Adult Guidelines Flashcards
What is perfusion?
The ability of the cardiovascular system to provide the tissues with adequate blood supply to meet their functional demands at that time and to effectively remove associated metabolic waste products
What is adequate perfusion?
Skin: Pink, warm to touch, dry Pulse Rate: 60-100/min Systolic Blood Pressure: >100mmHg Conscious State: Alert, Orientated to time & place Capillary Refill: < 2 seconds
What is borderline perfusion?
Skin: Cool, Pale, Clammy Pulse Rate: 50-100/min Systolic Blood Pressure: 80-100mmHg Conscious State: Alert, Orientated to time & place Capillary Refill: > 2 seconds
What is Inadequate Perfusion?
Skin: Cool, Pale, Clammy Pulse Rate: <50 or >100/min Systolic Blood Pressure: 60- 80mmHg Conscious State: Altered or Unconscious Capillary Refill: > 2 seconds
What is extremely inadequate perfusion?
Skin: Cool, Pale, Clammy Pulse Rate: < 50 or > 110/min Systolic Blood Pressure: <60mmHg or Unrecordable Conscious State: Altered or Unconscious Capillary Refill: >2 seconds
What is no perfusion?
Skin: Cool, Pale, Clammy Pulse Rate: Absence of palpable pulse Systolic Blood Pressure: Unrecordable Conscious State: Unconscious Capillary Refill: NIL
What factors can affect perfusion
Other factors may affect the interpretation of the observations made, e.g., the environment, both cold and warm ambient temp. may affect skin signs;
anxiety may affect pulse rate;
and the many causes of altered conscious state or unconsciousness. Other conditions may affect conscious state observations such as poor cerebral perfusion, respiratory hypoxia, head injuries, hypoglycaemia and drug overdoses.
What is a Normal Respiratory Status Assessment
General Appearance: Calm, Quiet Speech: Clear & Steady Sentences Breath Sounds & Chest Auscultation: Usually quiet no wheeze. No Crackles or scattered fine basal crackles e.g postural Respiratory Rate: 12-16 Respiratory Rhythm: Regular even cycles Breathing Effort: Normal chest movement Pulse Rate: 60-100 Skin: Normal Conscious State: Alert SpO2: >95%
What is Mild Respiratory Distress?
General Appearance: Calm or Mildly Anxious
Speech: Speaking in Full Sentences
Breath Sounds & Chest Auscultation: Able to cough.
Asthma: Mild expiratory wheeze LVF: may be fine basal crackles
Respiratory Rate: 16 - 20
Respiratory Rhythm: Asthma: may be Prolonged expiratory phase
Breathing Effort: Increased WOB (slight increase in normal chest movement)
Pulse Rate: 60-100`
Skin: Normal
Conscious State: Alert
SpO2: > 95%
What is Moderate Respiratory Distress
General Appearance: Distressed or Anxious
Speech: Short Phrases
Breath Sounds & Chest Auscultation: Able to cough Asthma: Expiratory +/- Inspiratory Wheeze. LVF: Crackles at bases to midzones
Respiratory Rate: >20
Respiratory Rhythm: Prolonged expiratory phase
Breathing Effort: Marked chest movement +/- accessory muscles
Pulse Rate: 100-120
Skin: Pale & Sweaty
Conscious State: may be Altered
SpO2: <95%
What is Severe Respiratory Distress (Life Threat)?
General Appearance: Distressed, anxious, fighting to breathe, exhausted, catatonic
Speech: Words only or unable to speak
Breath Sounds & Chest Auscultation: Unable to cough. Asthma: Expiratory +/- inspiratory wheeze or silent chest (late stage). LVF: Full field fine crackles, possible wheeze
Respiratory Rate: > 20 or < 8 (Bradypnoea)
Respiratory Rhythm: Prolonged expiratory phase
Breathing Effort: Marked chest movement with accessory muscle use, intercostal retraction +/- tracheal tugging
Pulse Rate: >120, bradycardia late sign
Skin: Pale, Sweaty +/- cyanosis
Conscious State: Altered or unconscious
SpO2: <90%
What is GCS?
Eye 4 Spontaneous 4 To Voice 3 To Pain 2 No Response 1
Verbal Response 5 Alert & Orientated to time & place 5 Confused 4 Inappropriate Response 3 Incomprehensible Response 2 No Response 1
Motor Response 6 Obeys Commands 6 Localises to Pain (purposeful movement) 5 Withdraws from Pain 4 Flexion to pain 3 Extension to pain 2 No Response 1
What are Time Critical Guidelines?
Actual: At the time of VSA the Pt is in physiological distress.
Emergent: At the time of the VSA the Pt is not in actual physiological distress however they have a “Pattern of Injury or Significant Medical Condition” which is known to have a high probability of deteriorating to actual physiological distress.
Potential: At the time the vital signs survey is taken, the Pt is not physiologically distressed and there is no significant “Pattern of actual Injury/Illness”, but does have a “Mechanism of Injury/Illness” known to have the potential to deteriorate to actual physiological distress.
A Pt under Trauma Triage Guidelines meets criteria for Major Trauma if they have a combination of MOI and other Co-morbidities constituting:
Systemic illness limiting normal activity/ constant threat to life: - Poorly controlled hypertension - Morbid Obesity - Controlled or uncontrolled CCF - Symptomatic COPD - Ischaemic Heart Disease - Chronic Renal Failure or Liver Disease Pregnancy Age <16 or >60
What are Trauma Actual Time Critical Guidelines?
Assess possible Major Trauma
- Assess Vital Signs for the following:
- Respiratory Rate <12 or >24
- HR <50 or >120
- Systolic BP <90mmHg
- GCS <13
- SpO2 <90%
What are Trauma Emergent Time Critical Guidelines?
VSS normal
- Assess Pattern of Injury for any of the following
Blunt Injuries:
- to head/neck/chest/axilla/abdomen/groin/pelvis
Penetrating Injuries:
- Significant injury to a single region:
Head / Neck / Chest / Abdomen / Axilla / Groin
- Injuries involving two or more of the above body regions
Specific Injuries:
- Limb amputations / limb threatening injuries
- Suspected spinal cord injury
- Burns > 20% or involving respiratory tract
- Serious crush injury
- Major compound fracture or open dislocation
- Fracture to two or more of the following: Femur / Tibia / Humerus
- Fractured pelvis
What are Trauma Potential Time Critical Guidelines?
No Pattern of Injury, VSS Normal - Assess Mechanism of Injury for any of the following: - Ejection from vehicle - Motor / cyclist impact > 30km/h - Fall from height > 3m - Struck on head by falling object > 3m Explosion - High speed MVA > 60km/h - Vehicle rollover - Fatality in same vehicle - Pedestrian impact - Prolonged extrication > 30min. Assess for following Co-morbidities: - Age > 60 - Pregnancy - Significant underlying medical condition
What are Actual Medical Time Critical Guidelines?
Assess for any of the following:
- Severe Respiratory Distress
- SpO2 <90% RA or <93% 100% Supplemental O2
- Inadequate Perfusion
- GCS <13 (unless baseline for Pt)
- 12 Lead ECG showing STEMI Pattern
What are Emergent Medical Time Critical Guidelines?
VSS Normal, Assess for any of the following:
Medical Symptoms/Syndromes;
- Acute Coronary Syndrome
- Acute stroke
- Severe sepsis, including suspected meningococcal disease
- Possible Abdominal Aortic Aneurysm
- Undiagnosed severe pain
- Acute Asthma / COPD with moderate resp. distress
Notify communications for possible need of hyperbaric treatment
e.g. acute decompression illness or cyanide poisoning
- Hyper/Hypothermia
What is a MSE?
A MSE is a Mental Status Examination. Primarily focuses on Pt behaviour and is used to assess mental function at time of assessment.
- Appearance - Neatness, cleanliness, Pupils – size, Extraocular movement
- Behaviour - Bizarre or inappropriate, Threatening or violent, Unusual motor activity, such as grimacing or tremors Impaired gait, Psychomotor retardation or agitation
- Speech - Rate, volume, quantity, content
- Mood - Depressed, agitated, excited or irritable
- Response - Flat – unresponsive facial expression, Appropriate / inappropriate
- Perceptions - Hallucinations
- Thought content - Delusions (i.e., false beliefs), Suicidal thoughts, Overly concerned with body functions (eg. Bowels)
8 Thought flow - Jumping irrationally from one thought to another - Concentration - Poor ability to organise thoughts, Short attention span, Impaired judgement, Poor memory, Lack of insight
What is a FAST Stroke Assessment?
Face - Pt shows teeth or smiles
Arm Drift - Test as for GCS
Speech - The Pt Repeats “you cant teach an old dog new tricks”
Time - Time of onset < 60 mins: Accurate timeframe for onset of symptoms is critical for Rx:
< 3hr. for IV thrombolytic < 6hr. for other therapies
BGL - Assessed to rule out hypo/hyperglycaemia
Assess for stroke mimics •Intoxication drug / alcohol • Hypo / hyperglycaemia • Seizures • Brain tumour primary / secondary • Syncope • Middle ear disorder • Migraine • Subdural haematoma • Sepsis • Electrolyte disturbances
What is oxygen therapy?
O2 is a treatment for hypoxaemia, not breathlessness. O2 has not been shown to have any effect on the sensation of breathlessness in non- hypoxaemic patients.
Treatment is aimed at achieving normal or near normal SpO2 in acutely ill patients. O2 should be administered to achieve a target SpO2 while continuously monitoring the patient for any changes in condition.
When is Pulse oximetry unreliable?
in patients with peripheral vascular disease, severe asthma, severe anaemia, cold extremities or peripherally ‘shut down’, severe hypotension and carbon monoxide poisoning.
