلد قرار خواهد گرفت، و عضو مخصوصا ًبرآمدگی های استخوانی )مانند آرنج( را بالشتک بزنید. برای نگه داشتن اتل، طرف و اتل را با بنداژ بپیچید. از مریض بپرسید که چه احساسی دارد مطمئن شوید که خیلی سخت نیست. اتل باید محکم باشد، اما به یاد داشته باشید که طرف متورم می شود، بنابراین مهم است که اتل و بنداژ خیلی سخت نباشد. نبض، احساس و حرکت اندام را پس از استفاده از اسپلینت و هر یک ساعت پس از آن بررسی کنید. کتاب دستور عملیات اشتراک کننده گان 591 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE بی تحرکی شکستگی: باز اگر زخم در نزدیکی محل شکستگی وجود دارد، شکستگی باز را در نظر بگیرید. محل های شکستگی باز اغلب ممکن است آلوده باشند و قبل از رفع شکستگی نیاز به تمیز کردن و دبریدمان بالقوه جراحی دارند. اگر مشکوک به شکستگی باز است، پس از اتل بندی، برای رجعت دهی/انتقال به یک مرکز جراحی یا ارتوپدی برنامه ریزی کنید. قبل از اسپلینت کردن، درد را تسکین دهید. کنترول خونریزی با فشار مستقیم. در قطع اندام اگر خونریزی کنترول نشده از تورنیکه استفاده کنید )به بالا مراجعه کنید(، احیای مایع را شروع کنید و برای رجعت دهی/انتقال سریع برنامه ریزی کنید. در صورت وجود علایم اروا ضعیف یا عدم وجود نبض در اطراف اندام را هموار کنید )کاهش دهید(. هرگونه ملوث کننده، شیشه آشکار یا سایر منابع انتان را از زخم جدا کنید و زخم را با 2 لیتر نارمل سلین شستشو دهید. زخم را با گاز مغطوس شده با سلاین بپوشانید. مانند بالا اتل بزنید، اما یک پنجره بگذارید تا بتوانید به نظارت بر زخم ادامه دهید. در قطع عضو، زخم را با گاز یا استریل و مغطوس شده با نارمل سالین بپوشانید. واکسن تیتانوس بدهید. انتی بیوتیک های وریدی را شروع کنید. بخش مهارت بی حرکتی: استفاده از بنداژ لگن خاصره شکستگی لگن خاصره میتواند با آسیب رساندن به رگ های خونی مجاور شکستگی ها باعث خونریزی خطرناک شود. اگر مصدوم و درد در ناحیه لگن خاصره و اطراف آن دارد، از یک تکه پهن بزرگ استفاده کنید )شکل ها را ببینید(. از آنجایی که لگن خاصره به صورت حلقه ای شکل می گیرد، باندر استخوان های جابجا شده را کنار هم می آورد و به محدود کردن خونریزی داخلی کمک می کند. علایم شکستگی لگن خاصره شامل درد یا حرکت غیر نارمل لگن خاصره در معاینه است. کبودی در اطراف باسن، بالای پاها یا اندام تناسلی؛ و اعراض و علایم شاک. ملحفه تخت یا مشابه آن را زیر لگن قرار دهید. اگر ملحفه پهن است، آن را تا کنید تا از قسمت پایینی پشت تا انتهای باسن باز شود. ممکن است نیاز داشته باشید که مریض را به پهلو قرار دهید تا بایندر در موقعیت خود قرار گیرد. ورقه باید روی تروکانترهای بزرگتر )استخوان های لگن، همانطور که توسط مربی نشان داده میشود( در مرکز قرار گیرد و در قسمت جلو کامًلا متقاطع باشد. محکم بکشید و گره بزنید، اما باعث درد بی مورد در فرد نشوید. باید احساس سخت شدن داشته باشد اما بیش از حد دردناک نباشد. زمان استفاده از بایندر لگن خاصره را ثبت کنید. هر ساعت بایندر را بررسی کنید. اطمینان حاصل کنید که بایندر هنوز به اطراف لگن فشار وارد می کند. اطمینان حاصل کنید که جلد در محل استفاده از بایندر و اطراف اندام تناسلی سالم است. erutcarf civlep nepO sivlep lamroN 72 egap لگن خاصره با شکستگی باز لگن خاصره نارمل قول 691 ارزیابی بخش مهارت بی حرکتی موفق سومموفق دومموفق اولارزیابی بخش مهارت بی حرکتی مًصونیت: استفاده از تجهیزات حفاظت فردی مورد استفاده را از یاد نبرید مهارت 1 - بی حرکتی ستون فقرات رقبی مریض را را در حالت استجاع ظهری وضعیت دهید. به مریض بگویید که چه کار می کنید. با استفاده از دو دست خود در دو طرف سر، سر مریض را در راستای ستون فقرات نگه دارید. یک همکار باید ملحفه لوله شده، کفش یا کیسه هاي مایع وریدي را در دو طرف سر قراردهد. ممکن است با چسب )شکاستیب( محکم شود اما روي تخت ثابت نشود. متوجه باشید که اگر مریض استفراغ کرد، از روش لاگ رول برای محافظت از طرق تنفسی استفاده کنید و سر را با بقیه بدن در یک راستا نگه می دارد. نظریات: مهارت 2 – روش llor goL استطباب لاگ رول را بیان کنید. درخواست کمک کنید. یک نفر را برای نگه داشتن گردن، یک یا دو نفر را برای نگه داشتن بدن و یکی را برای پاها در سر قرار دهید. فردی که کنترول سر دارد باید ستون فقرات رقبی را قبل و در حین رول کردن با بقیه ستون فقرات محکم نگه دارد. هنگامی که ارائه دهنده سر و گردن دستور می دهد، مریض را به پهلو دور دهید. برای هدایت رول از «1-2-3 رول» استفاده کنید. noitazilibommi civleP 82 egap بی حرکت ساختن لگن خاصره کتاب دستور عملیات اشتراک کننده گان 791 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE فردی که سر و گردن را کنترول می کند از «رول 1–2–3» برای بازگرداندن مریض به پشت استفاده می کند. به یاد داشته باشید در اسرع وقت تخته پشتی از مریض دور شود تا از زخم های فشاری جلوگیری شود. نظریات: مهارت 3 - بیحرکتی کامل ستون فقرات بیان استطباب - بیحرکتی کامل ستون فقرات برای کمک به حرکت دادن درخواست کمک کنید. برای انتقال، llor goL را روی تخته پشتی اجرا کنید. اطمینان حاصل کنید که شیشه یا زباله در یا زیر کمر مریض وجود ندارد. برای انتقال مریض به تخته پشتی دستگاه را محکم کنید ) تخته پشتی یا مریض را به تخت وصل نکنید(. در صورتی که مریض که مریض استفراغ میکند.، وضعیت lloR goL را انجام دهید. مهارت 4 - وضعت دادن به خانم حامله نشانه های موقعیت )بیش از هفته 02 حمل و نیاز به بی حرکتی ستون فقرات( را به صورت شفاهی بیان کنید. مریض به وضعیت جنبی چپ در حالیکه عنق آن بی حرکت است قرار داده و د رعین زمان یک بالشت یا قطعه کوچک در زیر تخت قرار دهید. . نظریات: مهارت ۵ – موقعیت ریکاوری استطباب وضعیت ریکاوری. مانور کنترول شده در موقعیت جانبی چپ برای اطمینان از باز بودن طرق تنفسی. وضعیت مناسبی برای مریض قرار دهید )پای بالایی خم شده به جلو، بازوی چپ هموار به طوری که سر مریض روی بازو قرار گیرد تا سر را بالا بیاورید و دهان را به سمت پایین قرار دهید(. نظریات: قول 891 مهارت 6 - بی حرکت کردن شکستگی لباس ها را درآورید تا آسیب را به وضوح ببینید، تمام جواهرات را دور کنید.. نبض، حس و حرکت اطراف را بررسی کنید و یافته ها را مستند کنید. اندازه اتل را مطابق به طرف برابر کنید. یک مفصل بالایی و مفاصل پایین از کسر را بیحرکت کنید. ملاحظات خاص را مشخص کنید: در صورت وجود علایم اروا ضعیف یا عدم وجود نبض در طرف، طرف را هموار کنید. در صورت نیاز خونریزی را کنترول کنید. زباله ها را بردارید و زخم شکستگی باز را با 2 لیتر نارمل سلین شستشو کنید. شکستگی های باز را با گاز مغطوس شده با نارمل سالین بپوشانید. مفصل را در موقعیت مورد نظر قرار دهید. اگر جراحت شامل انگشتان پا باشد، بین انگشتان پا و انگشتان گاز پد قرار دهید. اگر جراب ساق بلند در دسترس است، آن را بدون چین و چروک روی پا قرار دهید یا روی طرف اتل که در تماس با جلد است قرار دهید. اندام مریض به خصوص برجستگی های استخوانی را چیز نرم ماننده پنبه بگزارید. عضو و اتل را با بنداژ بپیچید تا اتل را نگه دارید. نبض، حس و حرکت عضو را پس از تطبیق اسپلینت بررسی کنید. متوجه باشید که مریضان با شکستگی باز به واکسیناسیون تیتانوس، اگردر 5 سال اخیر نگرفته باشد، و انتی بیوتیک نیاز دارند. نظریات: مهارت ۷ - استفاده از بایندر لگن خاصره درد لگن خاصره پس از صدمه را شناسایی کنید. یک روی جایی را زیر لگن خاصره قرار دهید. روی جایی را به اندازی هموار کنید تا به اندازه لگن خاصره باشد )کمر تا انتهای باسن(. بایندر را از قسمت کمر زیر پشت مصدوم قرار دهید. و و یا بطریقه lloR goL روی جایی را جابجا کرده و بشکل بایندر قرار دهید. روی تروکانترهای بزرگ )استخوان های لگن خاصره( وسط قرار دهید و از جلو به طور محکم عبور کنید. محکم کش کرده و گره بزنید، اما باعث درد بی دلیل فرد نشوید. باید احساس سخت شدن داشته باشد اما بیش از حد دردناک نباشد. کتاب دستور عملیات اشتراک کننده گان 991 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE زمان استفاده از بایندر لگن خاصره را ثبت کنید. نظریات: نخیربلیعلایم بهبود نشان داده شده نخیربلیاصلاح مورد نیاز است امضای تسهیلگر/ مجری: 6 . بخش های مهارت مدیریت زخم مدیریت زخم: مدیریت عمومی زخم کنترول خونریزی: خونریزی را مانند بالا متوقف دهید. جلوگیری از انتان: زخم را از لخته های خون، کثیفی، انساج مرده یا در حال مرگ، اجسام خارجی پاک کنید. جلد اطراف زخم را با آب و صابون یا مواد ضد عفونی کننده کامًلا شستشو کنید. زخم را با شستشو با حداقل 1 لیتر آب پاک کامًلا بشویید. آب با فشار زیاد بالای زخم بریزد تا زخم به طور کامل پاک شود. برای ایجاد جریان فشار بالا، از یک سرنگ )با سوزن گیچ 14 یا متصل به یک کنول وریدی( استفاده کنید یا یک سوراخ کوچک در یک بوتل پاک ایجاد کنید و بوتل را فشار دهید. حتما یک لیتر را کاملا استفاده کنید. اگر واکسینه نشده یا در 5 سال اخیر تطبیق نشده، واکسن تیتانوس تطبیق کنید.. زخم های پانسمان: در صورت وجود، زخم را با گاز استریل بپوشانید. اگر زخم همچنان خونریزی دارد از پانسمان فشاری استفاده کنید. اروا )پرشدن مجدد مویرگ ها و/یا نبض های دیستال( و حسیت را فراتر از زخم را قبل و بعد از پانسمان زخم بررسی کنید. مدیریت درد: در صورت در دسترس بودن پرسونل و تجهیزات، قبل از پاک کردن زخم، بی حسی موضعی بدهید. پارگی ها و شکستگی های بزرگ را اتل گذاری کنید. مدیریت زخم: مدیریت سوختگی برای مرطوب نگه داشتن ناحیه و کاهش خطر انتان، پوشاندن زود هنگام سوختگی ها مهم است. سوختگی میتواند بسیار دردناک باشد، بنابراین مطمئن شوید که درد را تسکین می دهید. از تکنیک استریل و نارمل سلین برای پاک کردن سوختگی استفاده کنید. هر گونه جلد شل، مرده و آبله های شکسته، متشنج یا عفونی را با احتیاط جدا کنید. پانسمان مرطوب به محل سوختگی بمالید تا یک محیط ترمیم مرطوب ایجاد کند. پوشش پلاستیکی تمیز را می توان روی محل سوختگی به عنوان یک اقدام موقت استفاده کرد و اگر فرد را به زودی به بخش جراحی منتقل می کنید. مطمئن شوید که کل سوختگی با پانسمان پوشانده شده است. اگر فرد دچار سوختگی قدیمی شده است که اکنون عفونی شده است، از یک انتی بیوتیک موضعی )مانند باسیتراسین یا سلفر سولفادیازین( استفاده کنید. این فرد ممکن است به انتی بیوتیک های وریدی یا عضلی نیز نیاز داشته باشد. در صورت تاخیر در رجعت دهی یا انتقال، اطمینان حاصل کنید که پانسمان ها روزانه تعویض می شوند. همیشه با تغییر پانسمان، درد را کنترول کنید. قول 002 مدیریت سوختگی بزرگسالان: تعیین سطح کل بدن (ASBT) این برای محاسبه مایعات مورد نیاز با استفاده از فرمول پارکلند استفاده می شود. از نمایه قانون نه برای بزرگسالان و نمونه اصلاح شده برای کودکان و نوزادان استفاده کنید )شکل را ببینید(. بدن به بخش هایی تقسیم می شود که هر کدام 9 درصد از کل سطح بدن را تشکیل می دهند. کودکان به دلیل نسبت های مختلف بدن، مانند سر بزرگتر و اطراف و نهایات کوچکتر، درصدهای متفاوتی دارند )شکل ها را ببینید(. فرد را با استفاده از نمودار زیر ارزیابی کنید. به نواحی سوختگی توجه کنید و روی آنها سایه بزنید. در کنار جایی که سایه می زنید، عمق سوختگی را بنویسید )به برآورد عمق سوختگی در زیر مراجعه کنید(. هنگامی که نمونه )جلو و پشت( را با تمام سوختگی هایی که روی فرد ارزیابی کرده اید علامت گذاری کردید، فیصدی را اضافه کنید. این به شما سطح کل سوختگی (ASBT( را می دهد. stluda ni aera ecafrus nruB ٪۵،۴ ٪۵،۴ ٪۸۱ ٪۸۱ ٪۹ ٪۹ ٪۹ ٪۹ ٪۵،۴ ٪۵،۴ ٪۵،۴٪۵،۴ ٪۱ 92 egap سطح سوختگی در بزرگسالان nerdlihc ni aera ecafrus nruB D A C B C B F E F E ٪٣١٪٣١ ٪٢٪٢ ٪٢٪٢ ٪٢٪٢ ٪٢ ٪٢ ٪٢ ٪٢٪٢٪٢ 03 egap aerA )D/A( daeH )E/B( hgi )F/C( geL ٪ ٠١ ٪ ٣ ٪ ٢ ٪ ٧ ٪ ٤ ٪ ٣ ٪ ٦ ٪ ٥ ٪ ٣ ٪ ٩ ٪ ٣ ٪ ٣ sraey ni ega yB ٠١ ٥ ١ ٠ ٪١ ٪١ ٪١ ٪١٪١ سطح سوختگی در کودکان کتاب دستور عملیات اشتراک کننده گان 102 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE مدیریت سوختگی در اطفال: سطح سوختگی تمام بدن را تعین کنید. بر اساس سن بر حسب سالساحه 01۵10 6%7%9%01%سر )A یا D( 5%4%3%3%ران )B یا E( 3%3%3%2%پا )C یا F( مدیریت سوختگی: عمق سوختگی را تخمین کنید: بهترین راه برای تخمین عمق سوختگی این است که به آرامی دو انگشت خود را روی محل سوختگی فشار دهیدتا پر شدن مجدد عروق شعریه را ارزیابی کنید. دستکش بپوشید. با احتیاط، مرکز سوختگی را با دو نوک انگشت به مدت 3 تا 4 ثانیه فشار دهید و سپس رها کنید. هرچه مویرگها سریعتر پر شوند، سوختگی سطحی تر است. اکنون لبه بیرونی سوختگی را ارزیابی کنید )عمق سوختگی میتواند برای نواحی مختلف سوختگی متفاوت باشد(. از نمونه زیر برای راهنمایی یافته های ارزیابی خود استفاده کنید. دریافت های جلدینوع سوختگی سرخ یا گلابی سطحی )درجه اول سابق( دردناک، جلد سالم، بدون آبله هنگامی که فشار داده می شود، جلد گلابی با پر شدن سریع مویرگ ها است سرخ یا سرخ خالدار متوسط )درجه دوم سابق( آبله های دست نخورده یا شکسته، مرطوب دردناک ممکن است با فشار دادن موقتا ًسفید شود سپس رنگ سرخ برمی گردد سفید یا سیاه عمیق )درجه سوم سابق( چرمی و خشک بدون احساس هنگامی که فشار داده می شود، بدون تغیر در رنگ مدیریت سوختگی: احیای مایعات در جروحات ناشی از سوختگی همانطور که در مودل AMUART بحث شد، یک کاهل یا کودک با جروحات ناشی از سوختگی ممکن است نیاز به احیای مایع داشته باشد. احیای مایع را در موارد زیر شروع کنید: سوختگی عمیق یا جزئی بیشتر یا متوسط 51% سطح کل سوختگی در کاهلان. سوختگی عمیق یا متوسط بیشتر یا مساوی 01% سطح کل سوختگی در کودکان. قول 202 مدیریت سوختگی: محاسبه فرمول پارکلند برای 42 ساعت اول 4 ملی لیتر مایعات وریدی × وزن بر حسب کیلوگرم × فیصدی مجموعه سوختگی بدن * * مجموعه فیصدی سطح سوختگی بدنی = فیصدی سوختگی سطح بدن به درجه متوسط + فیصدی سوختگی سطح بدن به درجه عمیق(%سطح سوختگی سطحی در محاسبه استفاده نمی شود) فرمول پارکلند یک استراتژی مدیریت احیای مایع برای 42 ساعت اولیه پس از سوختگی است. مریضانی که بیش از 42 ساعت پس از سوختگی اولیه مراجعه می کنند نیز به احیای مایع نیاز دارند، اما فرمول پارکلند بیش از 42 ساعت استفاده نمی شود. نیمه اول مایعات باید در 8 ساعت اول پس از سوختگی داده شود )نه پس از رسیدن به مراقبت(. نیمه دوم باید در 61 ساعت بعدی ارائه شود. برای بزرگسالان، نارمل سلین یا رینگر لاکتات بدهید. برای کودکان از مایع حاوی دکستروز )رینگر لاکتات با 5 درصد دکستروز یا نارمل سلین با دکستروز 5 درصد برای احیای اولیه( استفاده کنید. اگر مایعات حاوی دکستروز در دسترس نیست، یک دوز اضافی دکستروز )چه وریدی یا خوراکی( همراه با مایعات وریدی بدهید )به ادویه جات مراجعه کنید(. برای مراقبت مداوم از کودکان، مایعات احیای اضطراری پارکلند محاسبه شده در بالا باید به هر مایع نگهداری مورد نیاز بر اساس پروتوکول های مراقبت شفاخانهی اضافه شود )به منابع سازمان جهانی صحت OHW مراقبت های شفاخانهی برای کودکان، 3102 مراجعه کنید(. مربی شما نمونه هایی را با استفاده از فرمول پارکلند مرور خواهد کرد. به خاطر داشته باشید: مریضانی که بیش از 51 درصد از بدنشان سوختگی جدی دارند، سوختگی های دست، صورت، ناحیه کشاله ران، مفاصل یا سوختگی هایی که به طور کامل در اطراف بدن یا قسمتی از بدن قرار دارند، باید برای مراقبت های تخصصی انتقال یا رجعت دهی داده شوند. مدیریت زخم: بنداژ و بی حرکت کردن مار گزیدگی توجه: در صورت امکان از مار عکس بگیرید و با مریض ارسال کنید. بی حرکت کردن عضو پس از گزیدن مار برای کاهش تحرک و جلوگیری از جذب سم مهم است. همیشه نبض، پر شدن مجدد عروق شعریه و احساس را قبل و بعد از پانسمان یا اتل زدن هر زخم ارزیابی کنید. می توانید از بنداژ فشاری پهن استفاده کنید و از قسمت پایینی گزش به سمت بالا بپیچید. بنداژ باید سخت باشد، اما نباید نبضان اطراف را قطع کند. بنداژ را تا جایی که ممکن است به سمت بالا بپیچانید. اگر مارهای منطقه شما زهری هستند که به اعصاب آسیب می زند، باعث فلج می شود، فرد را بسیار بدحال و مریض می کند، یا اگر زمان حمل و نقل طولانی مدت باشد، توصیه می شود. اگر مارهای منطقه شما توکسین تولید می کنند که در سبب تخریبات نسج اطراف زخم می شود و علایمی در سراسر بدن ایجاد نمی کند، توصیه نمی شود. یک اتل را به طرف ببندید تا هر چه بیشتر طرف بی حرکت شود. به زمان گذاشتن باند توجه کنید. فرد را بی حرکت و دراز کشیده نگه دارید. در اطراف محل گزش ماربروی طرف تورنیکیت قرار ندهید. محل نیش را زخمی نکنید زیرا منجر به خونریزی غیر ضروری می شود. برای از بین بردن زهر، محل گزش را نه مکید. کتاب دستور عملیات اشتراک کننده گان 302 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE ارزیابی بخش مهارت مدیریت زخم موفق سومموفق دومموفق اولمعیارهای علامت گذاری بخش مهارت ایمنی: استفاده از تجهیزات حفاظت فردی را مراعات میکند ویا مشاهده میکنید.. مهارت 1- مدیریت عمومی زخم کنترول خونریزی: طبق مهارت قبلی، خونریزی را متوقف می کند. جلوگیری از عفونت زخم را از لخته های خون، کثیفی و اجسام خارجی پاک می کند. جلد اطراف زخم را با آب و صابون یا ضد عفونی کننده کامًلا تمیز می کند. با آب پاک، زخم را به طور کامل شستشو می دهد )1 لیتر آب تمیز یا بیشتر(. در صورت نیاز واکسن تیتانوس تطبیق میکند. پانسمان زخم ها قبل از پانسمان یا تطبیق اتل هر زخم، نبض، پر شدن مجدد مویرگ ها و احساس را ارزیابی می کند. در صورت موجودیت گاز، با گاز استریل زخم پانسمان می شود. اگر زخم همچنان خونریزی دارد، پانسمان فشاری تطبیق می کند. خونرسانی فراتر از زخم )پر شدن مجدد عروق شعریه و/یانبضان را در قسمت سفلی عضو( را قبل و بعد از پانسمان زخم بررسی می کند. مدیریت درد در صورت در دسترس بودن کارکنان و تجهیزات، قبل از پاک کردن زخم، انستیزی موضعی می دهد. پارگی ها و شکستگی های بزرگ را بعد از پانسمان اتل می کند. نبضان، پر شدن مجدد عروق شعریه و احساس پس از پانسمان یا اتل گزاشتن هر زخم را ارزیابی می کند. نظریات: مدیریت سوختگی مهارت 2 - مدیریت زخم سوختگی از یک روش پاک و استریل با نارمل سلین برای شستشوی سوختگی استفاده کنید. دور کردن هر گونه جلد شل، مرده و آبله های کشیده یا عفونی. یک پانسمان غیر چسبنده روی سطح سوختگی تطبیق می کند تا یک محیط مرطوب جهت احیا بهتر ایجاد کند. قول 402 اطمینان حاصل می کند که تمام سطح سوختگی با پانسمان پوشانده شده است. نظریات: مهارت 3 - احیای مایع در جروحات ناشی از سوختگی علایم ها را به درستی بیان می کند: سوختگی با درجه متوسط یا عمیق بیشتر یا مساوی 51% مجموعه سطح سوختگی بدن در کاهلان سوختگی با ضخامت متوسط ویا عمیق بیشتر یا مساوی 01% سطح تمام سوختگی در کودکان. تخمین عمق سوختگی مجموعه فیصدی سطح سوختگی بدن )ASBT( را تعیین می کند. محاسبه فرمول پارکلند تطبیق مایعات را توضیح می دهد (نیمه اول در 8 ساعت اول و نیمه دوم در 61 ساعت آینده). مایع مناسب را برای بولوس اولیه انتخاب می کند )کودکان با وزن کمتر از 02 کیلوگرم: رینگر لاکتات با 5 درصد دکستروز، نارمل سلین با 5 درصد دکستروز(. نظریات: مهارت چهارم: بنداژ و بی حرکتی مار گزیده گی از یک بنداژ فشاری پهن استفاده می کند و از قسمت پایین گزش به سمت بالا پیچیده می شود. بنداژ را تا آنجا که ممکن است به سمت بالا می پیچاند. تا جایی که ممکن است اندام را با آتل بی حرکت کنید. به مدت زمان بنداژ توجه می کند فرد را بی حرکت نگه می دارد محل زخم یا طرف را با تورنکیت بسته نکنید محل گزش را نه مکنید نظریات: نخیربلیشایستگی نشان داده شده است نخیربلیاصلاح مورد نیاز است امضای تسهیل کننده: کتاب دستور عملیات اشتراک کننده گان 502 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE ۷. بحث مهارت تجویز و تطبیق ادویه جدول زیر ادویه جاتی مورد بحث در این کورس را خلاصه می کند که تنها مجموعه ای بسیار ابتدایی از تداوی ها را برای شرایط اضطراری نشان می دهد. آنها بر اساس در دسترس بودن گسترده، مناسب بودن آنها برای استفاده توسط همه ارائه دهندگان خط مقدم که شامل اشتراک کننده گان مطلوب در کورس هستند، امکان استفاده آنها در مراکز صحی قبل از شفاخانه یا تسهیلات، و اهمیت بالقوه آنها به عنوان تداوی های اولیه برای شرایط اضطراری گنجانده شده اند. حتما ًغلظت های ادویه موجود در محل را بررسی کنید، زیرا ممکن است متفاوت باشد. رایج ترین غلظت ها در این جدول برای منبع جهت استفاده دوز مناسب شده است. تقریبا ًهر شرایطی که مورد بحث قرار می گیرد به تداوی های اضافی فراتر از این موارد نیاز دارد، و بسیاری از تداوی های عاجل مهمی که ممکن است توسط ارائه دهندگان پیشرفته استفاده شوند، در اینجا گنجانده نشده اند. جدول: ادویه جاتی مورد استفاده در کورس مراقبت های ابتدایی عاجل استطباب ادویه دوز ویا مقدار ادویه اثرات نامطلوب اضطراب/ترس تپش قلب تاکی کاردی )افزایش ضربان قلب( سرچرخی تعریق حالت تهوع استفراغ هیپرگلیسمی )گلوکوز خون بالا( درد صدری فشار خون بالا محل تزریق نکروز نسجی محلول: 1 میلی گرم در آمپول 1 میلی لیتری )0001:1( یادداشت: دوزهای زیر برای تجویز عضلی است نه وریدی محل ترجیحی برای تزریق قسمت بیرونی وسط ران است در کودکان. کاهلان: عضلی (MI): 05 کیلوگرم یا بیشتر: 5.0 میلی گرم MI )5.0 میلی لیتر از 0001:1( 04 کیلوگرم: 4.0 میلی گرم MI )4.0 میلی لیتر از 0001:1( 03 کیلوگرم: 3.0 میلی گرم MI )3.0 میلی لیتر از 0001:1( ممکن است در فواصل 5 دقیقه ای تکرار شود اطفال: عکس العمل شدید: 51.0 میلی گرم MI )51.0 میلی لیتر 0001:1(، در صورت نیاز هر 5 تا 51 دقیقه تکرار کنید. استما شدید: 10.0 MI gk/gm تا 3.0 میلی گرم، در صورت نیاز هر 51 دقیقه تکرار کنید. ادرینالین (اپی نفرین) عکس العمل شدید/عکس العمل حساسیتی شدید و ویزینگ شدید )به مشکلات تنفسی مراجعه کنید EDCBA در( قول 602 استطباب ادویه دوز ویا مقدار ادویه اثرات نامطلوب عکس العمل های حساسیتی مشکلات معده و معایی سایر تاثیرات سو با انتی بیوتیک متفاوت است ادویه جاتی خاص در این دسته با پروتوکول های تداویی محلی و در دسترس بودن تعیین می شوند. اینها باید شامل یک رژیم طیف وسیع برای انتانات تهدید کننده زندگی باشد که میتواند به صورت تجربی )قبل از اینکه منبع عفونی به طور قطعی شناسایی شود( در مریضان بسیار وخیم استفاده شود. انتی بیوتیک ها تحریک سیستم هضمی همراه با از دست دادن خون وزوز گوش عکس العمل شدید تابلیت: 001 میلی گرم، 003 میلی گرم خوراکی: 003 میلی گرم )ترجیحا ًجویده یا پراکنده در آب( بلافاصله به صورت یک دوز تجویز می شود. در صورت وجود موارد زیر، تا زمانی که توسط یک ارائه دهنده پیشرفته ارزیابی نشود، اسپرین ندهید: 1. هر گونه خونریزی فعال یا 2. درد قفس سینه که ناگهانی، حداکثر در شروع، تیز و شکافنده است و به پشت حرکت می کند )میتواند نشان دهنده پارگی ابهر باشد(. اسید استیل سالیسیلیک )اسپرین( مشکوک به حمله قلبی آرام بخش کاهش تعداد تنفسی فشار خون پایین برادی کاردی )ضربان قلب پایین( تهوع و استفراغ گرفتگی شکم تابلیت: 2 میلی گرم، ۵ میلی گرم محلول: آمپول ۵ میلی گرم / 1 میلی لیتر کاهلان: دوز اول: 01 میلی گرم فشار وریدی آهسته یا 02 میلی گرم از راه مقعدی دوز دوم بعد از 01 دقیقه: 5 میلی گرم زرق وریدی آهسته یا 01 میلی گرم از راه مقعدی حداکثر دوز وریدی: 03 میلی گرم اطفال: دوز اول: 2.0 gk/gm زرق وریدی آهسته یا 5.0 gk/gm مقعدی. در صورت ادامه تشنج/اختلاج، می توان نیمی از اولین دوز را بعد از 01 دقیقه تکرار کرد. حداکثر دوز وریدی: 02 میلی گرم اگر تعداد تنفس کمتر از 01 تنفس در دقیقه است، دوز دوم را تجویز نکنید. دیازپام را عضلی ندهید (جذب غیرقابل پیش بینی). نحوه دادن دیازپام رکتال: دوز را از یک آمپول دیازپام در یک سرنج کوچک )در صورت وجود توبرکولین( تطبیق کنید. در صورت امکان دوز را بر اساس وزن کودک تعیین کنید. سوزن را بردارید. سرنج را 4 تا 5 سانتی متر داخل رکتوم قرار دهید و محلول دیازپام را تزریق کنید. باسن را چند دقیقه کنار هم نگه دارید. بنزودیازپین ها - دیازپام تشنج / اختلاج [به SMA مراجعه کنید] کتاب دستور عملیات اشتراک کننده گان 702 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE استطباب ادویه دوز ویا مقدار ادویه اثرات نامطلوب هایپرگلیسمی )گلوکوز خون بالا( سرچرخی نکروز جلد در صورت تزریق خارج از ورید راه حل: 0۵٪ دکستروز (0۵D)، ۵2٪ دکستروز (52D)، 01٪ دکستروز (01D) توجه: دکستروز هرگز نباید به صورت عضلی داده شود زیرا ممکن است باعث صدمات نسجی می شود. کاهلان و اطفال بیشتر از 04 کیلوگرم: 52-05 میلی لیتر وریدی از 05D، یا 521-052 میلی لیتر وریدی 01D اطفال تا 04 کیلوگرم: 5 gk/lm وریدی 01٪ دکستروز )01D( 01D در کودکان زیر 04 کیلوگرم ترجیح داده می شود. اگر 01D در دسترس نیست، می توانید از قانون 05 برای به خاطر سپردن مقدار معادل دکستروز در محلول دیگری استفاده کنید. همه موارد زیر حاوی مقدار یکسان دکستروز هستند: 5 میلی لیتر 01D 2 میلی لیتر 52D 1 میلی لیتر 05D در صورت عدم دسترسی وریدی: 2 تا 5 میلی لیتر دکستروز 05 درصد را در داخل دهن )داخل گونه( قرار دهید. یا محلول شکر )1 قاشق چایخوری شکر مرطوب شده با آب هر 01 تا 02 دقیقه( در فضای باکال بدهید. گلوکوز )دکستروز( رهایپوگلایسیمی )شکر خون پایین( [به به مشکلات تنفسی مراجعه کنید در EDCBA] فشار خون پایین کاهش تعداد تنفسی خواب آلودگی گیجی از دست دادن رفلکس ها ضعف عضلی حالت تهوع استفراغ جلد برافروخته تشنگی توقف دهید اگر: کاهش تعداد تنفسی )تعداد تنفس کمتر از 16 در یک دقیقه( ایجاد می شود. سمیت: فشار خون پایین تنقیص تنفسی از دست دادن kreJ eenK xufleR کاهش تولید ادارار کمتر از 001 ملی لیتر در 4 ساعت. انواع محلول: 1 گرم در آمپول 2 میلی لیتری (0۵٪) ۵ گرم در آمپول 01 میلی لیتری (0۵٪) برای دادن وریدی، یک محلول 02٪ درست کنید: *3 میلی لیتر نارمل سالین را به آمپول 2 میلی لیتری اضافه کنید. یا * ۵1 میلی لیتر سالین استریل را به آمپول 01 میلی لیتری اضافه کنید. لودنگ دوز (وریدی + عضلی): * 4 گرم وریدی )به محلول 02 درصد رقیق شده و بدهید 02 میلی لیتر به آرامی در مدت 02 دقیقه( و *01 گرم MI (داخل عضلی(: 5 گرم )01 میلی لیتر محلول 05٪( با 1 میلی لیتر لیدوکائین 2٪ در ربع بیرونی بالایی هر باسن. مگنیزیم میتواند باعث کاهش فشار خون شود. با دقت نظارت کنید اگر نمی توانید وریدی را تزریق کنید، فقط 01 گرم MI تزریق کنید )مانند بالا، 5 گرم در هر باسن(. در صورت تکرار تشنج/اختلاج: پس از 51 دقیقه، 2 گرم اضافی )01 میلی لیتر 02 درصد( در مدت 02 دقیقه به او تطبیق کنید. در صورت تأخیر در حمل و نقل، تداوی را ادامه دهید: 5 گرم محلول 05 درصد MI به همراه 1 میلی لیتر لیدوکائین 2 درصد هر چهار ساعت در باسن متناوب تطبیق نماید. اکلامپسیا مگنیزیم سلفات برای خاننم های حامله با اختلاج )تغیر وضعیت ذهنی را ببینید وضعیت( قول 802 استطباب ادویه دوز ویا مقدار ادویه اثرات نامطلوب فشار خون بالا )فشار خون بالا( آریتمی های قلبی هایپرونتیلاسیون مشکل در تنفس تحریک *** نالوگزان اثرات آن فقط برای 1تا3 ساعت ماندگار است بسیاری از ادویه اپیوئیدی اثر طولانی تری دارند و ممکن است به دوزهای بیشتری از نالوگزان یا انفیوژن نالوگزان نیاز داشته باشند. هر مریض تحت تداوی با نالوگزان باید به دقت تحت نظر باشد*** محلول: lm/gcm 004 (هیدروکلراید) در آمپول 1 میلی لیتری وریدی: 001 میکروگرم تک دوز یا 004 مکروگرام بصورت عضلی در دوز واحد در صورت نیاز می توانید هر 5 دقیقه یک بار تکرار کنید. ممکن است به انفوزیون مداوم 4.0 میلی گرم در ساعت برای چند ساعت برای اپیوئیدهای طولانی اثر نیاز داشته باشد. نالوگزان مصرف بیش از حد مواد مخدر )به EDCBA، وضعیت ذهنی تغییر یافته، مشکل در تنفس مراجعه کنید( تهوع/استفراغ سردرد راش های جلدی عکس العمل شدید سپزم رحم )در دوزهای کم( تحریک بیش از حد رحم )در دوزهای بالا( محلول: 01 واحد بین المللی در آمپول 1 میلی لیتری دوز اولیه: 01 MI UI داده و مایعات را با 02 L/UI با 06 قطره در دقیقه شروع کنید. پبعد از ولادت پلاسنتا، اگر همچنان خونریزی دارد، مایعات را با 02 L/UI با 03 قطره در دقیقه ادامه دهید. اگر پلاسنتا به واسطه دستی خارج شود یا رحم منقبض نمی شود: 01 MI UI تکرار کنید. مایعات وریدی را با 02 L/UI با 02 قطره در دقیقه به مدت 1 ساعت پس از قطع خونریزی ادامه دهید. حداکثر دوز: 3 لیتر مایع وریدی حاوی اکسیتوسین. اکسیتوسین تداوی خونریزی بعد از ولادت راش های جلدی آسیب کبدی به تعقیب مصرف بیش از حد تابلیت: 0۵2 میلی گرم، 00۵ میلی گرم شیاف رکتوم: 0۵2 میلی گرم، 00۵ میلی گرم کاهلان: 005 میلی گرم – 1 گرم هر 6 ساعت حداکثر 4 گرم در روز یا حداکثر 2 گرم در روز در صورت اختلال کبدی ویا سیروز کودکان: gk/gm 01-51 تا 6 بار در روز پاراستامول )استامینوفن( درد خفیف تا متوسط، تب و سردرد کتاب دستور عملیات اشتراک کننده گان 902 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE استطباب ادویه دوز ویا مقدار ادویه اثرات نامطلوب تکان قلبی لرزش خوب سردرد هیپرگلیسمی )پس از دوزهای بالا( تاکی کاردی )ضربان قلب بالا( در صورت موجودیت، می توان از نبولایزر با دوز مناسب استفاده کرد. استنشاقی: 001 میکروگرم در هر پف دستگاه تنفسی با اسپیسر کاهلان: با پنج پاف شروع کنید و هر دو دقیقه دو پاف از طریق اسپیسر بدهید تا بهبود یابد. کودک: پف مستفیم شروع کرده و با دو پف در طریق اسپیسر ادامه دهید . اسپیسر را برای سه تا پنج نفس در دهان کودک نگه دارید. این کار را تا زمانی تکرار کنید که شش پف شروع از ادویه به کودک کمتر از 5 سال یا 21 پف برای بیش از 5 سال داده شود. به طور منظم تا زمانی که وضعیت بهبود یابد تکرار کنید. در موارد شدید می توان 6 یا 21 بار در یک ساعت چند بار پاف تطبیق کنید. به یاد داشته باشید: کودک باید بتواند دهان را در اطراف دهانه اسپیسر ببندد. نوزادان احتمالا به ماسک اسپیسر یا نبولایزر نیاز دارند. نبولایزر: )کاهل( 5 میلی گرم در 5 میلی لیتر سالین استریل. )کودک( 5.2 میلی گرم در 3 میلی لیتر سالین استریل. برای ویزینگ شدید، دوزهای بالاتر را می توان چندین بار در یک ساعت تجویز کرد. سالبوتامول )البوترول( ویزینگ شدید به مشکلات تنفسی مراجعه کنید در EDCBA درد در محل تزریق عکس العمل حساسیتی تب حالت تهوع محلول: ۵ واحد در ۵.0 میلی لیتر MI ۵.0 میلی لیتر به تمام اطفال آسیب دیده ای که واکسیناسیون آنها به روز نیست و در بزرگسالانی که در ۵ سال گذشته این واکسین نگرفته اند، تزریق کنید. اگر معلومات راجع به تطبق و یا عدم تطبیق واکسین در دست نباشد.، واکسین تطبیق نماید. واکسین تیتانوس 8. بحث مهارت های انتقال و واگذاری این کورس برای کارمندان صحی است که در ساحات خارج شهری، آمبولانس ها ویا در مراکز مراقبت های صحی اولیه کار می کنند. انتقال مریضان از محل حادثه به مرکز اولیه یا مارکز با امکانات متوسط نیازمند توجه ویژه به برنامه ریزی مقصد، مدیریت مستمر و رجعت دهی است. برنامه ریزی هدف بسیاری از مریضانی که در ساحه تداوی می شوند برای مدیریت بیشتر نیاز به انتقال به یک مرکز مراقبت های صحی دارند. علاوه بر این، مریضانی که در حال حاضر در یک مرکز هستند ممکن است برای مراقبت های پیشرفته تر نیاز به انتقال به یک مرکز دیگر داشته باشند. به عنوان مثال، یک خانم حامله مبتلا به تشنج برای مراقبت های پیشرفته و ولادت زود هنگام نیاز به انتقال دارد. مریض با سوختگی شدید برای مدیریت پیشرفته قول 012 طرق تنفسی و مراقبت های جراحی نیاز به انتقال دارد. مریضکه در شاک ناشی از دست دادن خون است نیاز به رجعت دهی به مرکزی با قابلیت انتقال خون دارد. هنگام برنامه ریزی برای هر گونه حمل و نقل، مطمئن شوید که: سطح خدمات در مرکز مقصد با نیازهای مریض مطابقت دارد )به عنوان مثال در صورت نیاز به جراحی، عملیاتخانه وجود دارد(. منابع مورد انتظار در حال حاضر در دسترس هستند )به عنوان مثال، عملیاتخانه فعال در حال اجرا است، و خون برای انتقال خون وجود دارد(. و اینکه بتوان با توجه به شرایط مریض در فاصله زمانی لازم به مقصد رسد. در صورت امکان انجام آزمایش ها یا مداخلاتی که برای مصونیت مریض مهم نیستند، حمل و نقل را به تاخیر نیندازید. پروتوکول های انتقال محلی و مقصد را در جایی که وجود دارند تعقیب کنید. در جایی که پروتوکول های واضحی وجود ندارد، زمان حمل و نقل را با قابلیت های تسهیلات در نظر بگیرید. - هدف این است که در اسرع وقت به مراقبت های مورد نیاز برسید. بهتر است که از اول جای مناسب را جهت انتقال در نظر بگیرید اگر چه مدت زیاد را در بر کیرد زیرا بهتر است از این که در جای انتقال دهید که خدمات مطلوب را نداشته باشد و دوباره به مرکز دیگر راجع شود. هنگامی که تسهیلات مناسب تعیین شد، ارتباط با ارائه خدمات در تسهیلات دریافت کننده ضروری است )به «رجعت دهی» زیر مراجعه کنید(. این به مرکز دریافت کننده امکان می دهد تا برای ورود مریض آماده شود و منابع )مانند خون، آماده سازی عملیات خانه ( را ترتیب دهد. پروتوکول های ارتباطی محلی خاص را در جایی که وجود دارد تعقیب کنید. در صورت امکان، پروتوکول های رسمی هم برای حمل و نقل قبل از شفاخانهی و هم برای انتقال بی خود شفاخانه یعنی بی دیپارتنمت های یک شفاخانه باید وجود داشته باشد. این موارد باید شامل معیارهای صریح برای زمان انتقال مریض باشد. ترانسپورت انتقال شامل دو جنبه است: حمل و نقل مریض و مراقبت از مریض در تمام زمان های حمل و نقل. یک نفر نمیتواند هر دو کار را انجام دهد. در طول حمل و نقل، حداقل یک ارائه دهنده باید همیشه در همان قسمت وسیله نقلیه با مریض باشد تا امکان نظارت، ارزیابی و مدیریت مداوم را فراهم کند. عملکرد EDCBA باید برای ارزیابی و ارزیابی مجدد تمام مریضان در طول حمل و نقل استفاده شود. علایم حیاتی )از جمله UPVA یا SCG( باید هر 51 دقیقه بررسی شود و مریضان باید از نظر پاسخ به تداوی ها و علایم بدتر شدن آن به دقت تحت نظر باشند. به یاد داشته باشید که زمان و مسیر کلی حمل و نقل را برنامه ریزی کنید و شرایط جاده و آب و هوا را بررسی کنید. این برای پیش بینی نیازهای مریض در حین حمل و نقل ضروری است )به عنوان مثال نیاز به مایع و ادویه(. اطمینان حاصل کنید که مریض و خانواده از برنامه انتقال مریض آگاه هستند. در صورت امکان به یکی از اعضای خانواده اجازه دهید تا کودکان را همراهی کند. رجعت دهی یا تسلیمی کتاب دستور عملیات اشتراک کننده گان 112 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE زمانیکه مریض از یک مرجع به مرجع دیگر انتفال میشود تمام مراقبت های مریض باید تسلیم داده شود. که، باید به طور رسمی رجعت دهی صورت گیرد، از جمله: بین ارائه دهندگان داخل یک تسهیل، یا از ارائه دهندگان حمل ونقل، یا از راه دور از یک مرکز ارسال کننده به یک ارائه دهنده تسهیلات دریافت کننده. علاوه بر گزارش شفاهی در زمان رجعت دهی مریض به ارائه دهنده جدید، اسناد کتبی از وضعیت کلینیکی و تداوی باید همیشه مریض را همراهی کند. خلاصه های تسلیمی را در جریان کورس در سناریوهای متعدد تمرین خواهید کرد. وضعیت، معلومات راجع به حالت مرضی، ارزیابی، توصیه ها (RABS( روشی ساختاریافته برای برقراری ارتباط اطلاعات کلیدی است و می تواند برای همه مواردی که در بالا ذکر شد استفاده شود. اجزا و نمونه های RABS عبارتند از: وضعیت اطلاعات اولیه مریض )به عنوان مثال سن، جنس(. شکایت اصلی )توضیحات اولیه مریض از مشکل، مانند مشکل در تنفس به مدت 3 روز، یا درد بازو پس از زمین خوردن و غیره(. معلومات راجع به حالت مریضی 2 تا 4 جنبه مهم و مرتبط مورد و/یا وضعیت مریض )اینها ممکن است عناصری از شرح حال، معاینه فیزیکی یا نتایج آزمایش باشند، بسته به مورد(. هر یافته / مداخله مهم EDCBA را درج کنید. ارزیابی آنچه شما فکر می کنید که در ازریابی مریض غیر نورمال است دلیل انتقال/رجعت دهی. توصیه ها موارد خاصی که ارائه دهنده جدید باید برای آنها آماده شود: مراحل بعدی در طرح تداوی؛ بدتر شدن احتمالی وضعیت مریض )به عنوان مثال نیاز به مشاهده دقیق طرق هوایی در صورت مشکوک شدن به سوختگی ناشی از استنشاق(؛ احتیاط در مورد تداوی ها یا مداخلات قبلی )مانند زمان آخرین دوز ادرینالین برای پیش بینی علایم بازگشت، نیاز به نظارت بر وضعیت روانی در صورت تجویز ادویه جاتی آرام بخش، نیاز به نظارت بر پانسمان سه طرفه برای لخته شدن و غیره(. مثال ها: مورد اول: جوان 22 ساله در حال موتر سایکل سواری بوده که با سرعت زیاد با وسیله نقلیه دیگری تصادف کرد. او از موتور سایکل خود پایین افتاد و کلاه ایمنی به سر نداشته است. طرق تنفسی او باز است. صدای تنفس طبیعی در دو طرف صدر او شنیده میشود. نبض او قوی و حدود 09 ضربه در دقیقه است. او فقط به درد پاسخ می دهد و دارای شکستگی استخوان ران که بیرون از گوشت و پوست یعنی یک زخم باز است. خراش قول 212 هایی روی پیشانی او وجود دارد. ستون فقراتش را بی حرکت کرده اید، و مایع وریدی شروع و شکستگی را اتل گذاری کرده . شما و همکارتان او را از محل جراحت منتقل کرده اید و او را به شفاخانه رجعت دهی می دهید. خلاصه رجعت دهی: این جوان 22 ساله است که تصادف کرده و کلاه ایمنی به سر نداشت واز موترسکلیت خود پایین افتاده است. او فقط به درد پاسخ می دهد و شکستگی استخوان ران باز دارد، اما در حال حاضر از طرق تنفسی خود محافظت کرده میتواند و شواهدی از شاک ندارد. ما نگران تغیر وضعیت روانی و شکستگی استخوان ران او هستیم، اما نمی توانیم بگوییم که آیا او ترضیض نخاعی دارد یا خیر. او برای مدیریت جراحی و ارزیابی عصبی بیشتر نیاز به انتقال دارد. بی حرکتی ستون فقرات باید حفظ شود و او باید از نظر بدتر شدن خونریزی و تغییرات وضعیت شعوری تحت نظر باشد. مورد دوم: دختری 41 ساله در مدرسه دچار تشنج/اختلاج شد. او را معلمانش نزد شما آوردند، زیرا که حمله اختلاج او قطع نشده و شما یک بنزودیازپین تجویز کردید که باعث توقف تشنج شد. پس از آن، توانستید ارزیابی EDCBA و سپس یک معاینه کامل سر تا پا را انجام دهید. و تب ندارد؛ او ضربان قلب، فشار خون و تعداد تنفس طبیعی دارد. او به صدا پاسخ می دهد. زبانش را جویده و روی خودش ادرار کرد. او هیچ جراحت یا راش های جلدی دیگری ندارد. خلاصه رجعت دهی: این دختر 41 ساله ای است که تشنج طولانی مدت داشته و در هنگام تحویل دهی هم تشنج داشته. تشنج های او با یک دوز 01 میلی گرمی دیازپام متوقف شد و اکنون خواب آلود است، علایم حیاتی طبیعی دارد و تب ندارد. او برای ارزیابی بیشتر تشنجش منتقل می شود. به دلیل دریافت ادویه جاتی آرام بخش )دیازپام( طرق هوایی او را کنترول کنید. مورد 3: مردی 57 ساله هنگام راه رفتن از بازار به خانه دچار درد صدری شد. او را با تاکسی پیش شما آوردند. او می گوید که درد صدری از 03 دقیقه قبل شروع شده و احساس می کند که فشار زیادی در مرکز صدر او وجود دارد. او هیچ حساسیتی ندارد. او یک ادویه فشار خون مصرف می کند، اما نام ادویه را به خاطر نمی آورد. او 2 سال پیش یک حمله قلبی داشته که بسیار شبیه درد امروزی بوده است. آخرین وعده غذایی او 6 ساعت پیش بود. درد زمانی شروع شد که او با چند کیسه سنگین به خانه راه می رفت، اما اکنون هیچ دردی ندارد. علایم حیاتی، بررسی EDCBA و معاینه سر تا پا طبیعی است. شما اسپرین داده اید و کنول وریدی را تطبیق کرده اید و اکنون به یکمرکز صحی که خدمات داخل بستر به مریضان قلبی را داشته باشد انتقال میدهید. خلاصه انتقال: این مرد 57 ساله با سابقه حمله قلبی است که درد صدری مشابه حمله قلبی قبلی خود داشته است. درد هنگام راه رفتن شروع شده و بیش از 03 دقیقه طول کشیده است، اما اکنون از بین رفته است. اسپرین دریافت کرده و و کنول وریدی باز دارد. من نگران هستم که او ممکن است قلب اش مشکل مشکل داشته باشد. او باید برای تغییر در EDCBA یا بازگشت درد صدری تحت نظر باشد. کتاب دستور عملیات اشتراک کننده گان 312 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE یادداشت 1انمهلقم 412 واژه نامه EDCBA در قدم اول ارزیابی هر مریض، که شامل ارزیابی و تداوی طرق تنفسی، تنفس، دوران خون، ناتوانی/ معلولیت و برهنه ساختن است. استفاده از عضلات اضافی (esu elcsum yrosseccA) استفاده از عضلاتی غیر از دیافراگم برای کمک به تنفس )معمولا ًگردن، دیوار قفس سینه و عضلات شکم (. ممکن است به صورت کشش/پسرفت بین اضلاع یا در عضلات گردن ظاهر شود. وضعیت ذهنی تغییر یافته (SMA) اصطلاحی که برای طیف وسیعی از اعراض از تغییر در رفتار یا حافظه گرفته تا گیجی، سردرگمی و کوما استفاده میشود. (sutatS latneM deretlA) SMA به وضعیت ذهنی تغییر یافته مراجعه کنید. کم خونی (aimeanA ) کاهش غلظت کرویات سرخ خون که منجر به کاهش توانائی در حمل آکسیجن می شود. عکس العمل شدید (sixalyhpanA ) یک عکس العمل حساسیتی شدید که میتواند باعث شاک شود. استما (amhtsA ) شرایطی که باعث تولید مخاط و اسپازم متناوب در راه های هوایی برونش میشود و در نتیجه سبب باریک شدن طرق تنفسی شده که باعث ویزینگ در صدر میشود. (suoicsnocnU niaP ecioV trelA) UPVA سیستمی برای ارزیابی سطح شعوری: هشدار، کلامی، درد، و عدم پاسخ. بگ و ماسک (MVB evlav-gaB) یک دستگاه دستی متشکل از یک کیسه پر از هوا که به یک ماسک متصل است. کیسه با دست فشرده می شود تا ماسک روی صورت مریض نگه داشته شود تا نفس بکشد. بولوس(suloB) حجم مشخصی از مایع یا ماده دیگر که به سرعت، معمولا ًبه صورت داخل تطبیق داده می شود. برادی کاردی (aidracydarB ) ضربان قلب کمتر از حد طبیعی است. کتاب دستور عملیات اشتراک کننده گان 512 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE (ksaM evlaV gaB) MVB به دستگاه ماسک بیگ والو )MVB evlav-gaB(. مراجعه کنید. برگشت مجدد خون به عروق شعریه (llfier yrallipaC) نشان دهنده اروا، با فشار دادن روی ناخن، کف دست یا کف پا و رها کردن آن برای مشاهده مدت زمان طولانی طول می کشد تا رنگ به جلد برگردد )جریان خون برای بازگشت(. محدوده طبیعی کمتر از 3 ثانیه است. احیای قلبی ریوی (RPC) انجام مساٰژ صدری و تهویه با هدف احیای مریض بدون نبض. ستون فقرات رقبی (enips-C) قسمتی از ستون فقرات در گردن که شامل هفت مهره اول است. سوختگی دوریی (nrub laitnerefmucriC) سوختگی هایی که در اطراف یک قسمت بدن گسترش می یابند می توانند مانند یک نوار سخت عمل کنند و ممکن است جریان خون )به اندام( یا تنفس )سوختگی در اطراف قفس سینه یا شکم ( را محدود کنند. کولرا (arelohC) انتان باکتریایی باعث اسهال شدید آبگین می شود که اغلب به عنوان مدفوع آب برنج توصیف می شود. مرض انسدادی مزمن ریوی (DPOC) اصطلاحی که به تجزیه ساختار ریه )آمفیزم( و التهاب مزمن که باعث اسپازم طرق تنفسی سفلی و ویزینگ میشود، می پردازد. کوما (amoC) حالت بیهوشی طولانی مدت. سندروم کمپارتمان (emordnys tnemtrapmoC) وضعیت افزایش فشار ناشی از پندیدگی در ناحیه ای از بدن که نمی تواند منبسط شود، مانند محفظه هایی در ساعد یا ساق پا. سندروم کمپارتمان جریان خون را در ناحیه کاهش می دهد و ممکن است منجر به درد شدید و همچنین آسیب به اعصاب و سایر انساج شود. گنگسیت (noisufnoC) مشکلات در وضاحت رفتار، حضور ذهن و تنظیم افکار . اختلاج (noisluvnoC) رجوع به اختلاج شود. RPC به احیای قلبی ریوی مراجعه کنید. 1انمهلقم 612 کراکل (selkcarC) صدای بلند مانند قات شدن صحفه کاغذی که با استاتسکوپ شنیده می شود. کراکل ناشی از مایع موجود در فضای هوایی ریه ها است. رال یا کریپیتیشن )کرپس( نیز نامیده می شود. کریپیتیشن(snoitatiperC) به «کارکل» مراجعه کنید. کرپیتوس(sutiperC) هنگام فشار دادن بر روی جلد یا استخوان، ترق یا ترک خوردن. سیانوزس(sisonayC) رنگ آبی روی جلد یا لب ها که ناشی از سطح پایین اکسیجن خون است. ضد عفونی کردن (noitanimatnoceD) حذف یک ماده خطرناک مانند مواد کیمیاوی، سموم یا مواد عفونی از جلد یا لباس فرد. بسته به ماده، این کار با برس زدن ماده یا شستشو با آب انجام می شود. بسته بندی زخم عمیق(gnikcap dnuow peeD) بسته بندی محکم یک زخم بزرگ یا جرحه عمیق با گاز معقم و فشرده برای اطمینان از اینکه فشار خارجی میتواند به طور موثر ناحیه ای از خونریزی را که خیلی بزرگ یا عمیق است فشرده کند. دستگاه شاک (rotallirbfieD) دستگاهی که جریان الکتریکی پرانرژی را برای تبدیل ریتم های غیر نارمل قلب ارائه می دهد. کم آبی بدن یا دیهایدریشن (noitardyheD) کاهش مایعات در بدن. دیریلیم / هذیان (muirileD) حالت سردرگمی در حال تغییر سریع که با آشفتگی، از دست دادن تمرکز و ناتوانی در تعامل مناسب مشخص می شود. زوال عقل یا دیمینشیا (aitnemeD ) وضعیت مزمن که با وضعیت روانی غیرطبیعی، از جمله از دست دادن حافظه و مشکلات در فکر کردن مشخص می شود. اغلب هیچ تغییری در توانائی تمرکز بر زمان حال وجود ندارد. gninnalP noitanitseD برنامه ریزی برای انتخاب تسهیلات هدف برای حمل و نقل یا انتقال به منظور تطبیق بهترین زمان حمل و نقل و سطح خدمات موجود در مرکز پذیرش با نیازهای کلینیکی مریض. کتاب دستور عملیات اشتراک کننده گان 712 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE کتواسیدوز دیابتی (AKD) وضعیتی که در دیابتی ها اتفاق می افتد که در آن کمبود انسولین باعث افزایش شکر خون می شود که منجر به کم آبی شدید و تجمع اسید در خون می شود. siserohpaiD یا تعرق زیاد مشکلات تنفسی )BID( sisodicaoteK citebaiD کتواسیدوز دیابتی را ببینید. توسع (رگ های خونی) (noitaliD) بزرگ شدن یا کشیدگی بخشی از بدن )به عنوان مثال رگ های خونی(. مشکلات تنفسی (gnihtaerb ni ytlucffiiD) احساس مشکلات تنفسی )که گاهی تنگی نفس یا BOS نیز نامیده میشود( می تواند به دلایل بسیاری از جمله مشکلات ریه ها، مشکلات آکسیجن، انسداد )بندش( طرق هوایی، تنفس سریع، عضلات تنفسی ضعیف باشد. فشار مستقیم (erusserp tceriD) راهی برای کنترول خونریزی خارجی )خونریزی( از زخم با وارد کردن فشار محکم با دو یا سه انگشت در محل خونریزی. دیسپوزیشن ویا اتتقال (noitisopsiD) مرحله بعدی مراقبت از مریض - این ممکن است رجعت دهی مراقبت به ارائه دهنده دیگری از طریق پذیرش یا انتقال، یا ترخیص به خانه باشد. غرق شدن (gniworD ) به خطر افتادن تنفس از طریق ورود آب در ریه ها، که معمولا ًناشی از مدت زمان طولانی زیر آب است. اکلمپسیا (aispmalcE) وضعیتی که در آن خانم حامله یا تازه ولادت کرده تشنج، فشار خون بالا و پروتئین در ادرار دارد. میتواند تا کوما پیشرفت کند و تهدید کننده زندگی است. )«پری اکلامپسیاا» بر اساس معیارهای خاص تشخیص داده می شود و یک زن در معرض خطر پیشرفت به اکلامپسیاا را شناسایی می کند. حمل خارج رحمی( ynangerp cipotcE) حاملگی خارج از رحم، اغلب نفیر های رحمی یعنی در جای نامناسب واقع میشود.که میتواند به عضای مجاور صدمه رساند. و باعث خونریزی شدید ناگهانی شود. پارگی حاملگی خارج از رحم یک وضعیت عاجل جراحی است. مسموم سازی (noitamonevnE ) پروسه که طی آن سم با نیش یک حیوان به بدن کسی تزریق می شود. 1انمهلقم 812 اسکاروتومی (ymotorahcsE) یک روش جراحی برای بریدن و رهاسازی نسج سوخته که ممکن است تنفس یا خون رسانی به اندام را محدود کند. صدر متحرک tsehc lialF هنگامی که شکستگی های متعدد قبرغه ها در بیش از یک مکان باعث جدا شدن بخشی از قفس سینه از بقیه دیوار قفس سینه می شود و از حرکت طبیعی تنفس جلوگیری می کند. وضعیت مایع (sutats diulF) سطح مایعات در بدن. ممکن است کم )دیهایدریشن(، طبیعی یا زیاد )بیش از حد مایعات و/یا اذیما )پندیدگی( ( باشد. فونتانیل (ellenatnoF) شکاف )نقطه نرم( بین استخوان های در حال رشد جمجمه در نوزادان - تغییرات در حجم فونتانل ها ممکن است وضعیت مایع را منعکس کند. فونتانل ها معمولا بین 21 تا 81 ماهگی بسته می شوند. جسم اجنبی (ydob ngieroF) یک جسم خارج از بدن )به عنوان مثال یک جسم خارجی در طرق تنفسی(. شکستگی (erutcarF ) استخوان شکسته یا ترک خورده. SCG به مقیاس کوما گلاسکو مراجعه کنید التهابات معدی معایی (sitsiretneortsaG) انتان یا التهاب معده و روده که میتواند باعث استفراغ، اسهال و درد شکم شود. مقیاس کوما گلاسکو (SCG) سیستمی برای ارزیابی عملکرد عصبی یک مصدوم. این نمره از 3 )عدم پاسخ( تا 51 )طبیعی( است که پاسخگویی را بر اساس حرکت چشم، پاسخ کلامی و پاسخ حرکی ارزیابی می کند. انقباض گاردینگ (gnidrauG) انقباض ارادی یا غیرارادی عضلات دیوار شکم هنگام فشار دادن روی شکم . تسلیمی (revodnaH) خلاصه مختصری از اطلاعات مهم مریض که توسط ارائه دهنده فعلی در زمانی که مریض به یک ارائه دهنده جدید منتقل میشود، ارائه میشود. تسلیمی دادن، تظاهرات کلینیکی ، مراقبتی که مریض دریافت کرده است را خلاصه می کند و ارائه دهنده جدید را از هرگونه عوارض احتمالی آگاه می کند. علاوه بر ارائه دهندگان تسهیلات دریافتی، همیشه باید به ارائه دهندگان انتقال داده شود. حتی زمانی که مراقبت به یک ارائه دهنده جدید در همان مرکز منتقل می شود نیز باید تسلیم داده شود. کتاب دستور عملیات اشتراک کننده گان 912 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE خونریزی (egahrromeaH) خونریزی با حجم زیاد ممکن است خارج از بدن یا داخل بدن ایجاد شود. شاک ناشی از خون ریزی(kcohs cigahrromeaH) وضعیت اروا ضعیف به دلیل از دست دادن خون قابل توجه. هماتوم (amotameaH) خونریزی یا تجمع خون در داخل انساج ، خارج از فضای عروقی. به نام هیماتوم یاد می گردد. هموتوراکس (xarohtomeaH) تجمع خون در فضای بین دیوار قفس سینه و ریه ها. حمله قلبی (kcatta traeH) )به آن انفارکشن میوکارد نیز می گویند(. مرگ عضله قلب به دلیل عدم رسیدن خون غنی از آکسیجن به قلب. نارسایی قلبی(eruliaf traeH) هنگامی که قلب نتواند خون کافی را برای اروا اندام ها پمپ کند، معمولا ًمنجر به اذیما )پندیدگی( در ریه ها یا اندام ها می شود. لکه های جلدی (seviH) چندین نواحی خارش دار، سرخ و برجسته روی جلد نشان دهنده یک عکس العمل حساسیتی است. ویروس عدم کفایه معافیتی انسانی )suriV ycneicfiedonummI namuH( VIH ویروسی که سیستم معافیت را تضعیف می کند و میتواند منجر به ایدز شود، سندروم چندین عفونت. هایپرترمی (aimrehtrepyH) افزایش درجه حرارت بدن. هایپرونتیلاسیون طبلیت (noitalitnevrepyH) افزایش سرعت )سریع( تنفس. هایپررزونانس (ecnanoserrepyH ) صداهای هالو یا میان خالی در قرعه رهایپوگلایسیمی (aimeacylgopyH) شکر خون پایین. حرارت پایین بدن (aimrehtopyH) کاهش درجه حرارت بدن. 1انمهلقم 022 فشار خون پایین (noisnetopyH) فشار خون کمتر از حد طبیعی است. شاک هیپوولمیک (kohs cimealovopyH ) اروا ضعیف به دلیل حجم کم خون، که ممکن است ناشی از کاهش مصرف مایعات یا از دست دادن شدید مایعات یا خون باشد. هاییوکسیا ، کمبود آکسیجن (aixopyH ) سطوح پایین آکسیجن در خون. التهاب (noitammaflnI) سرخی و پندیدگی که ممکن است ناشی از ضربه، عفونت، آلرژی یا دلایل دیگر باشد. بلع ، گوارشی (noitsegnI) بلعیدن یک ماده - معمولا ًبرای مواد یا دوزهای خطرناک استفاده می شود. آسیب ناشی از استنشاق (yrujni noitalahnI) التهاب یا اذیما )پندیدگی( راه های هوایی یا ریه ها ناشی از تنفس گازهای داغ یا مواد شپکیمیاوی تحریک کننده )معمولا ًاستنشاق دود در هنگام آتش سوزی(. تیوب گذاری (noitabutnI) قرار دادن یک تیوب تنفسی از طریق دهان، بطرف گلو و از شزن برای تهویه ریه ها توسط امبوبک یا ونتیلاتور. ایسکمیا (aimeahcsI) آکسیجن و خون رسانی ناکافی به انساج که میتواند منجر به مرگ نسج شود مثال های آن شامل )ایسکمیا میوکارد، یا کمبود آکسیجن به عضله قلب(. VI (مخفف داخل وریدی) (suonevartni rof noitaiverbba VI) اغلب برای اشاره به یک کتیتر داخل وریدی یا برای مسیر تزریق داخل وریدی ادویه یا مایع استفاده می شود. مراقبت کانگورویی( erac ooragnaK ) استفاده از تماس جلد با جلد بین نوزاد و مادر و پوشاندن سر و بدن کودک برای جلوگیری از )aimrehtopyH( یا حرارت پایین بدن و تقویت پیوند عاطفی. پارگی (noitarecaL) برش یا شکاف روی انساج کنول وریدی با قطر بزرگ (VI erob-egraL) یک کتیتر وریدی بزرگ برای احیاء سریع حجم دموی نیاز است. در حالت ایده آل، این کتیترها باید در رگ های خونی بزرگ تر )که تمایل دارند به قلب نزدیک تر باشند، مانند التوای آرنج در بازوها یا سیاهرگ های بزرگ در گردن( قرار داده شوند. در بزرگسالان، این معمولا ًبه عنوان گیج 41 یا 61 تعریف میشود، اگرچه در بعضی تنظیمات، 81 ممکن است بزرگترین گیج موجود باشد. کتاب دستور عملیات اشتراک کننده گان 122 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE سطح شعوری (ssensuoicsnoc fo leveL) سطح پاسخگویی یا هوشیاری به محیط را توصیف می کند. بی حالی (ygrahteL) خواب آلودگی بیش از حد و کندی پاسخ. میتود لاگ رول(llor goL) روشی برای چرخاندن شخص به پهلو در حالی که از خم شدن ستون فقرات جلوگیری می کند. معمولا ًزمانی انجام می شود که مشکوک به آسیب ستون فقرات باشد تا از آسیب بیشتر جلوگیری شود. پرش مناخر انف (gnirafl lasaN) گشاد شدن سوراخ های بینی در حین تنفس - ناشی از افزایش تلاش است و نشانه مشکل در تنفس است. تیوب انفی بلعومی (APN) یک تیوب لاستیکی که از طریق سوراخ بینی وارد می شود و به دهانه گلو می رسد تا اجازه عبور هوا را بدهد. رفع فشار با سوزن(noisserpmoced eldeeN ) قرار دادن یک سوزن در دیوار قفس سینه برای کاهش فشار پنوموتوراکس فشاری. اذیما (پندیدگی) (amedeO) پندیدگی غیر نارمل یا تجمع مایع در انساج ی بدن، خارج از فضای عروقی. محلول آبرسانی خوراکی (SRO) مخلوطی از آب، گلوکوز و نمک که از طریق دهان یا ebuT GN تیوب به مریضان کم آب داده می شود تا از دست دادن مایعات را جایگزین کند. تشخیص دقیق زمان و مکان (noitatneirO) رابطه یک فرد با دنیای اطراف را توصیف می کند، از جمله توانائی شناسایی دقیق نام و مکان خود، و همچنین زمان و تاریخ فعلی. تیوب فمی بلعومی (APO) یک وسیله پلاستیکی که از طریق دهان وارد می شود و به دهانه گلو می رسد تا از مسدود شدن طرق هوایی توسط زبان جلوگیری کند و به هوا اجازه عبور دهد. (noitulos noitardyh-er larO) به «محلول آبرسانی خوراکی» مراجعه کنید. اشباع آکسیجن (noitarutas negyxO) فیصدی آکسیجن در خون. 1انمهلقم 222 فرمول پارکلند (alumrof dnalkraP ) فرمولی که برای تخمین مقدار مایع وریدی مورد نیاز برای احیای مریض سوختگی در 42 ساعت اول پس از سوختگی استفاده می شود. این است: 4 میلی لیتر مایع X وزن بر حسب کیلوگرم X فیصدی سطح سوختگی بدن. نصف باید در 8 ساعت اول و نیمی در 61 ساعت بعد داده شود. قرع (noissucreP) ضربه زدن به دیوار قفس سینه برای ارزیابی ریه ها. کیفیت صدای ضربه زدن ممکن است نشان دهنده مایع یا هوا در ریه ها باشد. اروا (noisufreP) انتقال خون به انساج بدن.. انصباب پریکارد (noisuffe laidracireP ) موجودیت مایع در کیسه اطراف قلب )پریکارد(. تامپوناد قلبی (edanopmat laidracireP) تجمع زیاد مایع که تهدید کننده حیات است در کیسه اطراف قلب )پریکارد( که قلب را فشرده می کند و در پمپ طبیعی خون به بدن اختلال ایجاد می کند که منجر به شاک می شود. وسایل حفاظتی شخصی (EPP) tnempiuqE evitcetorP lanosreP تجهیزاتی اند که برای محافظت شخص در برابر انتان یا جراحت استفاده می شود. که میتواند شامل دستکش، عینک، و لباس های محافظ مانند پیش بند یا روپوش های مقاوم در برابر مایعات باشد. انصباب پلورا (noisuffe laruelP) تجمع غیرطبیعی مایع در اطراف ریه که میتواند باعث مشکل در تنفس و حتی کولپس ریه شود. علل شایع آن عبارتند از توبرکلوز و سایر انتان ها، نارسایی قلبی و سرطان. درد پلورتیک (niap citiruelP ) دردی که با تنفس بدتر می شود که معمولا ًناشی از التهاب است. نمونیا یا سینه بغل (ainomuenP) انتان ریه ها. پنوموتوراکس (xarohtomuenP) موجودیت هوا در فضای بین ریه ها و دیوار قفس سینه )فضای جنب( که باعث فروپاشی ریه می شود. پری- ایکلامیسیا (aispmalce-erP) پره اکلامپسیاا رجوع کنید به اکلامپسیاا. پریاپیسم (msipairP) نعوظ مداوم و غیر نارمل آلت تناسلی. کتاب دستور عملیات اشتراک کننده گان 322 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE مشکلات روانی ویا سایکوزس (sisohcysP) به طور کلی به عنوان از دست دادن تماس با واقعیت تعریف می شود. آمبولی ریه پلمنوری امبولیزم (msilobme yranomluP) لخته خونی است که به سمت رگ های ریه حرکت می کند و آنها را مسدود می کند. که شایع ترین منبع آن پاها هستند. پلس اکسیمتر (retemixo esluP) دستگاهی که اشباع آکسیجن )درصد کرویات سرخ اشباع شده با آکسیجن( را تشخیص می دهد. ربیس یا ویرویس سگ دیوانه (seibaR) ویروسی که از طریق نیش یا گاز گرفتن حیوانات منتقل می شود و بر مغز و اعصاب تأثیر می گذارد و میتواند باعث تغییر وضعیت ذهنی شود. حساسیت برگشتی )ssnemrednet dnuobeR ( دردی که هنگام آزاد کردن فشار روی شکم ایجاد میشود )برخلاف فشار دادن روی شکم (. احیا (noitaticsuseR) مداخلات حساس به زمان در تلاش برای مدیریت شرایط تهدید کننده زندگی انجام می شود. انقباضات یا ریترکشن (snoitcarteR) انقباضات )گاهی اوقات به آنها «درون کشش» یا «رکود» نیز گفته می شود( حرکات قابل مشاهده عضلات بین ضلعی یا اطراف استخوان های ترقوه با شهیق عمیق . انقباضات نشانه ای از مشکل جدی در تنفس است. تاریخچه ELPMAS عملکردی برای پرسیدن یافته های تاریخچه کلیدی برای همه مریضان. ELPMAS مخفف: S اعراض و علایم، A : الرژی، M : ادویه جات، P : سابقه گذشته، L : آخرین مصرف خوراکی، E : رویدادهای مربوط به مریضی یا آسیب. تشنج یا اختلاج (eruzieS ) به آن تشنج یا غش نیز می گویند. فعالیت الکتریکی غیر نارمل در مغز، اغلب به صورت تغییر وضعیت ذهنی همراه با حرکات تکراری غیر نارمل دیده می شود. تشنج ممکن است یک وضعیت اولیه باشد یا ممکن است در اثر انتان، آسیب، سموم یا مشکلات تعادل کیمیاوی ایجاد شود. شاک (kcohS) حالتی که در آن اندام ها خون و آکسیجن کافی دریافت نمی کنند )اروا ضعیف( که منجر به عدم کارکرد صحیح اندام ها میشود. 1انمهلقم 422 تست جلدی ( gnitset hcnip nikS ) روشی آسان برای بررسی وضعیت هایدرشن در کودکان با نیشگون گرفتن پوست، معمولا ًروی شکم . پوستی که به خوبی هیدراته شده است باید در کمتر از 2 ثانیه به حالت عادی بازگردد. پیچ خوردن (niarpS) رباط کشیده، کشیده یا پارگی استریدور (rodirtS) صدای بلند هنگام تنفس که ناشی از پندیدگی یا انسداد )بندش( فیزیکی طرق هوایی فوقانی است. سکته (ekrotS) مرگ نسج مغز به دلیل ایسکمی ناشی از لخته شدن خون یا خونریزی. زخم مکنده صدری (dnuow tsehc gnikuS) زخمی در دیوار قفس سینه که اجازه ورود و خروج هوا به حفره قفس سینه را می دهد که نشان دهنده پنوموتوراکس باز است. افزایش ضربان قلب (aidracyhcaT) ضربان قلب سریعتر از حد طبیعی است. افزایش تعداد تنفس (aenpyhcaT) تنفس سریع و پی در پی. نوموتوراکس فشاری xarohtomuenp noisneT زمانی اتفاق می افتد که پنوموتوراکس فشارزیادی را در داخل حفره قفس سینه ایجاد می کند و سبب کولپس رگ های خونی میشود )میزان خونی که می تواند به قلب بازگردد کاهش می یابد و قلب نمی تواند خون کافی برای حفظ خونرسانی اندام ها را پر یا پمپ کند(. بیجا شدن شزن tfihs laehcarT تغییر در موقعیت شزن در دو طرف خط میانی را توصیف می کند، یافته ای که گاهی با تنشن پنوموتوراکس همراه است. بررسی اولیه صدمه yevrus yramirp amuarT بررسی اولیه صدمه اصطلاح دیگری برای روش EDCBA در مصدومین. این شامل ارزیابی اولیه یک فرد آسیب دیده و مدیریت تمام صدمات بلافاصله تهدید کننده زندگی، به ترتیب اولویت است. بررسی اولیه شامل EDCBA است: طرق هوایی، تنفس، دوران خون، ناتوانی و قرار گرفتن در معرض. بررسی ثانوی صدمه yevrus yradnoces amuaT معاینه سر تا پا )قدام و خلف( ترومایی که شامل گرفتن تارخچه به اساس ELPMAS است. هدف از این بررسی شناسایی و تداوی همه صدمات، با اولویت دادن به مشکلات که در ارزیابی اولیه دریافت نگردیده. کتاب دستور عملیات اشتراک کننده گان 522 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE موقعیت سه پایه noitisop dopirT نشستن عمودی با گردن کشیده اما کمی به جلو خم شده و دست ها روی زانو. افرادی که دچار مشکل شدید در تنفس هستند اغلب در این حالت می نشینند. ویزینگ gnizeehW صدای اشپلاق در نفس کشیدن به دلیل التهاب در ریه ها ایجاد می شود که نشان دهنده پندیدگیو یا تنگ شدن طرق تنفسی سفلی است. قللعیم لجقلنمزولهدم:نض 622 منابع سازمان جهانی صحت ارزیابی و تداوی تریاژ اضطراری )TATE(. ژنیو: سازمان صحی جهان; 5002. جون 6102 تجدید شده. کتابچه راهنمای کلینیکی ناحیوی مدیریت یکپارچه مریضی های نوجوانان و بزرگسالان )IAMI(. جلد 1 و 2. ژنیو: سازمان جهانی صحت; 1102: فصل 2-4; 6-8. کتاب جیبی برای مراقبت از کودکان در شفاخانه. چاپ دوم. ژنیو: سازمان جهانی صحت; 3102. کتاب دستور عملیات اشتراک کننده گان 722 ه م قد م BA DC E ه م صد ن رد ک س ف تن ک شا MA S ها ت ار ه م ه م نا ژه وا ER EF ER CN SE مراقبت های ابتدایی عاجل کارت های سریع عملکرد EDCBA به یاد داشته باشید... همیشه علایم صدمه را بررسی کنید )همچنین به کارت صدمه مراجعه کنید( یافته های ارزیابی مدیریت فوری اگر صدمه وجود ندارد: tlit daeH و tfel nihC، از APO یا APN برای باز نگه داشتن طرق تنفسی استفاده کنید، در وضعیت ریکاوری یا موقعیت راحت قرار دهید. در صورت امکان صدمه: از تراست الاشه tsurht waJ با محافظ ستون فقرات استفاده کنید و APO را برای باز نگه داشتن راه هوایی قرار دهید )در صورت ضربه به چهره یا روی، APN وجود ندارد(. بی هوش با تنفس محدود و یا بدون نتفس طرق تنفسی جسم خارجی قابل مشاهده را بردارید. سرفه را تشویق کنید اگر قادر به سرفه نیستید: فشارهای قفسه سینه/شکم/ضربات به پشت همانطور که نشان داده شد اگر مریض بیهوش شود: RPC بندش طرق تنفسی ناشی از جسم اجنبی راه هوایی را مانند بالا باز کنید، ساکشن کنید )جلوگیری ازتنبه عکسه بلع یا gaG( غرغر کردن مریض را آرام نگه دارید و اجازه دهید موقعیت راحتی داشته باشد. برای علایم آنافیلاکسی: آدرنالین عضلی بدهید برای هیپوکسی: آکسیجن بدهید استریدور آکسیجن بدهید، اگر تنفس کافی نیست به تهویه با MVB کمک کنید. به ebuT tsehC نیاز خواهد داشت نفس گرفتن علایم تنفس غیر نارمل یا هیپوکسی سالبوتامول بدهید. برای علایم آنافیلاکسی: آدرنالین عضلی بدهید. ویزینگ رفع فشار سوزن را انجام دهید، آکسیجن و مایعات داخل وریدی بدهید. علایم تنشن پنوموتوراکس )صداها وجود ندارد / تشدید بیش از حد در یک طرف همراه با افت فشار خون، رگهای گردن متوسع(. علایم استعمال زیاد مواد افیونی )SMA نلوگزان بدهید و تنفس آهسته با اشیای کوچک( در صورت عدم موجودیت نبض، پروتکل های RPC مربوطه را تعقیب کنید. آکسیجن و مایعات VI بدهید. دوران خون علایم اروا ضعیف/شاک علایم خونریزی داخلی یا خارجی خونریزی خارجی را کنترول کنید و مایعات VI بدهید. مایعات VI، آکسیجن بدهید. به تخلیه سریع پریکارد نیاز دارد علایم تامپوناد پریکارد )اروا ضعیف با توسع وریدهای گردن و صداهای خفه شده قلب( ناتوانی/ معلولیت تغیر وضعیت شعوری )SMA( اگر صدمه وجود ندارد، در وضعیت ریکاوری قرار دهید. تشنج بنزودیازپین بدهید. تشنج در حامله گی)یا بعد از ولادت مگنیزیم سلفات بدهید اخیر( . هایپوگلایسیمیا اگر <L/lomm5.3 یا ناشناخته است، گلوکز بدهید. علایم مصرف بیش از حد مواد افیونی نلوگزان بدهید SMA با تنفس آهسته و حدقه های کوچک سر تخت را بالا کنید، راه تنفسی را کنترول کنید. برای خدمات جراحی اعصاب نیاز به انتقال سریع دارد علایم کتله مغزی تهدید کننده حیات و خون)SMA( با عدم تناظر حدقه ها لباس های تر و را دور کنید و مریض را خشک نگهدارید. برهنه ساختن مریض جواهرات، ساعت و لباس های تنگ را دور کنید. از هیپوترمی جلوگیری کنید و حرمت مریض را محافظت کنید عضو را بی حرکت کنید. ارسال عکس مار با مریض. در صورت لزوم برای بی اثر سازی زهر و یا انتی دوت زهر مریض را منتقل کنید. مار گزیدگی اگر علت ناشناخته است، صدمه را به خاطر بسپارید: کل بدن را معاینه کنید و همیشه صدمات پنهان را در نظر بگیرید )همچنین به کارت صدمه مراجعه کنید( به یاد داشته باشید: مریضان با یافته های غیر نارمل EDCBA ممکن است نیاز به رجعت دهی / انتقال سریع داشته باشند. زودتر برنامه ریزی کنید ELPMAS تاریخچه علایم حیاتی طبیعی بزرگسالان علایم و نشانه ها آلرژی ها ادویه جات HMP آخرین مصرف خوراکی واقعات تعداد نبض: 06-001 ضربه در دقیقه تعداد تنفس: 01 تا 02 تنفس در دقیقه فشار خون سیستولیک > 09 میلی متر سیماب اشباع آکسیجن > 29% تخمین فشار خون سیستولیک )در کودکان و افراد مسن قابل اعتماد نیست(: نبض کاروتید )گردن( ← PBS ≥ 06 میلی متر نبض فمورال )کشاله ران( ← PBS ≥ 07 سیماب نبض رادیال )مچ دست(← PBS ≥ 08 سیماب ملاحظات ویژه در ارزیابی کودکان کودکان سر و زبان بزرگتر و گردن کوتاهتر و نرمتر از بزرگسالان دارند. طرق هوایی را نظر به سن مدیریت کنید.. همیشه اجسام خارجی را در نظر بگیرید. مراقب علایم افزایش کار تنفس باشید )مانند انقباض و فرورفتن قفسه سینه ، پرش مناخر انف(. به صداهای غیرعادی نفس )مانند خرخر کردن، استریدور، یا بی صدا قفسه سینه( گوش دهید. (تعداد تنفس، نفس در دقیقه) سن 04-06<2 ماه 52-052–21 ماه 02-041–5 سال ها علایم اروا ضعیف در کودکان عبارتند از: پر شدن آهسته موی رگ ها، کاهش ادرار، بی حالی، فونتانل فرورفته، ضعیف شدن الاستیکیت یا ارتجاعیت جلد به تعقیب علایم کم خونی و سوءتغذیه باشید )میزان مایعات را تنظیم کنید). به یاد داشته باشید که کودکان ممکن است همیشه صدمه را گزارش ندهند و ممکن است صدمات داخلی جدی با علایم بیرونی کمی داشته باشند. ضربان قلب به شکل نورمال عمر (به سال) (ضربان فی دقیقه) 001–061<1 09–0511–3 08–0414–5 هایپوگلایسیمی در کودکان مریض معمول است متوجع بی حالی یا تحریک پذیری باشید. همیشه UPVA را بررسی کنید تون عضلی و عکس العمل نسبت به تنبع را بررسی کنید. نوزادان و کودکان در حفظ دما مشکل دارند لباس تر را دور کنید و جلد مریض را خشک نگهدارید. در صورت امکان نوزادان را به تماس بدن قرار دهید. برای )aimrehtopyH( حرارت پایین بدن ، سر را بپوشانید )اما مطمئن شوید که دهان و بینی باز هستند(. برای حرارت بلند بدن )aimrehtrepyH(، نوزادانی را که محکم بسته شده اند باز کنید. علایم خطر در کودکان علایم انسداد )بندش( طرق تنفسی )ناتوانی در بلع کردن بزاق / ترشح آب دهان یا استریدور( افزایش کارایی تنفس )تنفس سریع، باز شدن بینی، وصف جوشیدن آب کردن، انقباض قفسه سینه( سیانوز )رنگ آبی پوست، به خصوص در لب ها و نوک دست( تغیر وضعیت شعوری )از جمله بی حالی یا خواب آلودگی غیرعادی، گیجی، بی نظمی( فقط زمانی حرکت می کند که تحریک شود یا اصًلا حرکتی نداشته باشد UPVA غیر از «A»( خوب تغذیه نمی کند، نمیتواند بنوشد یا شیر بخورد یا همه چیز را استفراغ کند تشنج/اختلاج کاهش درجه حرارت بدن )هیپوترمیا( وزن تخمینی بر حسب کیلوگرم برای کودکان 1-01 ساله: (سن بر حسب سال + 4) × 2 عملکرد بامریض مبتلا به صدمه یافته های کلیدی از سروی ابتدایی ترضیض (همچنین به کارت EDCBA مراجعه کنید) یافته های ارزیابی مدیریت فوری از tsurht waJ با محافظ ستون فقرات رقبی استفاده کنید. درصورت نیاز سکشن کنید، اجسام خارجی قابل مشاهده را بردارید. او پی ای را برای باز نگهداشتن راه تنفسی قرار دهید. صحبت نکردن، غیر متحرکیت کردن یا محدود کردن حرکت طرق هوایی طرق تنفسی آکسیجن بدهید، به دقت نظارت کنید - پندیدگی میتواند به سرعت طرق تنفسی را مسدود کند. ← به مدیریت طرق تنفسی بیشرفته نیاز دارد. علایم آسیب احتمالی طرق هوایی )هماتوم یا جروحات عنق، کرپیتوس، استریدور( کسیجن بدهید، به دقت نظارت کنید - پندیدگی میتواند به سرعت طرق تنفسی را مسدود کند. ← به مدیریت طرق تنفسی بیشتر نیاز است. علایم سوختگی احتمالی طرق تنفسی )دود در اطراف دهان یا بینی، سوختگی موهای صورت، سوختگی صورت( رفع فشار سوزنی را روی دست گیریدد. اکسیجن و مایعات VI را برایش بدهید. ← به ebut tsehc نیاز دارد علایم تنشن پنوموتوراکس )افت فشار خون همراه با معدومیت صداهای تنفسی/ تشدید بیش از حد در یک طرف، توسع ورید های( نفس گرفتن آکسیجن بدهید، پانسمان سه طرفه قرار دهید، تنشن پنوموتوراکس را کنترول کنید. ← به ebut tsehc نیاز دارد جروحات مکنده صدری تنفس کافی نیست آکسیجن بدهید، با MVB به تهویه کمک کنید. به ازای اندازه سوختگی مایعات وریدی بدهید، آکسیجن بدهید، جواهرات و لباس های تنگ را دور کنید. ← ممکن است نیاز به اسکاروتومی داشته باشد سوختگی های بزرگ قفسه سینه یا شکم )یا سوختگی حلقوی در اطراف بدن( آکسیجن تطبیق نمایید ← ممکن است به مدیریت پیشرفته طرق هوایی و تهویه کمکی نیاز داشته باشد علایم tsehC lialF )قسمتی از دیوار قفسه سینه که در جهت مخالف با تنفس حرکت می کند( آکسیجن بدهید، مایعات وریدی. ← به ebut tsehc نیاز دارد علایم هموتوراکس )کاهش صداهای نفس در یک طرف، موجودیت اصمیت در هنگام قرع( آکسیجن، مایعات VI بدهید، خونریزی خارجی را کنترول کنید خونریزی، اتل فمور/لگن همانطور که نشان داده شده است. نشانه های شاک )پر شدن مجدد عروق شعریه بیش از 3 ثانیه، کاهش فشار خون، ضربان سریع )aidracyhcaT( دوران خون اعمال فشار، بسته بندی زخم عمیق یا تورنیکیت همانطور که نشان داده شده است. خونریزی خارجی کنترول نشده علایم تامپوناد )اروا ضعیف، توسع ورید مایعات داخل وریدی، آکسیجن بدهید. های عنق، صدای خفه شده قلبی یا sdnuos traeh defflum( ستون فقرات رقبی را بی حرکت کنید، گلوکوز را چک کنید، چیزی از راه دهان ندهید. ← به مراقبت های جراحی مغز و اعصاب نیاز دارد علایم ترضیض قحفی )SMA با زخم، تغییر شکل یا کبودی سر/ صورت( ناتوانی/ معلولیت همانطور که در بالا ذکر شد، و انتی بیوتیک را مطابق پروتوکول های محلی تطبیق نمایید. علایم شکستگی باز جمجمه )مانند بالا، همراه با خون یا مایع از گوش/بینی( به یاد داشته باشید: مصدومین با یافته های غیرطبیعی EDCBA ممکن است نیاز به رجعت دهی / انتقال سریع به خدمات جراحی داشته باشند. زودتر برنامه ریزی کنید مدیریت شرایط خاص ستون فقرات رقبی را در صورت لزوم بی حرکت کنید، برای شکستگی های باز انتی بیوتیک کسور وجه وریدی بدهید، از تطبیق تیوب انفی بلعومی و انفی معدوی خودداری کنید. از فشار روی چشم خودداری کنید، جسم اجنبی را تثبیت کنید و هیج گاه را خارج نکنید، جرحه نافذ چشم انتی بیوتیک و تینانوس بدهید، سر تخت را بلند کنید. مایعات وریدی بدهید، هیچ چیزی از طریق دهن داده نشود. روده قابل مشاهده را با گاز جرحه باز بطن استریل آغشته به سیروم سلین استریل بپوشانید، انتی بیوتیک بدهید. مایعات وریدی بدهید، با ورقه یا چسب لگن خاصره تثبیت کنید.کسر حوصله از شکسته گی بیشتر جلوگیری کنید و اتل بگذارید.شکستگی با اروا ضعیف اندام به خوبی پاک کاری و شستشو کنید، زخم را پانسمان کنید، اتل بزنید، انتی بیوتیک بدهید، شکستگی باز رجعت دهی سریع برای مدیریت جراحی بدهید. برای جلوگیری از آسیب بیشتر، جسم را در جای خود بگذارید و آن را ثابت کنید.جسم نافذ مایعات وریدی بدهید، متوجع طرح کردن ادرار باشید. سندروم کمپارتمان را کنترول کنید. صدمات کوبیده شده فیصدی سطح سوختگی و نیاز به مایعات را محاسبه کنید، مایعات و آکسیجن را تطبیق جراحت سوختگی نماید. اذیما یا پندیدیگی طرق تنفسی را متوجح باشید. آکسیجن بدهید، سوختگی ها را مانند زیر تداوی کنید، مایعات وریدی بدهید، اثرات تاخیری آسیب انفجار صدمات داخلی را به دقت بررسی کنید. به یاد داشته باشید: مجروحین دیده با زخم، از جمله سوختگی و شکستگی های باز، نیاز به واکسین تیتانوس دارند. مکانیزم ها و جروحات با خطرات بالقوه صدمات پرخطرمکانیزم های پرخطر برخورد عابر پیاده یا بایسکل سوار توسط وسیله نقلیه تصادف موترسایکل یا هر حادثه وسیله نقلیه بدون سرنشینان سقوط از ارتفاع بیش از 3 متر )یا دو برابر قد کودک( شلیک مرمی یا چاقو زدن انفجار یا آتش سوزی در فضای بسته. جروحات نافذ به سر، گردن یا صدر جراحات ناشی از انفجار یا حادثه ترافیکی سینه فلیل دو یا چند شکستگی استخوان بزرگ، یا شکستگی لگن خاصره ترضیض ستون فقرات فلج اطراف قطع عضو بالای مچ دست یا مچ پا ملاحظات خاص در کودکان کودکان می توانند ظاهر خوبی داشته باشند اما حالت صحی آنها به سرعت خراب می شوند. کودکان نسبت به بزرگسالان استخوان های انعطاف پذیرتری دارند و می توانند صدمات داخلی جدی با علایم خارجی کمی داشته باشند. هنگام محاسبه دوز مایعات و ادویه جات احتیاط کنید. تا حد امکان از وزن دقیق استفاده کنید. مراقب هیپوترمی و هایپوگلایسیمی باشید. رجهت دهی و انتقال شرایطی که نیاز به رجعت دهی یا انتقال به مرکز صحی تخصصی دارد عبارتند از: یافته های EDCBA که نیاز به مداخله دارد شواهد خونریزی داخلی هر گونه پنوموتوراکس یا زخم مکنده صدری شاک، حتی اگر با موفقیت تداوی شود تغییر وضعیت ذهنی صدمه در دوران حاملگی ناهنجاری های EDCBA یا هر گونه ترضیضات صدری/شکم در کودک جروحات سوختگی قابل توجه ملاحظات انتقال: هر مریض که به اکسیژن نیاز دارد باید در حین حمل و نقل و پس از تحویل اکسیژن داشته باشد. برای علایم شاک، اطمینان حاصل کنید که مایع وریدی در حین انتقال شروع شده و ادامه دارد. هر گونه خونریزی خارجی را کنترول کنید و ناحیه مجروح را را از نزدیک در طول حمل و نقل متوجع باشید. اقدامات در مریضان با مشکلات تنفسی یافته های کلیدی EDCBA (همیشه ابتدا اقدامات کامل EDCBA را انجام دهید!) به یاد داشته باشید....اگر دریافتید .... جسم خارجیخفگی، سرفه انسداد )بندش( جزئی طرق هوایی به دلیل جسم خارجی یا التهاب )در اثر استریدور عفونت، قرار گرفتن در معرض مواد شیمیایی یا سوختگی( عکس العمل حساسیتی شدید، تاثیرات ادویه جاتپندیدگی وجه نشان دهنده انسداد )بندش( در بلع استریزش آب هان دوده اطراف دهان یا بینی، موهای سوخته صورت، سوختگی وجه استنشاق دود و سوختگی طرق تنفسی - پندیدگی سریع میتواند طرق تنفسی را مسدود کند شکستگی ضلع، شل شدن قفسه سینه، پنوموتوراکس، کوفتگی، تامپونادعلایم ترضیضات صدری پنوموتوراکس )تنشن پنوموتوراکس در صورت افت فشار خون و تشدید بیش کاهش صداهای نفس در یک طرف از حد قرع را در نظر بگیرید(، هموتوراکس، انصباب پلورایی بزرگ/پنومونی کاهش صداهای تنفسی و selkcarc در هر دو طرف اذیما )پندیدگی( ی ریوی، نارسایی قلبی استما، عکس العمل حساسیتی، DPOCویزینگ سینه AKDتنفس سریع یا عمیق فشار خون پایین، ضربان سریع )aidracyhcaT(، صدای خفه شده قلبی یا traeh defflum sdnuos تامپوناد پریکارد تغییر وضعیت ذهنی با حدقه های کوچک و تنفس آهسته مصرف بیش از حد مواد افیونی یافته های کلیدی از تاریخچه ELPMAS و ارزیابی ثانوی به یاد داشته باشید....اگر دریافتید .... نارسایی قلبی، حمله قلبیمشکلات تنفسی با تلاش یا فعالیت بدتر می شود مشکلات تنفسی که با خفگی یا در حین غذا خوردن شروع شد جسم خارجی، عکس العمل حساسیتی پنومونی، عفونتسابقه تب، سرفه مسمومیتقرار گرفتن در معرض ضد عفونی شکستگی ضلع، شل شدن قفسه سینه، پنوموتوراکس، کوفتگی، تامپونادسقوط اخیر یا آسیب های دیگر آلرژی های شناخته شده، قرار گرفتن در معرض آلرژن، گزیده گی و یا چک کنده شده عکس العمل حساسیتی عکس العمل حساسیتی یا عارضه جانبیآخرین تجویز ادویه ویا تغییر ادویه مصرف بیش از حدسابقه مصرف مواد مخدر یا ادویه جاتی آرام بخش استما یا DPOCتاریخچه ویزینگ ) خس خس ( سینه AKDسابقه دیابت تامپوناد پریکارد، انصباب پلوراسابقه توبرکلوز یا حالات اذیما )پندیدگی( ریویسابقه عدم کفایه قلبی سابقه مریضی کم خونی داسی شکل یا elkcis aimena llec سندروم حاد صدری اقدامات حیاتی برای شرایط پر تحدید کننده حیات خفگی قادر به سرفه کردن نیست صدا تولید نمی کند استریدور صداهای با پیچ بلند در هنگام گرفتن تنفس ویزینگ صداهای با پیچ بلند در هنگام خارج کردن تنفس صدمهانتان شدید هر جسم خارجی قابل مشاهده را بردارید. در صورت بیهوش شدن، فشارهای سینه/شکم یا ضربات پشت مناسب سن را انجام دهید. آرامش مریض را حفظ کنید و اجازه می دهد موقعیت راحتی در صورتیکه مشکوک به عکس العمل حساسیتی باشید ادرینالین عضلی تطبیق نماید. در صورت کمبود اکسیجن؛ اکسیجن تطبیق نماید. جهت مدیریت پیشرفته طرق تنفسی رجعت دهی و انتقال را سریعا انجام دهید. سالبوتامول بدهید در صورتیکه مشکوک به عکس العمل حساسیتی باشید ادرینالین عضلی تطبیق نماید در صورت کمبود اکسیجن؛ اکسیجن تطبیق نماید. آکسیجن انتی بیوتیک ها در صورت لزوم مایعات از طریق وریدی و فمی تطبیق نماید. -moced eldeeN noisserp و مایعات وریدی برای تنشن پنوموتوراکس پانسمان سه طرفه برای زخم های مکنده و انتقال سریع برای خدمات جراحی ملاحظات خاص در کودکان علایم زیر در کودکان با شکایات تنفسی عبارتند از: تنفس سریع افزایش کارکرد تنفسی -ni tsehC noitcarter tsehc/gniward سیانوز تغیر وضعیت شعوری )از جمله بی حالی( تغذیه یا نوشیدن ضعیف، یا همه چیز را استفراغ می کند تشنج/اختلاج، فعلی یا اخیر ریزش آب دهان یا استریدور در هنگام آرامش هیپوترمی ویزینگ در کودکان اغلب به دلیل استنشاق جسم در طرق تنفسی، انتان ویروسی یا استما یجاد می شود. استریدور در کودکان اغلب به دلیل بندش در طرق تنفسی یا التهاب طرق تنفسی در اثر انتان ایجاد می شود. تنفس سریع یا عمیق میتواند نشان دهنده بحران دیابت )AKD( باشد که ممکن است اولین علامت دیابت در کودک باشد. تنفس سریع ممکن است تنها نشانه یک مشکل جدی تنفسی در کودک باشد. رجهت دهی و انتقال اثرات سالبوتامول و ادرینالین MI حدود 3 ساعت باقی می ماند و علایم تهدید کننده زندگی ممکن است عود کنند. نظارت دقیق داشته باشید، همیشه دوز تکراری را در طول حمل و نقل در دسترس داشته باشیدو به ارایه دهنده جدید مراقبت های انجام شده را گزارش دهید. مدت تاثیر نالوگزان تقریبا 1ساعت است، در حالی که بیشتر مواد مخدر به مدت طولانی تر اثر دارند. نظارت دقیق داشته باشید، همیشه دوز تکراری را در طول حمل و نقل در دسترس داشته باشید و و به ارایه دهنده جدید مراقبت های انجام شده را گزارش دهید. پس از غوطه ور شدن در آب )غرق شدن(، ممکن است فرد پس از چند ساعت دچار مشکلات تنفسی تاخیری شود. نظارت دقیق و احتیاط ارائه دهندگان جدید مد نظر باشد. هرگز مریضانی را که در تنفس مشکل دارند در حین رجعت دهی/انتقال بدون نظارت رها نکنید برای هر مریض که ممکن است به تیوب گذاری یا تهویه کمکی نیاز داشته باشد، هر چه زودتر ترتیبات انتقال را انجام دهید. عملکرد بامریض مبتلا به شاک یافته های کلیدی EDCBA (همیشه ابتدا اقدامات کامل EDCBA را انجام دهید!) به یاد داشته باشید....اگر دریافتید .... مشکل تنفس، استریدور/ویزینگ، راش هاس جلدی، پندیدگی دهان عکس العمل حساسیتی شدید فشار پایین خون همراه با عدم موجودیت صداهای تنفسی هایپرریزونانس در یک طرف، توسع وریدهای گردن. xarohtomenp noisneT توسع وریدهای گردن، صداهای خفه کننده قلب، ضربان سریع )aidracyhcaT(، فشار پایین خون. تامپوناد پریکارد AKDتنفس با بوی شیرین، تنفس عمیق یا سریع خون ریزی های داخلی و یا محفی خون قابل توجه )معده، روده، ترضیضات سابقه صدمه یا بدون علت شناخته شده بسته بطنی، استخوان بلند( یا ترضیضات نخاعی. یافته های کلیدی از تاریخچه ELPMAS و سروی ثانوی به یاد داشته باشید....اگر دریافتید .... در مورد مخاطبین بپرسید و موارد را در پروتوکول گزارش دهید.استفراغ و اسهال خونریزی معده یا رودهاستفراغ یا مدفوع سیاه یا خونی تنفس سریع یا عمیق، کم آبی، گلوکوز بالا، نفس خوشبو، سابقه تکرر ادرار یا دیابت شناخته شده کیتواسیدوز دیابتی از دست دادن شدید مایع )محاسبه نیاز مایعات بر اساس اندازه سوختگی(سوختگی ها عفونتتب یا VIH خونریزی داخلی و خارجیسقوط اخیر یا آسیب های دیگر کم خونی شدید )تنظیم مایعات(منظمه خاسف یا سوء تغذی حمله قلبی )در صورت لزوم اسپرین بدهید(درد صدری خونریزی مرتبط با حاملگی و غیر حاملگیخونریزی مهبل بی حسی، ضعف یا شاکی که با مایعات بهبود نمی یابد شاک نخاعی )در صورت لزوم، ستون فقرات را بی حرکت کنید( اقدامات حیاتی برای شرایط پرخطر برای تمام شاک: آکسیجن بدهید مایعات وریدی بدهید کاهلان: 1 لیتر RL یا NS بولوس کودکان بدون کم خونی شدید، بدون سوءتغذیه، بدون اضافه بار در لیتر: 10-20 میلی لیتر / کیلوگرم بولوس کودکان مبتلا به سوءتغذیه یا کم خونی شدید: 10 تا 15 میلی لیتر/کیلوگرم دکستروز حاوی دکستروز را در مدت 1 ساعت تجویز کنید و هر 5 دقیقه یک بار اضافه بار در لیتر را ارزیابی کنید. برای حمله قلبی مشکوک همراه با شاک، بولوس های کوچک تری بدهید و از نظر بار اضافی مایعات به دقت مشاهده کنید. علایم حیاتی، وضعیت ذهنی، تنفس و تولید و طرح ادراد مریض را درج کنید و برای شرایط خاص: عکس العمل حساسیتی شدید پنوموتوراکس تنش اسهال تبتمپوناد آبگین خونریزی پس از زایمان صدمهAKD مانیتور برای عود دوباره ممکن نیاز به دوز های تکراری داشته باشد رفع فشار سریع سوزنی انتقال برای تطبیق تیوب صدری انتقال سریع به ارائه دهنده پیشرفته برای دریناژ . انتی بیوتیک ها )و ضد مالاریا در صورت وجود( منبع عفونت را ارزیابی کنید اقدامات احتیاطی کامل قبل از مداخله طرح ادرار را مشاهده کرده و مایعات را ادامه دهید. کولرا را ارزیابی کنید و به مقامات صحت عامه اطلاع دهید. اکسیتوسین و ماساژ رحم. فشار مستقیم برای پارگی های عجان و واژن. انتقال سریع به مراقبت های پیشرفته ولادی. نظارت دقیق برای اضافه بار مایعات در کودکان. انتقال / سریع همرا با تطبیق انسولین خونریزی خارجی را با فشار مستقیم، بسته بندی زخم، در صورت لزوم با تورنیکت کنترول کنید. نیاز به مایعات را بر اساس اندازه سوختگی محاسبه کنید. انتقال سریع برای جراحی/ تزریق خون در صورت نیاز. ملاحظات خاص در کودکان ارزیابی شاک در کودکان دستورالعمل 6102 OHW برای مراقبت از کودکان با مریضی شدید از وجود سه ویژگی کلینیکی برای تعریف شاک استفاده می کند: نهایات سرد نبض ضعیف و تند بر گشت خون به عروق شعریه بیش از 3 ثانیه سایر علایم مهم اروا ضعیف عبارتند از: چشمهای فرو رفته؛ فونتانل های فرو رفته در نوزادان تست غیرطبیعی جلدی رنگ پریدگی )تداوی کم آبی بدن با کم خونی دشوارتر است( کاهش و تیره شدن ادرار )تعداد پمپر برای نوزادان( فشار پایین خون تنفس سریع تغییر وضعیت ذهنی کاهش ادرار دهان و لب های بسیار خشک بی حالی )خواب آلودگی بیش از حد، دیر پاسخ، غیر تعاملی( ملاحظات مهم اضافی عبارتند از: کودکان خردسال ممکن است نتوانند به تنهایی نوشیدنی کافی بنوشند. کودکان نسبت سطح به حجم سطح بزرگتری دارند و می توانند سریعتر از بزرگسالان مایعات را از دست بدهند. برای کودکی که دچار شاک با سوء تغذی شدید یا اضافه بار مایعات است، دکستروز اضافه کنید و مایعات وریدی را کاهش دهید: 01-51 میلی لیتر/کیلوگرم در مدت 1 ساعت. در کودکان سوءتغذیه شدید، کم خونی شدید یا اضافه بار مایعات، به مدت 03 دقیقه مجددا ًمایعات را احیا کنید. حجم مایع )51 میلی لیتر/ کیلوگرم( وزن )کیلوگرم( 09 6 051 01 012 41 003 02 054 03 رجهت دهی و انتقال مریضان مبتلا به شاک باید نظر به نوع شاک در مرکز صحی باشند که قادر به انجام احیای مایع وریدی، انتقال خون و/یا جراحی باشد. در حین حمل و نقل مایعات را حفظ کنید. عملکرد EDCBA را تکرار کنید و اروا و تنفس را همیشه از نزدیک تحت نظر داشته باشید. او آر س SRO را از طریق تیوب هضمی بینی آغاز کنید آیا مایعات وریدی در نزدیکی قابل دسترس است؟ آیا مایعات وریدی فورا قابل دسترس است؟ ارزیابی مجدد فوری بعد از زرق وریدی کنید آیا زرق وریدی انکشاف نموده است؟ مایعات را از طریق دهن ادامه دهید. مایعات را از طریق دهن یا ورید طبق استطباب شروع کنید. آیا پرفیوژن انکشاف نموده است؟ او آر س SRO را از طریق زرق وریدی دوباره تیوب هضمی ادامه دهید. بلی بلی بلی بلی نخیر نخیر نخیر نخیر ارزیابی مجدد فوری بعد از زرق وریدی کنید 03 دقیقی> 03 دقیقی> 03 دقیقی> مایعات وریدی آغاز کنید توصیه مایعات در شاک )عدم سوء تغذی، اضافه بار مایعات یا کمخونی شدید( دوز احیاوی او آر اس 01-02 gk /lm او آر اس مایعات وریدی ابتدایی بزرگ سالان یک لیترنارمل سلین یا رنگر لکتات مایعات وریدی ابتدایی اطفال 01-02 gk/lm نارمل سلین یا رنگر لکتات فورا انتقال دهید. عملکرد با مریض با وضعیت ذهنی تغییر یافته (AMS) یافته های کلیدی EDCBA (همیشه ابتدا اقدامات کامل EDCBA را انجام دهید!) به یاد داشته باشید....اگر دریافتید .... کمبود آکسیجن، AKD، بلع سمیتنفس بیشتر انتانات، خونریزی داخلیاروا/شاک ضعیف ترک الکولضربان سریع )aidracyhcaT( با پرفیوژن طبیعی کمبود آکسیجن، قند خون بالا یا پایین، AKD و مصرف سمیکوما انتانات، عوارض جانبی ادویه )به عنوان مثال، ادویه جاتی دیابت، کینین(رهایپوگلایسیمی مصرف بیش از حد مواد اوپیاد هاحدقه های بسیار کوچک با تنفس آهسته گلوکوز غیر طبیعی، انتانات، مصرف سمی )مثًلا ادویه جات سل یا توبرکلوز( تشنج / اختلاج یا ترک )مثًلا الکول(. در صورت حاملگی فعلی یا ولادت اخیر، اکلامپسیاا را در نظر بگیرید. کتله مغزی یا خونریزیضعف در یک طرف یا اندازه حدقه نابرابر ترضیض قحفی را در نظر بگیرید )با آسیب احتمالی ستون فقرات(علایم صدمه یا علت ناشناخته SMA یافته های کلیدی از تاریخچه ELPMAS و سروی ثانوی به یاد داشته باشید....اگر دریافتید .... بحران DPOC شدید میتواند باعث SMA شودتاریخچه ویزینگ قند خون بالا یا پایین، AKDسابقه دیابت گیجی و خواب آلودگی پس از تشنج باید در عرض چند دقیقه تا چند ساعت سابقه صرع بهبود یابد. طولانی مدت SMA یا تشنج های متعدد بدون بیدار شدن از خواب، نیاز به کار بیشتر دارد. سابقه کار زراعتی یا قرار گرفتن در معرضحشره کش های شناخته شده مسمومیت با ارگانوفسفیت ترک الکولسابقه مصرف منظم الکول مسمومیت حاد، مصرف بیش از حد تصادفی یا عمدیسابقه مصرف مواد یا افسردگی انتانات، عوارض جانبی ادویه جات و غیرهتاریخچه VIH راش های جلدی در زیر شکم یا پاها یا فونتانل برآمده در نوزادان انتانات دماغی )مننژیت( عوامل انتانی، سمی و محیطیتب/هیپرترمی اقدامات حیاتی برای شرایط پرخطر (همیشه قند خون را در SMA چک کنید، یا اگر قادر به بررسی نیستید، گلوکوز بدهید.) مصرف بیش از حد رهایپوگلایسیمی اوپیات ها انتانات تهدید کننده زندگی قرار گرفتن در معرض دیهایدریشن شدید سموم یا ترک أن گلوکوز بدهید بررسی جهت انتانات مانیتور برای بازگشت رهایپوگلایسیمی نالوگزان نظارت بر نیاز به دوزهای تکراری )بسیاری از اوپیات ها بیشتر از نالوگزان دوام می آورند( مایعات وریدی انتی بیوتیک ها برای SMA همراه با تب یا رش یا سرخی جلدی، انتانات مغزی )مننژیت( را در نظر بگیرید - مریض را تجرید کنید و از ماسک استفاده کنید. اگر تب بسیار بالا نشان داده شده سرد شود )از لرزه خودداري کنید(. مایعات وریدی از نگاه انتان ارزیابی کنید AKD را در نظر بگیرید تاریخچه را جمع آوری کنید و با ارائه دهنده پیشرفته برای انتی دوت های مناسب محلی مشورت کنید. ترک الکول را با بنزودیازپین تداوی کنید. برای قرار گرفتن در معرض مواد کیمیاوی )مانند حشره کش ها( ضد عفونی کنید. ملاحظات اطفال همیشه بلعیدن مواد سمی بدون شاهد را در نظر بگیرید در مورد ادویه جاتی موجود در خانه و هر گونه مواد شیمیایی )مثًلا محصولات تمیز کننده، ضد یخ( در داخل یا نزدیک خانه سؤال کنید. قند خون پایین در کودکان خردسال مریض شایع استقند خون را چک کنید و مرتبا ًمجددا ًچک کنید گلوکوز خون بالا میتواند با SMA و کم آبی ظاهر شوداز هیپوترمی اجتناب کنید علایم خطر با بلعیدن استریدور سوختگی های کیمیاوی دهان تماس جلد را با مادر نگه دارید، سر کودک را بپوشانید. فقط قسمت هایی را که باید یکی یکی در حین امتحان ببینید، کشف کنید نظارت دقیق و ترتیب انتقال/انتقال برای مدیریت پیشرفته طرق تنفسی.وضعیت مایع را از نزدیک بررسی کنید ملاحظات رجعت دهی و انتقال مریضان مبتلا به SMA که ممکن است قادر به محافظت از طرق هوایی نباشند، هرگز نباید تنها باشند. نظارت دقیق و رجعت دهی مستقیم به ارائه دهنده جدید. نالوگزان تقریبا ً1 ساعت طول می کشد. بیشتر اپیوئیدها به مدت طولانی تر اثر دارند-- همیشه به ارائه دهندگان جدید هشدار دهید که مریضان ممکن است به دوزهای تکراری نیاز داشته باشند. رهایپوگلایسیمی اغلب دوباره بروز میکند. به ارائه دهندگان جدید هشدار دهید که قند خون را به طور مکرر در هر مریضی که تحت تداوی رهایپوگلایسیمی قرار گرفته است، کنترول کنند. ادویه جات استطبابدوزادویه محلول: 1 میلی گرم در آمپول 1 میلی لیتری (0001:1)ادرینالین )اپی نفرین( کاهلان: 05 کیلوگرم یا بیشتر: 5.0 میلی گرم MI )5.0 میلی لیتر از 0001:1( 04 کیلوگرم: 4.0 میلی گرم MI )4.0 میلی لیتر از 0001:1( 03 کیلوگرم: 3.0 میلی گرم MI )3.0 میلی لیتر از 0001:1( هر 5 دقیقه در صورت نیاز تکرار کنید اطفال: آنافیلاکسی: 51.0 میلی گرم MI )51.0 میلی لیتر از 0001:1(. در صورت نیاز هر 5 تا 51 دقیقه تکرار کنید استمای شدید: MI gk/gm10.0 تا gm3.0. در صورت نیاز هر 51 دقیقه تکرار کنید آنافیلاکسی/ عکس العمل حساسیتی شدید و ویزینگ شدید اسید استیل سالیسیلیک )اسپرین( تابلیت خوراکی: 001 میلی گرم، 003 میلی گرم 003 میلی گرم )ترجیحا جویده شده یا در آب( بلافاصله به صورت تک دوز. مشکوک به حمله قلبی تابلیت خوراکی: 2 میلی گرم، 5 میلی گرم محلول: آمپول 5 میلی گرم / دیازیپم 1 میلی لیتر کاهلان: دوز اول: 01 میلی گرم فشار وریدی آهسته یا 02 میلی گرم رکتال دوز دوم بعد از 01 دقیقه: 5 میلی گرم فشار وریدی آهسته یا 01 میلی گرم از راه مقعدی حداکثر دوز وریدی: 03 میلی گرم اطفال: دوز اول: 2.0 gk/gm فشار وریدی آهسته یا 5.0 gk/gm مقعدی. در صورت ادامه تشنج/اختلاج، می توان نیمی از دوز اول را بعد از 01 دقیقه تکرار کرد. حداکثر دوز: 02 میلی گرم در تمام مریضانی که دیازپام دریافت می کنند، تنفس را از نزدیک نظارت کنید. تشنج / اختلاج محلول: 05% دکستروز )05D(، 52% دکستروز )52D( یا 01% دکستروز گلوکوز )دکستروز( )01D( بزرگسالان و کودکان بیشتر از 04 کیلوگرم: 52-05 میلی لیتر وریدی 05D، یا 521-052 میلی لیتر از 01D کودکان تا 04 کیلوگرم: gk/lm5 وریدی از 01D )ترجیحا( gk/lm2 وریدی از 52D gk/lm1 وریدی از 05D در صورت عدم دسترسی: 2 تا 5 میلی لیتر محلول قند 05 درصد دکستروز یا قند در داخل دهن رهایپوگلایسیمی )شکر خون پایین( محلول: 1 گرم در آمپول 2 میلی لیتری )05 درصد یا 005 میلی گرم در مگنیزیم سلفیت میلی لیتر(، 5 گرم در آمپول 01 میلی لیتری )05 درصد یا 005 میلی گرم در میلی لیتر( 4 گرم وریدی )رقیق شده در محلول 02٪ و 02 میلی لیتر( به آرامی در مدت 02 دقیقه و 01 گرم MI: 5 گرم )01 میلی لیتر محلول 05٪( با 1 میلی لیتر لیدوکائین 2٪ در هر باسن. اگر نمی توانید از طریق وریدی تزریق کنید، فقط 01 گرم MI تزریق کنید )مانند بالا، 5 گرم در هر باسن( اگر تشنج/اختلاج عود کرد: بعد از 51 دقیقه 2 گرم اضافی )01 میلی لیتر 02 درصد( وریدی در مدت 02 دقیقه بدهید. در صورت تأخیر در حمل و نقل ادامه دهید: 5 گرم محلول 05 درصد را به صورت MI با 1 میلی لیتر لیدوکائین 2 درصد هر 4 ساعت در باسن زرق کنید. اکلامپسیاا یا حاملگی با تشنج/اختلاج محلول: lm/gcm004 (هیدروکلراید( در آمپول 1 میلی لیترینلوگزان وریدی: gcm001 تک دوز RO MI: gcm004 تک دوز در صورت نیاز می توانید هر 5 دقیقه یک بار تکرار کنید. ممکن است برای اپیوئیدهای که اثر طولانی دارد به انفوزیون 4.0 میلی گرم در ساعت برای چند ساعت نیاز باشد. مصرف بیش از حد اوپیادها محلول: 01 واحد بین المللی در آمپول 1 میلی لیتریاکسیتوسین دوز اولیه: 01 MI UI بدهید و مایعات را با 02 L/UI با 06 قطره در دقیقه شروع کنید. پس از زایمان پلاسنتا، اگر همچنان خونریزی دارید، مایعات را با 02 L/UI با 03 قطره در دقیقه ادامه دهید. اگر پلاسنتا با دست بیرون شود یا رحم منقبض نمی شود: 01 UI MI تکرار کنید. مایعات وریدی را با 02 L/UI با 02 قطره در دقیقه به مدت یک ساعت پس از قطع خونریزی ادامه دهید. حداکثر دوز: 3 لیتر مایعات وریدی حاوی اکسیتوسین. تداوی خونریزی پس از ولادت پاراستامول )استامینوفن( تابلیت فمی: 0۵2 میلی گرم، 00۵ میلی گرم. شیاف رکتال: 052 میلی گرم، 005 میلی گرم بزرگسالان: 005 میلی گرم - 1 گرم خوراکی/رکتال هر 6 ساعت حداکثر 4 گرم در روز یا حداکثر 2 گرم در روز در صورت عدم کفایه کبدی و یا سیروز کودکان: gk/gm 01-51 فمی/رکتال تا شش بار در روز درد خفیف تا متوسط، تب، سردرد استنشاقی: 001 میکروگرم در هر پفسالبوتامول )آلبوترول( کاهلان: با 5 پاف شروع کنید و هر 2 دقیقه 2 پاف از طریق اسپیسر بدهید تا بهبود یابد. اطفال: با 5 پاف آغاز کنید و 2 پف را داخل اسپیسر بدهید. اسپیسر را برای 3 تا 5 نفس در دهان نگه دارید. این کار را تا 6 پاف برای کمتر از 5 سال یا 21 پاف برای بیش از 5 سال تکرار کنید. نبولایزر: (بزرگسال) 5 میلی گرم در 5 میلی لیتر سالین استریل. )کودک( 5.2 میلی گرم در 3 میلی لیتر سالین استریل. برای ویزینگ شدید، دوزهای بالاتر را می توان چندین بار در یک ساعت تجویز کرد. ویزینگ شدید تزریق MI: 5.0 میلی لیتر )به اطفال و کاهلان که در پینج سال گذشته واکسین تیتانوس واکسین نشده و یا هم وضعیت واکسین شان نامعلوم اند واکسین تطبیق نماید.( زخم )شامل سوختگی و شکستگی باز( انتقال و رجعت دهی انتقال را ترتیب کنید: بررسی کنید که نیازهای مریض با خدمات موجود در مرکز مقصد مطابقت داشته باشد )مانند اتاق عملیات خانه فعال، بانک خون موجود( قبل از حرکت مستقیما ًبا یک ارائه دهنده پذیرنده در مرکز دریافت کننده ارتباط برقرار کنید اطمینان حاصل کنید که با توجه به شرایط مریض می توان به موقع به مرکز مقصد رسید اطمینان حاصل کنید که مریض و خانواده از دلایل، برنامه و مقصد حمل و نقل آگاه هستند نام و شماره تماس خانواده را در ریفر خط و در مدارک ارسالی با مریض ثبت کنید وسایل با ارزش مریض را برای حمل و نقل نگه دارید )در صورت امکان، با خانواده او واگزار کنید( یک سوابق کتبی مختصر )شامل نام، تاریخ تولد، تظاهرات کلینیکی و تمام مداخلات( باید همیشه همراه مریض باشد. برای نیازها در حین حمل و نقل آماده شوید EPP برای کارکنان تجهیزات طرق تنفسی و سکشن )قبل از حرکت بررسی کنید که آیا کار می کند یا خیر( آکسیجن کافی )در صورت نیاز بالون اکسیجن را تعویض کنید( و ماسک )MVB( داشتن ورید باز: بررسی کنید که وریدی قبل از حمل و نقل ایمن باشد. منبع دوم یا منبع پشتیبان را در نظر بگیرید ادویه جات: دوزهای اضافی از ادویه جات و مایعات را همراه داشته باشید و ادویه جاتی دیگری را که ممکن است لازم باشد در نظر بگیرید. متوجع علایم جدید و یا علایم که دوباره ظهور میکند باشید. مریضان تشنج/اختلاج: پدها/بالش ها را در اطراف مریض قرار دهید تا صدمات ناشی از تشنج در حین حمل و نقل را جلوگیری کنید. مراقب استفراغ باشید و مطمئن شوید که طرق تنفسی، به خصوص برای کسانی که ستون فقرات رقبی شان بی حرکت شده اند، باز است. بررسی کنید که سوخت کافی برای حمل و نقل وجود دارد. مطمئن شوید که تلفن یا رادیو در وسیله نقلیه وجود دارد و کار می کند انتقال مریض مریض را طوری وضعیت دهید که بشکل درست تنفس گرفته بتواند. در صورت نداشتن صدمه از وضعیت ریکاوری استفاده کنید. اگر مریض بیش تر از 20 هفته حامل دارد و آسیبی به ستون فقرات وارد نشده است: مریض را به سمت چپ قرار دهید. این کار از فشرده شدن رگ های خونی بزرگ توسط رحم محمل جلوگیری می کند. در صورت لزوم بررسی کنید که ستون فقرات رقبی بی حرکت باشد. آسیب احتمالی ستون فقرات: از مانور تخته پشتی و لاگ رول برای حرکت دادن مریضان استفاده کنید. هر 2 ساعت یکبار نقاط فشار را بررسی کنید. در خانم حامله مصدوم که سن حمل اش بیشتر 02 هفته است.، تخته پشتی را با استفاده از قطعه چوب، فلز و یا مواد دیگر کمی به سمت چپ خم کنید. برای محافظت از انساج نرم و کاهش درد و خونریزی، شکستگی ها را اتل گذاری یا بی حرکت کنید. مراقبت مداوم در حین حمل و نقل ارزیابی مجدد روش EDCBA حداقل هر 51 دقیقه، از جمله تکرار علایم حیاتی و دیدن شکر خون در صورتی که مریض رهایپوگلایسیمیا داشته باشد. قبل از حمل و نقل، خونریزی را کنترول کنید و همچنان احنمال برای وقوع خونریزی جدید مد نظر باشد. ارزیابی مجدد منظم اطراف و نهایات اتل شده را انجام دهید ادامه تداوی های لازم )مانند آکسیجن، مایعات وریدی، اکسیتوسین، گلوکوز( از گرم یا سرد شدن بیش از حد مریض در حین حمل و نقل جلوگیری کنید. ملاحظات اطفال تجهیزات اندازه مناسب و دوزهای تنظیم شده ادیه جات ضروری مطابق به وزن را آماده کنید. یکی از اعضای خانواده یا دوست مریض را بیاورید و به مرکز پذیرش بگوید که پایواز مریض میباشد. به یاد داشته باشید که کودکانو خیم و مصدوم می توانند در ابتدا خوب به نظر برسند و سپس به سرعت بدتر شوند. از نزدیک نظارت کنید. هیپوترمی و هایپوگلایسیمی در کودکان شایع است. از نزدیک نظارت کنید. رجعت دهی RABS وضعیت: اطلاعات اولیه مریض )به عنوان مثال سن، جنس(. شکایت اصلی )توضیحات اولیه مریض از مشکل، مانند مشکلات تنفسی به مدت 3 روز، یا درد بازو پس از زمین خوردن( زمینه: 2-4 جنبه مهم و مرتبط مورد و/یا وضعیت مریض. یافته ها / مداخلات مهم EDCBA ارزیابی: آنچه را که شما فکر میکنید برای مریض و یا مصدوم خطر ساز است. دلیل انتقال/رجعت دهی توصیه ها: مراحل بعدی در طرح تداوی. بدتر شدن احتمالی وضعیت مریض )به عنوان مثال نیاز به مشاهده دقیق طرق تنفسی در صورت مشکوک شدن به سوختگی ناشی از استنشاق(؛ احتیاط های مربوط به تداوی ها یا مداخلات قبلی )مانند زمان آخرین دوز ادرینالین برای پیش بینی علایم بازگشت، نیاز به نظارت بر وضعیت روانی در صورت تجویز ادویه جاتی آرام بخش، نیاز به نظارت بر پانسمان سه طرفه برای لخته شدن خون و غیره(.