CONSOLIDATED Flashcards
Where are the standard limb lead electrodes placed and what are their associated colours?
Right arm (white); left arm (black); left leg (red); right leg (green).
What view does limb lead I offer?
Lateral surface of the left ventricle.
What view does limb lead II offer?
Inferior surface of the left ventricle.
What view does limb lead III offer?
Inferior surface of the left ventricle.
What is the negative electrode in limb lead I?
Right arm.
What is the positive electrode in limb lead I?
Left arm.
What is the typical deflection seen in limb lead I?
Positive.
What is the negative electrode in limb lead II?
Right arm.
What is the positive electrode in limb lead II?
Left leg.
What typical deflection is seen in limb lead II?
Positive.
What is the negative electrode in limb lead III?
Left arm.
What is the positive electrode in limb lead III?
Left leg.
What typical deflection is seen in limb lead III?
Positive.
What are the augmented vector leads?
aVR; aVL; aVF.
*Computer generated negative leads.
What are the chest lead electrodes and their associated colours?
V1 (red); V2 (yellow); V3 (green); V4 (blue); V5 (orange); V6 (purple).
What are the septal chest leads?
V1; V2.
What are the anterior chest leads?
V3; V4.
What are the lateral chest leads?
V5; V6.
What is the placement of the chest leads in the order of placement?
V1 is right side of sternum in 5th intercostal space; V2 is left side of sternum in 5th intercostal space; V4 is midclavicular line in 6th intercostal space; V6 is midaxillary line in 6th intercostal space; V3 is placed between V2 and V4 creating a diagonal line; V5 is placed between V4 and V6 creating a horizontal line.
What is axis deviation in reference to an ECG?
A deviation or shift in the normal direction of electrical conduction through the heart.
What is the normal process of electrical conduction through the heart?
Electrical impulse is sent from sinoatrial node, travels down to the atrioventricular node, then the bundle of His and through the Purkinje fibres.
What is left axis deviation in reference to an ECG?
The electrical activity of the heart is traveling towards the left side of the heart in comparison to normal.
*Can be caused by left ventricular hypertrophy or blockage in right bundle branch.
What is right axis deviation in reference to an ECG?
The electrical activity of the heart is travelling towards the right side of the heart in comparison to normal.
*Can be caused by right ventricular hypertrophy or blockage in left bundle branch.
What ECG lead do we monitor vectors through?
Limb lead II.
Using the R and S waves of an ECG, how do you distinguish positive, equiphasic and negative deflection?
In positive deflection, the R wave is greater in length than the S wave; in equiphasic deflection, the R and S wave are equal in length; in negative deflection, the S wave is greater in length than the R wave.
If limb lead I and lead aVF are showing positive deflection on an ECG, how would you describe the axis deviation?
Normal axis deviation.
If limb lead I is showing positive deflection but lead aVF is showing negative deflection on an ECG, how would you describe the axis deviation?
Possible left axis deviation.
If limb lead I is showing negative deflection but lead aVF is showing positive deflection on an ECG, how would you describe the axis deviation?
Right axis deviation.
If limb lead I and lead aVF are showing negative deflection on an ECG, how would you describe the axis deviation?
Extreme axis deviation.
What values of axis deviation are associated with left axis deviation?
-30 degrees to -90 degrees.
What values of axis deviation are associated with normal axis deviation?
-30 degrees to +90 degrees.
What values of axis deviation are associated with right axis deviation?
+90 degrees to +180 degrees.
What values of axis deviation are associated with extreme axis deviation?
-90 degrees to +180 degrees.
Additional to left ventricular hypertrophy and left bundle branch blocks, what conditions may cause left axis deviation?
Obesity; inferior acute myocardial infarctions; ventricular pacing.
Additional to right ventricular hypertrophy and right bundle branch blocks, what conditions may cause right axis deviation?
Height; age; COPD; pulmonary embolism; lateral acute myocardial infarction.
What conditions may cause extreme axis deviation?
Ventricular tachycardia; idioventricular rhythm; accelerated idioventricular rhythm; hyperkalaemia; severe right hypertrophy.
What lead can provide a view of the right ventricle?
V4R.
*Take lead V4 from left side of the chest and place it in the same spot on the right side of the chest.
What factors can cause ECG artifact?
Poor electrode contact; hair; diaphoresis; oily skin.
When determining the heart rate on an ECG, what is the 6 second method?
Counting the QRS complexes within a 6 second ECG strip using lead II.
When determining the heart rate of an ECG, what is the R-R method?
Using the location of one R wave and counting each large box until the location of the next R wave.
First box is 300, second box is 150, third box is 100, fourth box is 75, fifth box is 60 and sixth box is 50.
How should a normal P wave on an ECG present?
Upright, rounded and precede each QRS complex.
How many seconds should a normal PR interval on an ECG be?
0.12 to 0.2 seconds.
How should the Q wave on an ECG present?
1/4 height of the following QRS complex.
How many seconds should the QRS complex on an ECG be?
<0.12 seconds.
*Should be upright in lead I and lead II.
How should the T wave on an ECG present?
Upright and rounded.
How many seconds should the QT interval on an ECG be?
<0.44 seconds.
How should the ST segment on an ECG present?
Should return to the isoelectric line and not be elevate or depressed.
What is a U wave in reference to an ECG?
Small wave that sometimes occurs after the T wave and indicates remainder repolarisation of the Purkinje fibre network.
What forms a diagnostic ECG?
Paper speed of 25mm/sec; voltage or amplitude of 1mV; minimum hertz of 0.05 to 40.
What is another name for chest leads?
Precordial leads.
What are the indications for the modified valsalva manoeuvre?
Haemodynamically stable SVT.
What are the contraindications for the modified valsalva manoeuvre?
- Requirement for immediate cardioversion
- Hypotension (SBP <90mmHg)
- Atrial fibrillation or atrial flutter
- Aortic stenosis
- Recent myocardial infarction (within 3 months)
glaucoma - Retinopathy
- Third trimester pregnancy.
What are the complications of the modified valsalva manoeuvre?
- Syncope
- Prolonged hypotensive state.
How do you perform the modified valsalva manoeuvre?
Obtain baseline ECG; explain procedure to patient; assign roles; position patient in semi-recumbent position; instruct patient to perform forced expiration into 10mL syringe for 15 seconds; remove syringe after 15 seconds; lay patient supine with legs raised straight to 45 degrees for 15 seconds; reposition patient to semi-recumbent position for 45 seconds; repeat ECG.
How many times can you perform modified valsalva manoeuvre?
3 times.
When do you perform fibrinolysis or a pPCI referral?
In the event of a STEMI.
What is the modified valsalva manoeuvre?
A safe and effective way of restoring sinus rhythm in patients that are experiencing narrow complex SVT and are haemodynamically stable.
What is CPR?
Cardiopulmonary resuscitation that exists to provide perfusion and preserve life until definitive procedures can be performed.
What are the general principles of CPR?
Provide good quality compression; minimise interruptions to chest compressions; oxygenate the lungs; avoid excess ventilation.
What are the indications for CPR?
- There are no signs of life:
- Unresponsive
- Not breathing normally
- Carotid pulse cannot be
confidently palpated in 10
seconds
OR
- There are signs of inadequate perfusion:
- Unresponsive
- Pallor or central cyanosis
- Inadequate pulse, evidenced by:
- <40bpm in adults or children
>1 - <60bpm in infant <1
- <60bpm in newborn
- <40bpm in adults or children
What are the contraindications for CPR?
Nil.
What are the complications of CPR?
- Using the presence/absence of a pulse as the primary indicator of cardiac arrest is unreliable.
- Injury to the chest can occur in some patients.
How do you perform CPR on an adult?
Ensure patient is on firm surface; place heel of one hand on lower half of sternum and other hand on top of first; compress sternum by 1/3 depth of the chest; compress at rate of 100-120 per minute; ventilate with 2 breaths every 30 compressions.
How do you perform CPR on a child <1?
Ensure patient is on firm surface; compress using two fingers on sternum or two thumbs with fingers around thorax and supporting the back; compress sternum by 1/3 depth of the chest; ventilate with 2 breaths every 30 compressions (two officers) or 15 compressions (single officer).
How do you perform CPR on a child 1-8?
Ensure patient is on firm surface; compress using two fingers on sternum or two thumbs with fingers around thorax and supporting the back; compress sternum by 1/3 depth of the chest; ventilate with 2 breaths every 30 compressions (two officers) or 15 compressions (single officer).
How do you perform CPR on child 9-12?
Ensure patient is on firm surface; place heel of one hand on lower half of sternum and other hand on top of first; compress sternum by 1/3 depth of the chest; compress at rate of 100-120 per minute; ventilate with 2 breaths every 30 compressions (two officers) or 15 compressions (single officer).
How do you perform CPR on a newly born that is immediately postpartum?
Ensure patient is on firm surface; compress using two thumbs with fingers around thorax and supporting the back; compress lower sternum by 1/3 depth of the chest; ventilate with 1 breath every 3 compressions.
What is defibrillation?
A direct current countershock which produces simultaneous depolarisation of a mass of myocardial cells which may enable the resumption of organised electrical activity.
What modes can defibrillations be performed in?
Manual mode; AED mode.
What are the indications for defibrillation?
- VF
- Pulseless VT
What are the contraindications for defibrillation?
- Non-shockable rhythms:
- Asystole
- Pulseless electrical activity
- Perfusing rhythms
What are the complications for defibrillation?
- Patient injury including burns
- Explosion
- Transmitted shock to the operator or bystanders
How do you perform defibrillation using a corpulse machine in AED mode?
Prepare patient and skin for electrode placement; start AED mode by pressing AED key; press analyse key to initiate analysis; machine will advise whether shock is recommended or not recommended; when delivering the shock, defibrillator will begin charging; hold the heart key to deliver shock; confirm delivery of shock.
How do you perform defibrillation using a corpuls machine in manual mode?
Prepare patient and skin for electrode placement; start in manual mode by pressing the manual key; select required energy level with jog dial or soft keys; confirm joule setting by pressing the jog dial; press charge key to charge; hold heart key to deliver the shock; confirm defibrillation.
What is the initial pad placement for defibrillation on an adult?
Antero-laterally.
Anterior pad is placed to the right of the sternum below the clavicle.
Lateral pad is positioned sufficiently laterally on the mid-axillary line and centred immediately below the left armpit.
What is the alternative pad placement for defibrillation in an adult?
Antero-posteriorly.
Anterior pad is placed on left precordium, immediately below nipple or breast tissue.
Posterior pad is placed just below left scapular to the left of the spine.
Where do you place a defibrillation pad if the patient has an implanted medical device?
8cm from the medical device or antero-posteriorly.
When should you consider changing the pads in defibrillation?
After several defibrillations (3).
*Change positioning from antero-lateral to antero-posterior.
What are the joule settings for a child <6?
4J/kg rounded to the next highest setting on the defibrillator.
What are the 4 safety checks performed prior to any defibrillations?
Non-conductive environment; non-explosive environment; no contact; no movement.
What are the indications for 12-lead ECG aquisition?
- Any patient requiring detailed ECG analysis:
- Suspected ACS
- Cardiac dysrhythmias
- Conduction disturbances
- Electrolyte imbalances
- Drug toxicity
What are the contraindications for 12-lead ECG acquisition?
Nil.
What are the complications of 12-lead ECG acquisition?
Nil.
What is acute coronary syndrome?
Spectrum of conditions resulting from myocardial ischaemia.
What are the clinical features of acute coronary syndrome?
Chest pain or discomfort; referred pain to jaw or arm; dyspnoea; diaphoresis; nausea/vomiting; feeling of impending doom.
What procedure/skill should you perform in suspected acute coronary syndrome and how quickly?
12-lead ECG within 10 minutes.
What management should you consider for a patient with suspected acute coronary syndrome?
12-lead ECG; oxygen; GTN; aspirin; antiemetic; fentanyl.
What management should you consider for a patient whose 12-lead ECG is consistent with STEMI?
pPCI referral; pre-hospital fibrinolysis administration.
What is bradycardia?
A heart rate of <60bpm in adults.
What are the two classifications of bradycardia?
Cardiac; non-cardiac.
What is bradycardia associated with if it is cardiac?
Diseased sinoatrial node, atrioventricular node, or His-Purkinje system.
What is bradycardia associated with if it is non-cardiac?
Environmental conditions; metabolic conditions; endocrine disorders; toxicology.
What are common bradycardic rhythms?
Sinus bradycardia; sick sinus syndrome; high degree AV block.
What are the clinical features of bradycardia?
Hypotension (<90mmHg systolic); syncope; ALOC; chest pain or discomfort; congestive cardiac failure; dyspnoea; diaphoresis; nausea/vomiting; dizziness.
What management should you consider for a patient with symptomatic bradycardia that does not require resuscitation?
Treating reversible causes; CCP backup.
What can a CCP possibly do for a patient with bradycardia?
Atropine; transcutaneous pacing; adrenaline; isoprenaline.
What is narrow complex tachycardia?
A heart rate >100bpm in adults with a QRS complex width <0.12 seconds.
What is broad complex tachycardia?
A heart rate >100bpm in adults with a QRS complex width >0.12 seconds.
What are the two classifications of narrow complex tachycardia?
Cardiac; non-cardiac.
What appears on an ECG strip in addition to a narrow QRS complex that indicates non-cardiac tachycardia?
P wave.
If non-cardiac narrow complex tachycardia is suspected, what may be causing this patient’s fast heart rate?
Pain; anxiety; hyperthermia; fever; drugs; anaemia.
If cardiac narrow complex tachycardia is supraventricular in origin, what may be causing the patient’s fast heart rate?
Stimulants; increase in sympathetic tone; electrolyte disorders; hyperventilation; emotional stress.
If cardiac narrow complex tachycardia is atrial in origin, what may be causing the patient’s fast heart rate?
Atrial fibrillation; multiple atrial ectopics; atrial flutter.
What are the clinical features of tachycardia?
Palpitations; chest pain or discomfort; dyspnoea; ALOC; haemodynamic instability; syncope.
What management should you consider for a patient with suspected cardiac narrow complex tachycardia and haemodynamic compromise?
Synchronised cardioversion; oxygen; aspirin; IV fluid.
What procedure/skill should be performed for a patient with suspected cardiac narrow complex tachycardia and haemodynamic compromise?
Synchronised cardioversion.
What management should you consider for a patient with suspected cardiac narrow complex tachycardia, no haemodynamic compromise, and a regular rate?
Oxygen; aspirin; modified Valsalva manoeuvre.
What management should you consider for a patient with suspected cardiac narrow complex tachycardia, no haemodynamic compromise, and an irregular rate?
Oxygen; aspirin.
While it is part of the management considerations for cardiac narrow complex tachycardia, when should you actually give aspirin to this patient?
When myocardial ischaemia is suspected.
What procedure/skill should be performed for a patient with broad complex tachycardia who has a pulse but is haemodynamically compromised?
Synchronised cardioversion.
What management should you consider for a patient with broad complex tachycardia who has a pulse and is not haemodynamically compromised?
CCP backup.
What can a CCP possibly do for a patient with broad complex tachycardia who has a pulse and is not haemodynamically compromised?
Amiodarone; magnesium sulphate.
What is cardiac arrest?
Occurs when there is the cessation of blood circulation due to the inability of the heart to maintain tissue perfusion.
What are the two shockable rhythms in cardiac arrest?
Pulseless VT; VF.
What are the non-shockable rhythms in cardiac arrest?
Pulseless electrical activity; asystole.
What is pulseless VT?
Pulseless ventricular tachycardia.
Regular broad complex tachycardia which occurs when the pacemaker of the heart originates from a single point in the ventricle.
What is VF?
Ventricular fibrillation.
Results from rapid, irregular, asynchronous depolarisation and contraction of multiple areas of the ventricles.
What is pulseless electrical activity?
The occurrence of organised electrical activity on an ECG with no resulting cardiac output (no palpable pulse).
What is asystole?
Absence of cardiac electrical activity with no cardiac output.
What are the clinical features of cardiac arrest?
There are no signs of life (unresponsive; not breathing normally; carotid pulse cannot be confidently palpated within 10 seconds); there are signs of grossly inadequate perfusion (unresponsive; pallor or central cyanosis; inadequate pulse).
What is an inadequate pulse considered to be in adults, infants and newborns in the event of cardiac arrest?
<40bpm in adult/child >1; <60bpm in infant <1; <100bpm in newborn.
When is it appropriate to withhold CPR?
- When the patient is exhibiting obvious signs of death (decomposition; putrefaction; hypostasis; rigor mortis)
- When the patient has sustained injuries totally incompatible with life (decapitation; cranial and cerebral destruction; hemicorporectomy; incineration; foetal maceration)
- When performing CPR may endanger the life, health or safety of the paramedic
- Where a lawful direction to withhold has been provided
What is the general discontinuation criteria for resuscitation?
Resuscitation may be discontinued after 20 minutes if:
- There is no return of spontaneous circulation at any stage during resuscitation
- Cardiac arrest was not witnessed by QAS personnel
- No shockable rhythm at any stage during resuscitation
What is the rapid discontinuation criteria?
Resuscitation may be discontinued before 20 minutes if:
- The patient was observed to be unconscious, unresponsive to stimuli, not breathing and pulseless for at least 10 minutes prior to the arrival
- No CPR was provided during this period
- The patient is exhibiting signs of life extinct
- The patient’s cardiac rhythm is asystole or a broad PEA <40bpm.
What is ROLE criteria?
Recognition of life extinct.
- No palpable carotid pulse
- No heart sounds heard for 30 continuous seconds
- No breath sounds heard for 30 seconds
- Fixed dilated pupils
- No response to centralised stimuli
What is ROSC?
Return of spontaneous circulation.
What is the non-traumatic adult resuscitation procedure in a patient with no evidence of foreign body obstruction?
Begin compressions; apply defibrillation pads; initiate rhythm analysis with first analysis in AED mode.
In the event of a non-traumatic adult resuscitation, where the patient’s initial rhythm analysis reveals a shockable rhythm, how do you proceed?
Deliver shock; resume chest compressions.
In the event of a non-traumatic adult resuscitation, where the patient’s initial rhythm analysis reveals a non-shockable rhythm, how do you proceed?
Resume chest compressions; consider adrenaline; consider reversible causes.
In the event of a non-traumatic adult resuscitation, where the patient has had 3 defibrillations and has remained in a shockable rhythm, how do you proceed?
IV access; amiodarone; adrenaline; change pad position.
In the event of a non-traumatic adult resuscitation, where the patient has had 5 defibrillations and has remained in a shockable rhythm, how do you proceed?
Second dose of amiodarone.
What are the reversible causes associated with a cardiac arrest?
Hypoxia; hypo/hyperthermia; hypo/hyperkalaemia; hypovolaemia; acidosis; toxins; thrombus; tension pneumothorax; tamponade.
What advanced airway is placed in the event of a non-traumatic adult resuscitation and when is it placed?
I-gel is placed after first defibrillation.
What are the ventilations following the application of an I-gel in a non-traumatic adult resuscitation?
1 every 6 seconds; 10 breaths/minute.
What are the components of the initial newborn assessment?
Tone; breathing; heart rate.
What are the clinical features associated with a newborn requiring resuscitation?
No signs of life (limp muscle tone; slow or irregular respirations; pulse cannot be confidently auscultated or identified on palpation of the umbilical cord); signs of inadequate perfusion (centrally pale or blue; pulse less than 100bpm); inadequate respiratory effort (rib/sternal recession; retraction or indrawing; persistent expiratory grunting).
In the event of a newborn resuscitation, how should the newborn be positioned to support the airway?
Supine with head supported in a neutral position by placing appropriate padding behind the shoulder blades.
How should intermittent positive pressure ventilation be performed in a newborn resuscitation?
At a rate of 40-60 breaths/minute, with an inspiratory time of 0.5 seconds.
Should PEEP be applied in a newborn resuscitation?
Yes.
*At 5cmH2O.
If you attend a birth where the baby is delivered at full term, but is limp, has a slow respiratory rate and a heart rate of 85bpm, how should you proceed?
Stimulate patient; ensure airway patency with neutral head position; maintain normothermia.
If you attend a birth where the baby is delivered at full term, but still has a heart rate of 85bpm following the commencement of IPPV, the application of pulse oximetry and reassessment, how do you proceed?
Apply high concentration oxygen to IPPV; consider two person BVM technique; consider PEEP at 5cmH2O.
If you attend a birth where the baby is delivered at full term, but has a slow respiratory rate and a heart rate of 85bpm following stimulation, airway patency and the maintenance of normothermia, how do you proceed?
Commence IPPV at a rate of 40-60 breaths/min on room air; place pulse oximetry on patient’s right hand; reassess after 30 seconds.
If you attend a birth where the baby is delivered at full term, but has a heart rate of 55bpm following the commencement of IPPV with high concentration oxygen and PEEP, how do you proceed?
Commence newborn CPR; consider access; consider adrenaline; consider sodium chloride 0.9%.
If you attend a birth where the baby is delivered at full term, but has a heart rate of 120bpm following the commencement of IPPV on room air, the application of pulse oximetry and reassessment, how do you proceed?
Continually reassess.
If you attend a birth where the baby is delivered at full term, but has a heart rate of 140bpm following stimulation, airway patency and maintenance of normothermia, how do you proceed?
Continually reassess.
If you attend a birth where the baby is delivered at full term, but has a heart rate of 140bpm, and during continuous reassessments, the baby becomes centrally cyanotic, what would you consider?
Oxygen therapy at 2 litres/minute.
What are the priorities of non-traumatic paediatric resuscitation?
Airway patency; adequate oxygenation; two-person BVM; high-quality continuous CPR; correction of reversible causes; minimisation of on-scene times.
What are the age-dependant rate of respirations for a non-traumatic paediatric resuscitation?
25 breaths/minute for child <1; 20 breaths/minute for child >1; 15 breaths/minute for child >6.
In paediatric resuscitation, what age are adult defibrillation pads placed?
6 and older.
After initial ROSC, what are the primary aims?
Support circulation, airway and breathing; maintain cerebral perfusion; manage cardiac dysrhythmias.
In a ROSC patient who has already had a 12-lead ECG applied, their dysrhythmias treated and reversible causes managed and considered, how do you optimise ventilation and oxygenation?
Maintain SpO2 >94%; consider advanced airway; maintain EtCO2 30-40mmHg (may need to ventilate at 8-12 breaths/min).
In a ROSC patient who has already had a 12-lead ECG applied, their dysrhythmias treated, reversible causes managed and considered, and their ventilation and oxygenation optimised, how do you optimise circulation?
Aim for systolic BP >100mmHg for adults and systolic BP >80mmHg for children; consider posture; consider adrenaline.
What issue can arise with positive pressure ventilation in patients with asthma or COPD who require resuscitation?
Can trigger further bronchoconstriction and breath stacking.
What is the appropriate management for patients with asthma or COPD who require resuscitation?
Reduce respiratory rate; apply smaller tidal volume; prolonged expiratory time.
How many breaths should a patient with asthma or COPD who require resuscitation receive?
6-8 breaths/minute.
How should you perform CPR on a pregnant woman?
Higher hand position; position the patient 15 to 30 degrees to the left or move the graviduterus to the patient’s left side to avoid aortocaval compression.
What are the reversible causes of traumatic cardiac arrest?
Hypovolaemia; hypoxaemia; tension pneumothorax; cardiac tamponade.
In an adult patient requiring traumatic resuscitation and presenting with suspected hypovolaemia, what would your management consist of?
External/internal haemorrhage control; volume replacement.
What does volume replacement in suspected hypovolaemia in an adult patient requiring traumatic resuscitation consist of?
Sodium chloride 0.9% at 20mL/kg.
In an adult patient requiring traumatic resuscitation and presenting with suspected hypoxia, what would your management consist of?
Basic airway adjuncts and manoeuvres; IPPV; supraglottic airway/ETT.
In an adult patient requiring traumatic resuscitation and presenting with suspected tension pneumothorax, what would your management consist of?
Bilateral chest decompression.
In an adult patient requiring traumatic resuscitation and presenting with suspected tamponade, what would your management consist of?
Resuscitative thoracostomy.
What is a direct laryngoscopy?
Technique used to achieve visualisation of the glottis for the purpose of oral endotracheal tube insertion or removal of foreign body.
What are the indications for a direct laryngoscopy?
- Visualisation of the glottis for the purpose of:
- Oral endotracheal tube insertion
- Removal of a foreign body
What are the contraindications for a direct laryngoscopy?
- Suspected or known epiglottis.
What are the complications of a direct laryngoscopy?
- Laryngospasm
- Hypoxia due to delays in oxygenation while performing procedure
- Trauma to the mouth or upper airway, particularly teeth
- Exacerbation of underlying c-spine injuries
- Vomiting/regurgitation
What patient is a size 2 Macintosh during a direct laryngoscopy recommended for?
Large child.
What patient is a size 3 Macintosh during a direct laryngoscopy recommended for?
Small adult.
What patient is a size 4 Macintosh during a direct laryngoscopy recommended for?
Large adult.
What patient is a size 0 Miller during a direct laryngoscopy recommended for?
Infant.
What patient is a size 1 Miller during a direct laryngoscopy recommended for?
Small child.
What is the difference between a Macintosh blade and a Miller blade (piece of equipment for direct laryngoscopy)?
Macintosh is curved while Miller is straight.
How do you perform a direct laryngoscopy?
Position for optimal visualisation; place patient’s head in appropriate position; open patient’s mouth and inspect oral cavity; remove dentures or plates; grip laryngoscope handle with left hand; place laryngoscope blade into right side of patient’s mouth; sweep tongue to the left; position blade midline in the mouth; move laryngoscope blade progressively down the tongue; gently place tip of laryngoscope blade in the vallecula; lift blade upwards and forward at 45 degree angle to expose epiglottis.
How do you position the head of an older child or adult patients during a direct laryngoscopy?
Extend the head.
How do you position the head of an infant patient during a direct laryngoscopy?
Slightly elevate the shoulders.
How do you position the head of a small child patient during a direct laryngoscopy?
Slightly extend the head.
What are you attempting to align with head positioning in a direct laryngoscopy?
The oral, pharyngeal, and laryngeal axes.
How do you position the head for a direct laryngoscopy in all patients that are suspected to have a C-spine injury?
Maintain neutral position.
What should you try if a Macintosh blade is difficult to position correctly during a direct laryngoscopy?
Insert the blade separate and reconnect handle when in position; insert the blade while the handle is angled and then - once in oral cavity - rotate laryngoscope to midline.
What should you try if a Miller blade is difficult to position correctly during a direct laryngoscopy?
Insert laryngoscope blade tip under and slightly beyond epiglottis; gently advance laryngoscope blade further down tongue until epiglottis has been identified.
What is the Comack-Lehane classification?
A grading system for airway visibility.
What are the different Comack-Lehane classifications?
Grade 1 is complete glottis visibility; grade 2 means anterior glottis can’t be seen; grade 3 means the epiglottis is seen, but not the glottis; grade 4 means the epiglottis can’t be seen.
How many times can you attempt a direct laryngoscopy?
Twice.
What is laryngeal manipulation?
Technique that improves visualisation of the larynx during a direct laryngoscopy.
What is an external laryngeal manipulation?
Directional movement of the larynx.
What is the BURP technique of laryngeal manipulation?
Backwards, upwards, rightwards, pressure.
Displaces the larynx superiorly, posteriorly and rightward laterally.
What are the indications for laryngeal manipulation?
- Sub-optimal visualisation of the larynx during direct laryngoscopy.
What are the contraindications for laryngeal manipulation?
- Active vomiting.
What are the complications of laryngeal manipulation?
- Incorrect application
- May worse visualisation of the larynx
- Potential for airway trauma
How do you perform an external laryngeal manipulation?
Gently grasp thyroid cartilage between thumb and index or middle finger; direct thyroid cartilage posteriorly and cephalad until visualisation is achieved.
How do you perform a BURP laryngeal manipulation?
Gently grasp thyroid cartilage between thumb and index or middle finger; apply smooth and gentle pressure backwards, upwards, rightwards until visualisation is achieved.
What are Magill forceps?
Long, angled forceps designed to grasp objects lodged in the pharynx without obscuring view.
What patient are the 205mm Magill forceps recommended for?
Paediatrics.
What patient are the 250mm Magill forceps recommended for?
Adults.
What are the indications for Magill forceps?
- Removal of pharyngeal foreign bodies causing airway obstruction in an obtunded patient
- To facilitate the insertion of an orogastric tube
What are the contraindications for Magill forceps?
- Patients with an effective cough
What are the complications of Magill forceps?
- Trauma to the tissue surrounding the pharynx uvula and tongue
- Manipulating a partially obstructed airway may cause the object to totally occlude the airway
How do you use the Magill forceps to remove a foreign body?
Open mouth; inspect oral cavity; remove dentures and plates; perform laryngoscopy; suction if required; grasp forceps in right hand with thumb and ring finger in holes; insert forceps; close and open Magill’s as required to grasp object.
What is an NPA?
A nasopharyngeal airway.
Soft, anatomically designed airway adjunct which is inserted into the nasal passageway to provide airway patency.
What aspects create advantages to NPAs over OPAs?
Can be used in patients with intact gag reflexes, trismus, and oral trauma.
What are the indications for an NPA?
- Potential or actual airway obstruction
What are the contraindications for an NPA?
Nil.
What are the complications of an NPA?
- Airway trauma, particularly epistaxis
- Incorrect size or placement compromises effectiveness
- Exacerbate injury in base of skull fracture, with NPA potentially displacing into the cranial vault
- Can stimulate a gag reflex in sensitive patients, precipitating vomiting or aspiration
How do you apply an NPA?
Place patient’s head in neutral position; identify correct size of NPA; lubricate NPA; advance device along floor of nasopharynx, following natural curvature until flange rests against nostril.
What do you lubricate an NPA with?
Water-soluble lubricant.
How do you measure an NPA to ensure correct size?
Measure from tip of patient’s nose to earlobe.
What are the three sizes of NPA and their internal diameters?
24 (6mm); 28 (7mm); 32 (8mm).
When placing the NPA into the nose which way is the bevel facing?
Nasal septum.
What is an OPA?
Oropharyngeal airway.
Short term, easily inserted airway management device that extends from the lips to the pharynx which prevents the base of the tongue from falling back and occluding the airway.
What does the OPA not provide that is essential to maintaining an airway?
Protection from fluids and aspiration.
What are the indications for an OPA?
- Maintain airway patency
- Bite block for intubated patients
What are the contraindications for an OPA?
- Conscious patients
- Patients with an intact gag reflex
What are the complications of an OPA?
- Airway trauma from OPA placement
- Intolerance of OPA requiring removal
- Can precipitate vomiting/aspiration in patient with intact gag reflex
- Incorrect size or placement can potentially exacerbate airway obstruction
How do you place an OPA in an adult?
Identify correct size of OPA; insert OPA by facing adjunct to roof of the mouth; advance OPA until about 1/3 of the way; rotate 180 degrees over tongue; advance OPA until flange is on lips.
How do you place an OPA in a paediatric?
Identify correct size of OPA; insert OPA by facing adjunct to floor of the mouth; advance OPA until flange is on lips.
How do you measure an OPA to ensure correct size?
Measure from centre of patient’s incisors to angle of the jaw.
What are the sizes of OPA and their associated patients?
3cm (neonate); 4cm (infant); 5cm (toddler); 6cm (small child); 7cm (child); 8cm (adolescent/adult female); 9cm (adult male); 10cm (large male).
What does the appropriate suctioning do for a patient?
Decreases risk of aspiration; promotes pulmonary gas exchange; prevents nosocomial pneumonia.
What are the different types of catheters used in suctioning?
Y-suction catheter; Yankauer catheter; SSCOR DuCanto catheter; Meconium aspirator.
What is an I-gel?
A supraglottic airway device that seals the pharyngeal, laryngeal and perilaryngeal structures without inflation.
What are the indications for an I-gel?
- Actual loss of airway patency and/or airway protection.
What are the contraindications for an I-gel?
- Conscious breathing patients
- Continuous use for >4 hrs
What are the complications of an I-gel?
- Failure to provide adequate airway or ventilation
- Patient intolerance
- Hypoxia
- Can precipitate vomiting and aspiration in a patient with intact airway reflexes
- Oropharyngeal trauma
How do you apply an I-gel?
Prepare equipment; slide airway support strap under patient’s neck; inspect I-gel for issues; place half of the lubricant on the inner surface of the cradle’s neck; lubricate back, sides and front of I-gel cuff; place patient’s head in sniffing position; open patient’s mouth; inspect mouth; remove dentures and plates; grasp I-gel along integrated bit block; face cuff outlet toward patient’s chin; open patient’s mouth using pressure on chin; direct I-gel toward hard palate as it is inserted; continue until definitive resistance; tape I-gel into place and secure with strap; attach BVM.
What procedure/skill do you perform if there is early resistance during the insertion of an I-gel?
Triple airway manoeuvre; insertion with deep rotation.
How do you confirm an I-gel is in the correct position once inserted?
Patient’s incisors should be resting on the bite block.
How do you tape an I-gel in place?
Maxilla to maxilla.
How do you check for airway patency once an I-gel is in place and a BVM is connected?
Equal rise and fall of the chest; no resistance on the BVM; fogging and misting in the I-gel and other clear tubing.
What are the sizes of I-gel and their associated patients?
1 (neonate); 1.5 (infant); 2 (small child); 2.5 (large child); 3 (small adult); 4 (medium adult); 5 (large adult).
What does a triple airway manoeuvre consist of?
Head tilt; jaw thrust; mouth opening.
When would you perform a double airway manoeuvre over a triple airway manoeuvre?
When a c-spine injury is suspected.
What are the indications for a triple airway manoeuvre?
- Patients unable to maintain airway patency
What are the contraindications for a triple airway manoeuvre?
Nil.
What are the precautions of a triple airway manoeuvre?
- Potential c-spine injury
What is a blood glucose analysis?
The assessment of a patient’s blood glucose level.
What blood glucose readings are considered normal?
4-8mmol/L and 4-6mmol/L when patient has fasted.
What are the indications for a blood glucose analysis?
- Point of care glucose assessment
What are the contraindications for a blood glucose analysis?
- Routine use in newborns unless clinically indicated
What is waveform capnography?
Continuous measurement of exhaled carbon dioxide.
What is a normal entitled CO2 reading?
35-40mmHg.
What are the four key phases of carbon dioxide capnograms?
Phase I (inspiratory baseline); phase II (expiratory upstroke); phase III (alveolar plateau); phase 0 (inspiratory downstroke).
What are the indications for waveform capnography?
- CPR
- Sedation and procedural sedation
- Endotracheal intubation
- Ongoing monitoring of ventilation
What are the contraindications for waveform capnography?
Nil
What are the complications of waveform capnography?
- When performing effective CPR during cardiac arrest, entitled CO2 values must not be used to vary IPPV rates.
Where is the oral entitled CO2 connector attached regardless of advanced airway?
Connected to BVM and filter and plugged into defibrillation machine.
If you are using a nasal entitled CO2 connector, how do you apply it to your patient?
Like nasal cannulas for oxygen therapy and to the defibrillation machine.
What are the possible causes of reduced entitled CO2 levels?
Shock; pulmonary embolism; effective CPR.
What is the possible cause of a sudden increase in entitled CO2 levels?
ROSC.
What is pulse oximetry?
Estimation of the oxygen saturation in arterial blood.
What are the indications for pulse oximetry?
- To determine patient oxygen saturation
- Assessment of the newborn
What are the contraindications for pulse oximetry?
Nil.
What are the complications of pulse oximetry?
- Reliability (correct sensor size and placement; adequate arterial blood pulsation at the site)
- Inaccurate readings:
- Excessive patient movement
- Exposure to ambient light
- Dirt/nail polish
- Carbon monoxide
What is a normal pulse oximetry reading?
SpO2 94-100%.
What hand should the pulse oximetry be placed on for a newborn?
Right hand.
What is a tympanic temperature?
An assessment of a patient’s core body temperature through their ear.
What are the indications for a tympanic temperature?
- Intermittent measurement of human body temperature when clinically indicated.
What are the contraindications for a tympanic temperature?
- Blood or drainage in ear canal
- Inflammatory conditions of the external ear canal
- Perforated tympanic membranes
- Small or pre-term babies
What is a normal core body temperature
36.5 to 37.5 degrees.
What does IV access refer to?
The insertion of a peripheral intravenous catheter.
What are the indications for peripheral intravenous catheter insertion?
- Vascular access for the administration of medications, hydration fluids and blood products.
What questions should you ask before inserting a peripheral intravenous catheter?
Is there a clinical requirement for this procedure?
- Will it add value?
- Do the benefits outweigh the risks?
- Is there a simpler, less invasive alternative?
- Can it be justified at this point in time?
What are the contraindications for peripheral intravenous catheter insertion?
- Whenever possible avoid sites of burns, infection, trauma or significant oedema
- Pre-existing medical conditions that exclude particular limbs from being used
What are complications of peripheral intravenous catheter insertion?
- Redness, pain or swelling of the vein
- Localised or systemic catheter or line related infections
- Drug/fluid extravasation into superficial tissue
What veins can be used for peripheral intravenous catheter insertion?
Metacarpal and forearm veins; antecubital fossa; foot and ankle veins.
How do you perform a peripheral intravenous catheter insertion?
Identify appropriate insertion site; adjust patient position; explain procedure to patient; apply tourniquet above insertion site; palpate vessel; clean insertion site with swab; allow insertion site to dry; identify appropriate size catheter; remove and discard needle safety cap; rotate catheter barrel 360 degrees; stabilise vein; insert catheter into vein at 30 degree angle; observe flashback; lower catheter and advance needle; thread catheter into vein; release tourniquet; use white button to retract needle; dispose of sharps; apply bung; secure catheter with one strip of dressing; flush with saline; apply remainder of dressing.
How much above the site of insertion should you apply the tourniquet in a peripheral intravenous catheter insertion?
5cm.
How long should you swab the site of insertion when gaining IV access?
15 seconds each direction; total of 30 seconds.
In what gauges/sizes will you observe flashback along the catheter when inserting a peripheral intravenous catheter?
20; 22; 24.
In what gauges/sizes will you observe flashback behind the white button when inserting a peripheral intravenous catheter?
16;18.
In what procedure is a 14 gauge peripheral intravenous catheter applied?
Chest decompression.
In what procedures are 16 gauge peripheral intravenous catheters applied?
Chest decompression; volume replacement.
In what procedures are 18 gauge peripheral intravenous catheters applied?
General medication administration; fluid administration.
In what procedures are 20 gauge peripheral intravenous catheters applied?
General medication administration; fluid administration.
In what patients are 22 gauge peripheral intravenous catheters applied?
Paediatric patients; difficult access.
In what patients are 24 gauge peripheral intravenous catheters applied?
Paediatric patients; difficult access.
How many times can you attempt intravenous cannulation?
3.
What are the indications for intravenous administration?
- Administration of medication via the IV route
What are the contraindications for intravenous administration?
- Evidence of a misplaced or dislodged IV cannula
What are complications of intravenous administration?
- Pain or discomfort
- Air embolus
- Infection, bacteraemia or sepsis
- A misplaced or dislodged cannula resulting in extravasation and possible tissue necrosis
What should occur immediately following intravenous administration?
Flush with sodium chloride 0.9%.
What is an IM injection?
Intramuscular injection.
Insertion of a needle into the patient’s muscle to administer medication.
What needles do we use for IM injections?
3mL VanishPoint; 1mL VanishPoint.
What are the indications for an IM injection?
- Required intramuscular drug administration
What are the contraindications for an IM injection?
- Inadequate muscle mass at selected injection site
- Patients in cardiac arrest
- Ability to administer medication by equally effective and less invasive route
What are complications of an IM injection?
- Pain
- Minor haemorrhage
- Abscess formation
- Cellulitis
- Nerve and blood vessel damage
How do you perform an IM injection?
Prepare required dose in VanishPoint syringe; label syringe; ensure air bubbles are expelled from syringe; identify appropriate site if injection; encourage patient to relax muscle; swab skin if dirty; stabilise and stretch skin around injection site; insert using dart-like technique at 90 degree angle; inject contents; depress plunger until needle is retracted; dispose of sharps; apply pressure to site.
What sites can be used for IM injections?
Deltoid muscle; vastus lateralis.
What should you do if a recommend IM dose exceeds 2mL?
Separate doses into two different VanishPoint syringes; administer in different sites.
What is intranasal administration?
The administration of aerosoled medication directly on the nasal mucosa.
What size syringe is used for intranasal administration?
1mL.
In addition to a 1mL syringe, what is needed to perform administration intranasally?
Nostril cushion; atomiser.
What are the indications for intranasal administration?
- The administration of medications via the intranasal route.
What are the contraindications for intranasal administration?
- Suspected nasal fractures
- Blood or mucous obstructing nasal passages
What are the complications of intranasal administration?
- Underdosing if not administered correctly
- Mild, short lasting nasal discomfort from drug
How much extra medication should be drawn up when administering intranasally and why?
0.1mL to account for dead space.
How do you perform intranasal administration?
Prepare required dose in 1mL syringe; connect atomiser and nasal cushion; place tip against nostril; aim upwards and outwards; compress plunger to deliver medication.
What are you aiming for when placing the device for intranasal administration?
The top of the ear.
What do you do in an intranasal administration that is between 0.5mL and 2mL in volume?
Deliver half in one nostril and half in the other.
What do you do in an intranasal administration that exceeds 2mL?
Find an alternative route of administration.
What is nebulisation?
A process where oxygen is pumped through a liquid to form a vapour that is inhaled directly into the lungs.
What are the indications for nebulisation using a nebuliser mask?
- The administration of medications via the nebuliser route.
What are the contraindications for nebulisation?
Nil.
How do you apply nebulisation using a nebuliser mask?
Position patient upright; unscrew nebuliser chamber; place medication into chamber; screw chamber back together; attach oxygen hose to nebuliser; place nebuliser face mask on patient; begin oxygen flow; nebulise until drug stops.
At what flow rate should oxygen be set to in the event of nebulisation using a nebuliser mask?
6-8L/minute.
How much solution can a nebuliser chamber hold?
10mL.
What are the indications for oral medication administration?
- The administration of medications by the oral route.
What are the contraindications for oral medication administration?
- Impaired conscious state
- Ability to swallow impaired
What are the complications of oral medication administration?
- Aspiration
- Airway compromise
What device do you use for the oral administration of liquid solutions?
Purple safety syringe.
Where do you place ODT oral medications?
On the tip of the patient’s tongue.
What is a subcutaneous injection?
A needle that goes into the layer of fat between the skin and muscle.
What are the indications for a subcutaneous injection?
- The administration of medications via the subcutaneous route
What are the contraindications for a subcutaneous injection?
- Injection into scar tissue, burns, bruises, infection, or broken skin
What are the complications of subcutaneous injections?
- Pain
- Bleeding
What are sites used for subcutaneous injections?
Lower abdomen.
*3cm from umbilicus.
How do you perform a subcutaneous injection?
Prepare medication in syringe; position patient in reclined position; identify site; swab site; pinch about 5cm of skin between thumb and index finger; insert needle in dart-like motion at 90 degree angle; completely cover needle by skin; aspirate; inject contents; remove needle; dispose of sharps.
What is sublingual administration?
Medications delivered under the tongue.
What are the indications for sublingual administration?
- The administration of medication via the sublingual route
What are the contraindications for sublingual administration?
Nil.
What is the difference between an emergency chest decompression using a cannula and an emergency chest decompression using a pneumodart needle?
Patient’s <50kg (<14) require a cannula for chest decompression, while for patient’s >50kg (>14) it is recommended that a pneumodart be used.
What are the indications for emergency chest decompression using either a pneumodart or cannula?
- Traumatic cardiac arrest (with torso involvement)
- Suspected tension pneumothorax with respiratory and/or haemodynamic compromise
What is the contraindication for emergency chest decompression using either a cannula or pneumodart?
- Obvious non-survivable injury in the traumatic cardiac arrest
What are the complications for emergency chest decompression using either a cannula or pneumodart?
- Improper diagnosis and insertion may lead to the creation of a simple or tension pneumothorax
- Incorrect placement may result in life-threatening injury to the heart, great vessels, or damage to the lung.
- Bilateral pleural decompression in the spontaneously breathing patient may result in significant respiratory compromise
What is the insertion site for a pneumodart or cannula during an emergency chest decompression?
2nd intercostal space, mid-clavilar line.
Once you have located the site of insertion for an emergency chest decompression in a patient that is 12, what device do you prepare and how do you proceed?
Prepare a 14 gauge cannula.
Swab site; remove of needle safety cap; rotate catheter barrel 360 degrees; stabilise chest wall with non-dominant hand; insert cannula; cease insertion when appropriate; thread catheter off needle until flush with skin; retract needle with white button; dispose of sharps.
How do you correctly insert a needle for an emergency chest decompression and why?
Perpendicular to patient’s back along superior border of third rib.
To avoid inferior neurovascular bundle.
What will occur to indicate you can cease the insertion of the needle during an emergency chest decompression?
A release of air; a sudden give or loss of resistance.
Once you have located the site of insertion for an emergency chest decompression in a patient that is 25, what device do you prepare and how do you proceed?
Prepare a pneumodart.
Swab site; check pneumodart; stabilise chest wall with thumb and index finger of non-dominant hand; insert pneumodart; cease insertion when appropriate; count and record depth markers on pneumodart; stabilise pneumodart with umbilical clamp and tape.
What do you assess following emergency chest decompression to ensure success?
Breath sounds; haemodynamic status.
What is CPAP?
Continuous positive airway pressure.
Non-invasive ventilation used in spontaneously breathing patients to reduce the work of breathing and improve pulmonary gas exchange.
What occurs in patients suspected of experiencing acute cardiogenic pulmonary oedema when CPAP is administered?
Increase in intrathoracic pressure; reduced venous return (preload); reduced afterload; improved cardiac function.
What are the indications for CPAP?
- Acute pulmonary oedema
What are the contraindications for CPAP?
- Patients <6
- GCS <8
- Inadequate ventilatory drive
- Hypotension (systolic BP <90mmHg)
- Pneumothorax
- Facial trauma
- Epistaxis
What are the complications of CPAP?
- Aspiration
- Gastric distention
- Hypotension
- Corneal drying
- Barotrauma
What are the sizes of CPAP masks, how do you identify them and what patients are they recommended for?
Size 4 (red) for small adult; size 5 (blue) for large adult.
How do you apply CPAP?
Place patient in seated position; explain procedure to patient; prepare equipment; select appropriately sized mask; attach vectored flow valve to mask and oxygen tubing; adjust oxygen flow rate; position mask on patient’s face; monitor patient; increase airway pressure every 3-5 minutes.
How do you ensure CPAP mask fits patient correctly?
Inner circumference of air cushion encompasses bridge of nose, side of mouth and inferior border of the bottom lip.
What is the appropriate initial oxygen flow rate for CPAP?
8-10 L/minute.
If you are delivering an oxygen flow rate of 8-10L/minute in CPAP, how many cmH2O are you administering?
5 or 10cmH2O.
What are you monitoring specifically while administering CPAP?
Respiration rate; SpO2; BP; chest sounds; work of breathing.
What is the maximum cmH2O for CPAP?
15cmH2O.
When do you discontinue CPAP?
When patient shows evidence of deterioration.
What is acute pulmonary oedema?
Rapid build-up of fluid in the lungs.
What are the two types of acute pulmonary oedema?
Cardiogenic; non-cardiogenic.
What is cardiogenic acute pulmonary oedema?
Fluid in the lungs that occurs because cardiac output has decreased despite the increase in systemic resistance.
Blood returning to left atrium exceeds blood leaving left ventricle.
Pulmonary venous pressure increases, causing capillary hydrostatic pressure in lungs to exceed oncotic pressure of blood.
Protein poor fluid is drawn out of lungs.
What is non-cardiogenic pulmonary oedema?
Fluid in the lungs that occurs as a result of direct or indirect pathological processes impacting the pulmonary vascular permeability.
Proteins leak from capillaries, increasing interstitial oncotic pressure.
Interstitial oncotic pressure exceeds that of the blood and fluid is drawn out of capillaries.
