Clinical Skills Flashcards
What must you be before every kit dump?
Establish a sterile field
Check equipment is in date and packaging is intact
Check if fluids are clear and not contaminated
Check you have a sharps box
What is an adverse reaction from an IM injection?
Swelling/oedema
What can occur with poor cannulation/infusion techniques?
Air embolism
What is an adverse reaction from infusion?
Allergic reaction
What is an adverse reaction from advanced airway interventions?
Gastric distension (excessive air pressure within abdomen)
What is an adverse reaction from cannulation?
Tissuing (accidental introduction of fluid into bodily tissue)
If a problem arises when using clinical skills, who do you report to?
Patient
Crewmate
Other clinicians at hospital
Management
When is Endotracheal intubation used?
Unconscious patients with no gag reflux
When airway has been managed with basic adjuncts
ROSC patients who remain unconscious and require transportation
What does Endotracheal intubation protect against?
Protects against aspiration of solid or liquid - inflation of cuff within trachea creates a seal
What is a mistake that happens within endotracheal intubation?
Inflating within oesophagus instead of the trachea - likely to result in death
When doing a kit dump what must we do to keep items sterile?
Keep items in packaging until use
Do NOT place items on the floor
What is part of a endotracheal intubation kit dump?
Oxygen + BVM
OPA might be already inserted
Suction
Laryngoscope
Forceps
Bougie
ET tube
Etco2 monitor
Catheter mount
Stethoscope
10ml syringe
Thomas tube holder
Explain the steps of endotracheal intubation
Bougie is inserted first - bent end goes into the mouth first
ET tube is threaded over bougie - bevelled end entering mouth first
Hold top of bougie while paramedic inserts tube into trachea
Bougie is removed and paramedic still holding ET tube in place
Etco2 monitor is then attached to tube
Catheter mount then BVM attached
Stethoscope is used to auscultation to confirm correct tube placement
10ml syringe is used to inject 6-8ml of air into inflation valve to inflate cuff while pt is being ventilated
Thomas tube holder is used to secure ET tube
How can a para confirm correct ET tube placement in endotracheal intubation?
Check Etco2
Observe bilateral chest movement
Auscultate
Check if air is entering stomach
What is BURP and when is it used?
BURP is used to improve visibility of the epiglottis
Place thumb and index/middle finger on either side of the patient’s thyroid cartilage and follow BURP
Backwards
Upwards
Rightwards
Pressure
What are complications that can happen during endotracheal intubation?
Displacement - etco2 can be an early warning sign showing patient is not being ventilated adequately
Obstruction - thick pulmonary secretions
Pneumothorax - unilateral chest movement (reach for Steph) - decompression of chest
Equipment failure
Stomach - overuse of BVM can lead to abdominal distension - especially in children can splint diaphragm and impede ventilation - insert nasogastric tube and apply gentle pressure over abdomen to expel air
What must every clinician do before performing any intervention?
Obtain consent
When do we use IV?
When administering drugs or fluid
To expedite ongoing care in hospitals
Prophylactically in unstable patients (preventing infection)
What the downsides of IV?
Painful
Delays ONS times
Provides direct entry for infectious pathogens
Accidental damage to nerves, tendons, arteries
Extravasion - leakage of fluid if cannula not sited properly
When do we NOT use IV?
Presence of injury, inflammation, or infection on site
Arterio-venous fistulas
Dorsum of hand in pt’s who are going for PPCI (primary percutaneous coronary intervention)
What is included in an IV dump?
Tourniquet
Chloraprep
Cannula
Gauze
Syringe
Saline flush
Sharps box
What is included in an IV infusion dump?
IV dump + giving set + fluids
How do you prepare an infusion?
Confirm correct drug and concentration
Check drug is not expired, clear and free of contaminants and packaging is intact
Hang fluids (avoid placing on floor or contaminated surfaces)
Close roller clamp
Puncture bag with piercing spike
Fill drip chamber half way
Open roller clamp/remove protective cover from leur lock and run fluid slowly to remove air bubbles
Close roller clamp and if chamber has become too full invert the bag and squeeze the chamber to return some of the fluids back into the bag
DO NOT let tubing drop onto floor
When do we use intraosseous?
Vascular access is required urgently and IV cannulation has failed or is not possible to obtain
When do we NOT use intraosseous?
Conscious patients
When the targeted bone has sustained a fracture
Previous orthopaedic procedures at insertion site e.g. prosthetic
If an IO has been attempted on bone within past 48 hours
Infection at area of insertion
Excessive tissue/absence of adequate anatomical landmarks
What are the downsides of intraosseous?
Painful
Extravasation of fluid
Compartment syndrome - if extravasation goes undetected limb can require surgical intervention or amputation
Osteomyletis - serious infection following IO insertion
What is included in an intraosseous kit dump?
Power driver
Needle set, ez connect extension set
Stabiliser dressing
Cleansing agent
Luer lock syringe with sterile saline flush
Sharps container
5mm (black mark closest to hub) must be visible when needle inserted
What are the typical insertion sites for intraosseous?
Humerus
Proximal tibia
What is high-pitched inhalations/sometimes expirations indications of?
Upper airway narrowing - stridor
What are lower-pitched inhalations usually heard on expirations indications of?
Wheeze
If snoring is heard what must be done?
Manual airway manoeuvres or adjuncts
If gurgling is heard what must be done?
Suctioning
What is see-saw movements (paradoxical) of abdomen with chest an indication of?
Complete airway obstruction
Chest expands and abdomen sinks and vice versa
When is a head tilt chin lift indicated and not indicated?
Indicated - unresponsive patients who have an airway obstruction
NOT indicated - patients who have a potential spinal injury
When is a jaw thrust indicated and not indicated?
Indicated - unresponsive patient who has obstruction caused by loss of pharyngeal muscle
NOT indicated - patients who have fractured jaws
What does a jaw thrust do?
Maintain neutral alignment of the head
What are the downsides of a jaw thrust?
Difficult to maintain for prolonged periods
Requires second person to ventilate
How do you do a jaw thrust?
Place fingers behind mandible and lift upwards, use thumbs to open pt’s mouth
What should ideally be done before suctioning?
Preoxygenation
What PPE should you use when suctioning?
Eyewear and gloves
What are the differences between the two suction catheters?
Rigid and wide-bore - suitable for blood and vomit
Smaller flexible one can fit the oropharyngeal/nasopharyngeal airway - unsuitable for blood and vomit
How do we suction appropriately?
Visualise end of catheter at all times
Suction for no more than 15 seconds
Re-oxygenate patient
Reassess constantly
When can postural drainage be used?
Immobilised patients on an orthopaedic stretcher
When is an OP indicated?
Unconscious patients with absent gag reflux
Clear airway
How do you sized an OP?
Measure incisors to the angle of the jaw
When is an NP indicated?
Unresponsive patient with reduced LOC and intact gag reflux
When is an NP not indicated?
If not tolerated
Basal skull fracture
Nasal polyps
How do you use NP?
Lubricate beforehand (not over open ends)
Insert bevel end facing nasal septum
Rotate 180 degrees once enters nasopharynx
How do we know if an NP is not being tolerated?
Blanching of nostrils
Remove it and insert smaller size
What do we do after inserting adjuncts?
Check chest rise and listen for breath sounds
When is a supraglottic airway indicated?
BVM ventilation not effective
Prolonged ventilation required
Intubation fails
When is a supraglottic airway NOT indicated?
Patient has a gag reflex
Patient is not deeply unconscious
Patient has truisms or limited mouth opening
What is included in a supraglottic kit dump?
Suction
BVM + oxygen
Forceps
Laryngoscope
Igel
Lube
OPA
Stethoscope
Etco2 - connect igel to capnography, catheter mount and BVM
Catheter mount
Securing device - thomas tube
What are the steps of an i-gel?
Place small amount of lube onto inner and outer rim of the device
Push I-gel in until resistance is felt - bite block should end at incisors
Connect gel to capnography, catheter mouth and BVM
Check end-tidal co2 and bilateral chest air entry/movement of chest
Secure igel
How do we handle oxygen safely?
Keep free from naked flames, fuel pumps, and extreme temps, defib shocks
Check cylinders before use for damage/oil/grease i.e. check clean
Do NOT handle if just used alcohol rub
Do NOT use if leaky valve/avoid poorly ventilated rooms - oxygen in room at 24% increases danger dramatically
How do we know entonox is fit for use?
Store above 10 degrees 24 hours prior to use
If not, warm to 10 degrees then invert x3 times prior to usage - gas mixture separates
When do we administer oxygen?
Hypoxia
Critically ill pt’s requiring oxygen supplementation
COPD - monitor and do not go above 92 as can increase co2 levels in blood and lead to respiratory depression
When do we not administer oxygen?
If in explosive environments
Defib pads being used
Around fire hazard
Paraquat poisoning - can worsen with oxygen supplementation so target 88-92 saturations
Not indicated
When is entonox indicated?
Moderate to severe pain
Labour pains
ACS bundle
When is entonox not used?
Severe head injuries with impaired consciousness
Decompression sickness
Violently disturbed psychiatric patients
Risk of pneumothorax
Abdominal obstruction
