CPG Need to know Flashcards
When should COPD be expected?
- Any pt over 40 yrs, smoker or ex smoker, experiencing dyspnoea that is worse with exercise, chronic cough or sputum production, family hx of COPD
When might pulse oximetry be unreliable in pts?
Peripheral vascular disease, severe asthma, severe anaemia, cold extremities or peripherally ‘shut down’, severe hypotension and CO poisoning
When is 02 exchange at its greatest?
Upright position
Women >20 weeks pregnant who are hypoxaemic?
Managed with left lateral tilt to improve cardiac output
Face masks should not be used for flow rates..?
< 5 L/min due to the risk of Co2 retention
SP02 85-93% ?
Titrate 02 flow to SP02 94-98%
Nasal cannulae: 2-6L/min
Simple face mask: 5-10L/min
Critical Illnesses (8)
Cardiac Aresst/ resuscitation CO poisoning Anaphylaxis Major trauma/ head injury Shock Severe sepsis Status epilepticus Decompression Illness
Sp02 < 85 %
Non rebreather mask 10-15L/min
(If inadequate consider BVM with 100% 02)
Once pt haemodynamically stable, titrate 02 flow to 94-98%
Chronic hypoxaemia (3)
COPD/ Pulmonary disease
Neuromuscular disorders
Obesity
Chronic Hypoxaemia management
Titrate o2 flow to 88-92 %
If no critical illnesses present: initial dose 2-6L/min
Consider simple face mask: 5-10L/min
If Pt deteriorates or Sp02 < 85%
- BVM ventilation with 100% 02
- Consider LMA
Perfusion definition
The ability of the cardiovascular system to provide tissues with an adequate oxygenation blood supply to meet their functional demands at that time and to effectively remove the associated metabolic waste products
Adequate Perfusion
Skin: Warm, pink, dry
Hr: 60-100
BP: > 100
Conscious state: Alert & Orientated
Borderline Perfusion
Skin: Cool, pale, clammy
Hr: 50- 100
BP: 80-100
Conscious state: Alert & Orientated
Inadequate Perfusion
Skin: Cool, pale, clammy
Hr: < 50 or > 100
BP: 60-80
Conscious state: Either alert and orientated or altered
Extremely Poor Perfusion
Skin: Cool, pale, clammy
Hr: < 50 or > 110
BP: < 60
Conscious state: Altered or unconscious
No perfusion
Skin: Cool, pale, clammy
Hr: No palpable pulse
BP: Unrecordable
Conscious state: Unconscious
Normal Respiratory Status
Appearance: calm, quiet Speech: Clear, sentences Sounds: no wheeze, crackles, equal air entry Rate: 12-16 Rhythm: regular WoB: normal chest movement Hr: 60-100 Skin: normal Conscious state: alert
Mild Respiratory Distres
Appearance: calm or mildly anxious
Speech: Full sentences
Sounds: Able to cough, mild expiratory wheeze, LVF may be some fine crackles at bases
Rate: 16-20
Rhythm: Asthma: may have prolonged expiratory phase
WoB: Slight increase in normal chest movement
Hr: 60-100
Skin: Normal
Conscious state: alert
Moderate distress
Appearance: Distressed or anxious
Speech: Short phrases only
Sounds: Able to cough, expiratory wheeze +/- inspiratory wheeze LVF: crackles at bases to mid- zone
Rate: > 20
Rhythm: Asthma: prolonged expiratory phase
WoB: Marked chest movement +/- use of accessory muscles
Hr: 100-120
Skin: Pale & sweaty
Conscious state: May be altered
Severe Respiratory distress (Life threat)
Appearance: Distressed, anxious, exhausted, catatonic
Speech: Words only, or unable to speak
Sounds: Unable to cough Asthma: Expiratory wheeze +/- inspiratory wheeze, maybe no breath sounds (late) LVF: Fine crackles- full field with possible wheeze. Upper Airway Obstruction; Inspiratory stridor
Rate: > 20 or Bradypnoea (<8)
Rhythm: Asthma: Prolonged expiratory phase
WoB: Marked chest movement with accessory muscle use, intercostal retraction +/- tracheal tugging
Hr: > 120, bradycardia = late sign
Skin: Pale and sweaty +/- cyanosis
Conscious state: altered or unconcious
GCS: Eye Opening
Spontaneous 4
To voice 3
To pain 2
None 1
GCS: Verbal Response
Orientated 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 None 1
GCS: Motor Response
Obeys command 6 Localises to pain 5 Withdraws from pain 4 Abnormal flexion to pain 3 Abnormal extension to pain 2 None 1
AVPU
A= Alert V= Verbal P= Pain U= Unresponsive
Actual time critical
As the time of VSS, the pt is in actual physiological distress
Emergent time critical
At the time of VSS, the pt is not in physiological distress but does have a pattern of injury or significant medical condition which is known to have a high probability of deteriorating to actual physiological distress
Potential time critical
At the time of VSS, the pt is not physiologically distressed and no pattern of actual injury/ illness , but there is a mechanism of injury knwn to have potential to deteriorate to actual physiological distress
Trauma Triage
Pts meeting criteria for major trauma should be triaged to highest major trauma care within 45 mins, receiving hospital must also be notified
Obstetric trauma pts
All obstetric pts who meet the time critical trauma criteria or any pt who is > 24 wks gestation with any trauma or potential harm to unborn child should be transported to Royal melb hospital within 45 mins. If > 45 mins, transport to nearest alternative highest level of trauma service
A pt under trauma triage guidelines meets the criteria for major trauma if that have a combination of MOI and other co morbidities …:
Systemic illness limiting normal activity/ systemic illness constant threat to life: -Poorly controlled hypertension -Obesity - Controlled or uncontrolled CCF - Symptomatic COPD - Ischaemic heart disease - Chronic renal failure or liver disease Pregnancy Age < 15 or > 55
In the setting of major trauma, an adult is considered time critical if they meet any of the following criteria:
- HR < 60 or > 120
- RR <10 or >30
- SBP < 90
- Sp02 < 90%
- GCS < 13
Specific Injuries meeting potential major trauma criteria:
All penetrating injuries (except isolated superficial limb injuries)
Blunt Injuries
- Serious injury to a single body region such that specialised care or intervention may be required or such that life, limb or long- term quality of life may be at risk
- Significant injuries involving more than one body region
Specific Injuries
- Limb amputation or limb threatening injury
- Suspected spinal cord injury or spinal fracture
- Burns > 20% TBSA or suspected respiratory tract burns
- High voltage burn injury
- Serious crush injury
- Major compound fracture or open dislocation
- Fracture to 2 or more of femur/ tibia/ humerus
- Fractured pelvis
High risk criteria for major trauma:
Assess for mechanism of injury:
- Motor/ cyclist impact > 30km
- High speed MCA > 60km
- Pedestrian impact
- Ejection from vehicle
- Prolonged extrication
- Fall from height > 3m
- Struck on head by object falling > 3m
- Explosion
Actual time critical - Medical
Any of the following:
- Moderate or severe respiratory distress
- Oxygen Sats < 90% room air < 93% on 02
- < Adequate Perfusion
- GCS < 13
Emergent time critical - Medical
Medical symptoms/ syndromes - ACS - Acute stroke - Severe sepsis incl. suspected meningococcal disease - Possible AAA - Undiagnosed severe pain Need for possible hyperbaric treatment e.g. acute decompression illness, cyanide poisoning Hypothermia or hyperthermia
Mental Status Assessment (BASSETS PCA)
Behaviour Appearance Safety Speech Environment Thought process Self- harm Perception Cognition Affect Thought Content
Mental Health high risk symptoms ?
- Suicidal ideation (attempt, thoughts, intent or plan)
- Self- harming behaviours or actions
- Intentional overdose/ poisoning
- Cognitive impairment (except if normal for pt)
- Erroneous or altered perceptions e.g. delusions, hallucinations
Clinical Red Flag
- Pt characteristics: <1yo, frailty
- GCS <15 (unless normal for pt)
- Abnormal VSS (unless normal for pt)
- Pain > 5 requiring opioids
- Possible cardiac symptoms e.g chest pain, dizziness/ syncope, palpitations
- Abdominal pain (acute or undiagnosed)
- Obstetric cases
Yellow Clinical Flag
- History of mental health
- VSS not taken (for any reason)
- Multiple co morbidities/ complex medical history > 5 meds
- History of falls, stroke, TIA, AF
- Current alcohol/ drug intoxication
- Communication difficulties eg. NESB, intellectual disability, dementia
Causes of PEA arrest
- Hypoxia
- Exsanguination
- Asthma
- TPT
- Anaphylaxis
- Upper airway obstruction
Clinical assessment of deceased person
- No palpable carotid pulse
- No heart sounds heard for 2mins
- No breath sounds heard for 2mins
- Fixed (non- responsive to light) and dilated pupils
- No response to centralised stimulus
- No moter (withdrawal) response or facial grimace to painful stimulus
ECG strip that shows asystole over 2mins
I-Gel Contraindications
- Intact gag reflex or resistance to insertion
- Strong jaw tone and/ or trismus
- Suspected epiglottitis or upper airway obstruction
- The use of sedation to either assist or maintain placement is C/I
I- Gel Precautions
- Inability to place pt in sniffing position
- Pts who require high airway pressures e.g. advanced pregnancy, morbid obesity, decreased pulmonary compliance or increased airway resistance
- Pts < 14 years due to enlarged tonsils
- Significant amount of vomit in airway
Signs of an inferior AMI include:
ST elevation in leads 2 and 3
Cardiac output =
HR x SV
ACS general management
Aspirin 300mg GTN 300mcg (no prev. admin) 600mcg repeat 300-600mcg at 5 min intervals if symptoms persist and BP remains > 110 GTN patch 50 mg if BP > 90 Pain Relief- treat until pain free
SVT - stable BP > 100
12- lead ECG
Abdominal valsalva
- repeat x2 at 2min intervals (max. 3 attempts)
Valsalva instruction
- Supine position
- Pressure- pt blowing into a 10mL syringe hard enough to move the plunger to create the pressure needed
- Duration- at least 15s if tolerated by the pt
Non- cardiac causes of pulmonary oedema incl:
Smoke inhalation/ toxic gases, near drowning and anaphylaxis
Pulmonary Oedema CPG only relates too:
Cardiogenic, secondary to LVF or CCF
Basal/ midzone crackles Mx
BP>110 GTN 300mcg (no prev. admin) GTN 600mcg Repeat 300-600mcg GTN @5 min intervals if symptoms continue BP >90 GTN patch, remove if BP falls below 90
Full Field crackles Mx
- GTN as per basal/ mid zone crackles
If no improvement or deteriorates:
Suction if required, providing assisted ventilation with 100% o2
CPAP if available
Specific indications for fentanyl
- Contraindication to morphine
- Short duration of action desirable (e.g. dislocations)
- Hypotension
- Nausea and/ or vomiting
- Severe headache
Mild pain mx
Paracetamol 1000mg oral
- If elderly, frail, weight <60kg, malnourished or liver disease: 500mg
Moderate pain mx
If IV access available: Morphine or Fentanyl IV
Fentanyl IN
Elderly, frail, or weight <60kg
Fentanyl 100mcg, repeat up to 50mcg IN at 5min intervals
Max dose = 200mcg
All other adults: 200mcg IN Fentanyl
repeat 50mcg every 5 mins, max dose = 400mcg
OR methoxyflurane 3ml, repeat 3ml if required. max dose = 6ml
Severe pain- IV morphine mx
Morphine up to 5mg IV
- Repeat up to 5mg at 5min intervals.
Max dose= 20mg
Severe pain- IV fentanyl mx
Fentanyl up to 50mcg IV
- Repeat up to 50mcg at 5min intervals
Max dose= 200mcg
Severe pain IM Morphine
Consider IM morphine as a last resort if elderly or frail or weight <60kg morphine 0.1mg/kg IM (single dose only) All other adults: 10mg Morphine IM, repeat 5mg IM after 15mins if required (once only)
Warning signs of an intracranial event incl.
- Abnormal neurological findings or atypical aura
- New onset headache in older pts (age > 50) or those with a history of cancer
- Altered level of consciousness or collapse
- Seizure activity
- Fever and/ or neck stiffness
Headache of any severity Mx
- Paracetamol 1000mg oral if not already administered in last 4hrs
- Prochlorperazine 12.5mg IM
If after 15 mins of above therapy and pt headache remains severe and hospital remains >15mins, treat as per severe headache
Severe headache Mx
Fentanyl 25-50mcg IV at 5min intervals titrated to pain or side effects. Max dose= 200mcg
- Aim is to reduce pain to <7
If unable to administer IV fentanyl.
IN fentanyl.
Elderly: 100mcg IN, repeat 50mcg at 5min intervals Max dose = 200
Other adults: 200mcg IN, repeat 50mcg at 5min intervals. Max dose= 400mcg
Mild/ moderate Asthma Mx
- Salbutamol pMDI and spacer
deliver 4-12 doses at 20min intervals until resolution of symptoms
-pt to take 4 breaths for each dose
If spacer unavailable: - Salbutamol 10mg (5Ml) nebulised
repeat 5mg (2.5ml) nebulised at 5min intervals in required
Severe Asthma Mx
- Salbutamol 10mg (5ml) and Ipratropium Bromide 500mcg (2ml) Nebulised
Repeat salbutamol 5mg (2.5ml) nebulised at 5min intervals if required
Severe Asthma Mx- inadequate response to above therapy
Adrenaline 500mcg IM
Repeat 500mcg IM at 5-10min intervals
Max dose - 1.5mg
Asthma: becomes unconscious with poor or no ventilation but still with CO
- Ventilate at 6-7ml /kg @ 5-8 Ventilations/min
- Moderately high respiratory pressures
- Allow for prolonged expiratory phase
Asthma: pt loses C.O
- apnoea for 1min
- prepare for resuscitation
Exacerbation of pre- existing COPD can be defined as the following:
- Increased dyspnoea
- Increased cough
- Increased sputum production
- Complete removal of wheeze in this pts may not be possible due to chronic airway disease
Indications for CPAP (mica)
Sp02 <90% room air or <95% on supplemental 02
Indications for removal of pre- hospital CPAP:
Ineffective - Cardiac/ respiratory arrest - Mask intolerance/ pt agitation - Nil improvement after 1hr of treatment Vital signs - Hr < 50 or BP <90 - Loss of consciousness or GCS <13 - Decreasing sp02 Active risk to pt - Loss of airway control - Copious secretions - Active vomiting - Paramedic judgment of clinical deterioration
Exacerbation of COPD Mx
- Salbutamol 10mg + 500mcg Ipratropium bromide nebulised
- Inadequate response after 10mins?
MICA - CPAP
Mx for undifferentiated nausea and vomiting:
- Ondansetron 8mg IV or ondans 4mg oral
- If known allergy to ondansetron:
Prochlorperazine 12.5mg IM
Vestibular nausea-
- Potential for motion sickness
- Planned aeromedical evacuation
- Vertigo
Age > 21
- Prochlorperazine 12.5mg IM
Age < 21 Ondansetron 4mg Oral
Prophylaxis for:
- Awake pt with potential spinal injuries and immobilised
- Eye trauma e.g. penetrating eye injury
Ondansetron 4mg oral or IV 8mg ondansetron
Why do you need to ensure IV is patent before administering Dextrose?
Extravasation of Dextrose can cause tissue necrosis.
All IVs should be flushed before and after Dextrose administration (minimum 10ml)
BGL <4mmol Pt does not respond to commands:
- IV cannula in large vein
(confirming IV patency) - Dextrose 10% 15g (150ml) IV
- Normal saline 10mL flush
If unable to insert IV - Glucagon 1 IU IM
IF after 15mins GCS <15
Repeat dextrose 10% 10g (100mL) titrating to pt conscious state
What does status epilepticus (SE) refer too?
> 5mins of continuous seizure activity or multiple seizures without full recovery of consciousness
What is the type of seizure we can only treat?
Generalized convulsive status epilepticus (GCSE), characterised by tonic clonic movements of the extremities with altered conscious state
Other causes of seizure activity?
Hypoglycaemia, hypoxia, head trauma, stroke/ ICH, electrolyte disturbance, meningitis
Generalised convulsive SE Mx
- Manage airway and ventilation as required
- if airway patent, administer high flow 02
- Midazolam 10mg IM
small (<60kg), frail or elderly pts should be administered 5mg IM, repeat once after 5 mins if required
After 10 mins and seizure activity continues
Repeat Midazolam 10mg IM once only
When to Mx for Anaphylaxis?
- Sudden onset of symptoms (mins-hrs)
AND - Two or more of the following with or without confirmed antigen exposure:
Respiratory distress (SOB, wheeze, cough, stridor)
Abdominal symptoms (Nausea, vomiting, diarrhoea, abdo pain/ cramps)
Hypotension (or altered conscious state)
OR - Isolated hypotension following exposure to known antigen (SBP < 90)
Anaphylaxis Mx
500mcg IM adrenaline
- repeat 500mcg IM every 5mins until satisfactory results occur
Small (<60kg), frail, elderly adults should be administered 300mcg instead
- Provide 02
- Mx bronchospasm as asthma and consider nebulised adrenaline for upper airway obstruction and consider fluids
Sepsis criteria
2 or more of:
- Temp > 38 or < 36
- Hr > 90
- RR > 20/min
- BP <90
Inadequte or extremely poor perfusion Mx
If sepsis is suspected and chest is clear and Mica not immediately available:
- Confirm request for MICA support
- Normal Saline up to 20ml/kg over 30mins
Important for Meningococcal Septicaemia *
Ensure face mask protection and medical follow up for staff post exposure
Signs and symptoms of Meningococcal
- Typical purpuric rash
- Septicaemia signs
Fever, rigor, joint and muscle pain
Cold hands and feet
Tachycardia, hypotension
Tachypnoea - Meningeal signs
Headache, photophobia, neck stiffness
Nausea and vomiting
Altered conscious state
Meningococcal Mx
IV accèss Ceftriaxone 1g IV Dilute with water for injection to make 10mL Administer slowly over 2mins No IV access Ceftriaxone 1g IM Dilute with 3.5mL 1% lignocaine HCL to make 4ml Administer to upper lateral thigh
Evidence of opioid OD
- Altered conscious state
- Respiratory depression
- Substance involved
- Exclude other causes (incl no obvious head injury)
- Pin point pupils
- Track marks
Opioid OD Mx
Naloxone 1.6mg-2mg IM
Inadequate response after 10mins
Naloxone 0.8mg IM
Clinical causes of Agitation:
AEIOUTIPS Alcohol/ drug intoxication Epilepsy (post- ictal) Insulin or other metabolic cause- hypo/hyperglycaemia, renal/ liver failure Overdose/ oxygen (hypoxia) Underdose (incl. alcohol/drug withdrawal) Trauma (head trauma) Infection/ sepsis Pain/ psychiatric condition Stroke/ TIA
Mild/ moderate agitation Mx
Midazolam 5-10 mg IM
- Administer lower doses (2.5-5mg) for elderly/ frail, weight <60kg, SBP <100, or sedating drug/ alcohol involvement
- Repeat at 10min intervals
Max dose= 20mg
Extreme agitation Mx
Ketamine IM
< 60kg 200mg
60-90kg 300mg
> 90kg 400mg IM
