REC modules Flashcards
Primary survey steps
Danger
1.1 Assess for danger and minimise hazards
1.2 Apply appropriate PPE
Response
2.1 Identify the client’s response and establish their conscious state
Send for help
3.1 Using appropriate resources and means available to you in the context of the scenario provided
Airway with C spine considerations
4.1 ask about and consider mechanism of injury
4.2 decide if the client needs c-spine immobilisation based on MOI, and complete if required
4.3 determine if client can talk
4.3.1 if no, look for signs of airway compromise (open mouth and inspect - foreign body, blood, vomit/secretions, soft tissue swelling, laryngospasm, depressed LOC)
4.3.2 if no, demonstrate basic airway manoeuvres to help maintain the airway (considering MOI and c-spine protection) - head-tilt chin-lift, jaw thrust, OPA, NPA.
Breathing
5.1 RR - look, listen, feel; fast, normal, slow
5.2 assess chest expansion - identify possible underlying pathology
5.2.1 symmetrical (pulmonary fibrosis, reducing lung elasticity and restricting overall chest expansion) or asymmetrical (pneumothorax, pneumonia and plural effusion can cause ipsilateral chest expansion)
5.3 listen for abnormalities such as bronchial breathing, quiet/reduced breath sounds, wheeze, stridor and coarse crackles
5.4 apply oxygen to all critically unwell clients during your initial assessment. Use a non-rebreathe mask with an O2 flow of 15L.
Circulation with haemorrhage control
6.1 Assess the client’s central pulse (femoral or carotid) for rate, rhythm and strength
6.2 Inspect the skin - pallor (?haemorrhage or poor perfusion), oedema
6.3 assess temp - warm, cool, clammy
6.4 measure CRT (>2s suggests poor peripheral perfusion (hypovolaemia) and so need to assess central CRT)
6.4 assess for obvious signs of haemorrhage
6.5 Interventions - IV cannulation (insert at least 1 wide-bore IV cannula 14G or 16G), management of haemorrhage e.g. replacement of intravascular volume with fluid and blood products as well as measures to slow or stop bleeding such as applying pressure to the wound
Disability with neurological and BGL management
7.1 Assess the LOC using AVPU
- Alert (fully alert but not necessarily orientated)
- verbal (responds when you talk to them e.g. words or grunts)
- pain (responds to painful stimulus e.g. supraorbital pressure)
- unresponsive (no eye, voice or motor responses to pain)
7.2 assess pupils - size, symmetry, reactivity, equal and reactive to light?
7.3 blood glucose
Exposure/environment control
8.1 prioritise dignity and conservation of body heat
8.2 inspect skin for rashes, bruising, signs of infection or any life-threatening injuries
Reassess DRSABCDE
9.1 start from start to identify any changes in clinical condition and assess the effectiveness of previous interventions
9.2 recognise and respond to deterioration immediately
Secondary survey
F - full set of vitals, focused interventions, family presence
G - give comfort
H - history and head-to-toe
I - inspect posterior surfaces
J - jot everything down
History taking mnemonic for acute incidents and gathering critical info
DeMIST
De - description of the incident/illness
M - mechanism of injury
I - injuries sustained
S - signs and symptoms
T - treatment given so far
History taking mnemonic for secondary survey and gaining further info
AMPLE
A - allergies?
M- medications?
P - past illnesses?
L - last meal?
E - event (what happened, MOI, injuries, interventions and response)
What things should you do when attending an emergency at the roadside?
- park vehicle safely and put on a fluoro vest or jacket
- if on a road, send someone to manage the traffic and bystanders and put out hazard signs
- check if clients are lying on hot/cold bitumen roads
Common hazards for vehicle crash
- Car engine still running
- Hazardous materials from leaking chemicals/battery/petrol
- Un deployed airbags
- Live broken electricity cables
- Toxic gases
- Traffic hazards
- Risk of fire or explosion
- Unstable vehicles
- Hazardous materials
Common hazards for environmental dangers
- Unstable surfaces
- Water, ice
- Weather extremes
Common hazards for crime scene
- Potential violence
- Potentially violent client or bystanders
- Guard dogs, wild animals
Hazards within structures
- Low-oxygen areas
- Toxic substances, fumes
- Risk of collapse
- Risk of fire or explosion
How to assess response
- Ask “how are you going?” or “what’s your name?”
- If no response, pinch ear lobe or gently shake shoulders (with child tap shoulder, with baby tap foot)
- If still no response, presume unresponsive and move on to airway
What are you assessing for in Airway?
- inhalation injury
- penetrating injury
- partial or complete obstruction
- severe allergic reaction
- altered consciousness
Airway assessment - what are you looking and listening for?
Look:
- vomit, tongue or other objects or swelling obstructing the airway
- burned nasal hairs or soot around the nose or mouth
- head or neck trauma
- assess for altered mental status
- tongue swelling
Listen for:
- talking or hoarse voice
- abnormal airway sounds: gurgling, snoring, stridor, noisy breathing
- wheeze
What are the 4 main airway interventions?
If required: Cervical stabilisation: manual inline stabilisation and collar
- Open airway: look at client’s position, use a basic manoeuvre - head tilt chin lift or jaw thrust
- Clear airway: if conscious - can clear it? If not use suction if available to remove foreign body. To clear the airway the mouth should be opened and the head turned slightly downwards to allow any obvious foreign material to drain. Loose dentures should be removed (well fitting ones can be left in place). If unresponsive a finger sweep can be used if solid material is visible in the airway.
- Establish and maintain airway: if you have opened the airway do you need to maintain it with a simple adjunct? OPA or NPA or advanced - LMA?
- Monitor the airway; simple rule of thumb, if you have to intervene to establish or maintain an airway then it remains a priority to monitor the situation meaning someone should stay with the client at all times.
GCS assessment
EVM
Eye opening
4 - spontaneous
3 - sound
2 - pressure
1 - none
Verbal response
5 - oriented
4 - confused
3 - words, not coherent
2 - sounds but no words
1 - none
Motor response
6 - obeys command
5 - localising
4 - normal flexion
3 - abnormal flexion
2 - extension
1 - none
Causes of life-threatening airway obstruction or compromise. Including upper airway (5), pulmonary (8), cardiac (8), toxic and metabolic (7), neurological (2), miscellaneous (7).
Upper airway
- foreign body obstruction
- Angioedema
- Anaphylaxis
- Infections of pharynx and neck
- Airway trauma
Pulmonary
- pulmonary embolism
- COPD exacerbation
- Asthma
- pneumothorax
- Pulmonary infection
- Noncardiogenic pulmonary oedema (ARDS)
- Direct pulmonary injury
- Pulmonary haemorrhage
Cardiac
- Acute coronary syndrome
- Acute HF
- Acute pulmonary oedema
- High output HF (precipitated by severe anaemia, pregnancy, thiamine deficiency, and thyrotoxicosis
- Cardiomyopathy
- cardiac arrhythmias (
- valvular dysfunction (aortic stenosis, mitral regurgitation)
- cardiac temponade (due to trauma, malignancy, uraemia, drugs or infection)
Toxic and metabolic - poisoning
- salicylate poisoning
- carbon monoxide poisoning
- toxin related metabolic acidosis
- diabetic ketoacidosis
- sepsis
- Anaemia
Neurological - Stroke
- Neuromuscular disease
Miscellaneous - lung cancer
- pleural effusion
- Intra abdominal processes (bowel obstruction, ruptured viscous, peritonitis)
- Ascites (distends to abdominal cavity, placing pressure on diaphragm)
- pregnancy
- Massive obesity
- Hyperventilation and anxiety
How might a compromised airway present?
SOB, stridor, drooling, or obvious facial injuries such as swelling or bleeding.
How do infants and children differ from adults?
Smaller physiological reserves and increased risk of dehydration, hypoglycaemia and hypothermia
NPA:
- benefits/when to use
- when to avoid
- what to do prior to insertion
- what to do after insertion to keep secure
-may be more easily tolerated than an OPA
- can be used when the client’s jaw is clenched, when they are semiconscious and can not tolerate an OPA, or when there is oral trauma.
- avoid in the presence of maxillary or base skull fractures
- lubricate prior to insertion
- place safety pain across tube against nostril to prevent it from slipping down
LMA:
- benefits
- requirement for use
- safe and swift airway which is more secure than an NPA With less dead space
- only use if no gag reflex
Presentations considered at risk of spinal injury + Precautions you can take if you are by yourself
- Blunt multi-system trauma, e.g. pedestrian vs car, high impact falls/collisions
- Significant injury above the level of the clavicles
- Impaired LOC
- New neurological defect
- Midline cervical tenderness
May decide to apply temporary steps e.g. encouraging them to lie still and sandbags/rolled towels either side of the clients head.
Paediatric airway management: 3 most common airway issues
- Obstruction from foreign body (complete or partial)
- Inflammation - stridor (partial), croup, anaphylaxis
- Apnoea
Pregnant women and airway considerations:
3 Anatomical changes that start to occur from 12w gestation
- Large tongue
- Large breasts
- Mucosal and airway oedema of the oropharynx (incr. circulatory vol.)
3 considerations for pregnant women regarding airway management
- A smaller airway adjunct may be required
- Anticipate a difficult airway in a heavily pregnant woman
- Be prepared
What constitutes adequate breathing in an adult
- RR 12-20
- Regular pattern of inhalation and exhalation
- Adequate depth
- Bilaterally clear and equal lung sounds
- Regular and equal chest rise and fall
How to insert LMA
- Deflate LMA fully
- Lubricate
- Jaw thrust client and insert
- Inflate LMA
Small is for infant and child
Medium is for adult
Large is for large adult (>90-100kgs)
Hand ventilation rates: adult, child, asthma.
Adult: 8-10 breaths/min (squeeze, release, release, release… repeat)
Child: 16-20 bpm (squeeze, release, release… repeat)
Asthma: 6 bpm (use your watch)
When to not use assisted ventilation
Do not hand ventilate a patient who is breathing spontaneously if there spO2 is ok.
Breathing assessment: look, listen and feel - for what?
Look:
- movement of chest or upper abdo
- colour
- RR (note: >25 or increasing = pt may deteriorate suddenly)
- Depth of breaths
- Chest deformity, tracheal position, symmetry
Raised JVP (indicates possible acute severe asthma or tension pneumothorax)
- WOB
- visible injury (bleeding, bruising, flail chest, imprints, seatbelt marks, penetrating injuries, burns)
Listen:
- escape of air from nose and mouth
- auscultate lung fields (2 point only) to confirm breath sounds present and equal
- absence of breath sounds on one side? Dull sound with percussion to the same side?
- audible breath sounds (wheeze, grunt, rattling noises, etc.)
Feel:
- For movement of air at the mouth and nose
- soft tissue and bony wall integrity
- chest retractions
- flail segments (multiple adjacent ribs are broken in multiple places, separating a segment so a part of the chest wall moves independently)
- trachea feel midline?
- crepitus, cracking and popping with palpation
Circulatory assessment: look, listen and feel for what?
Look:
- colour of skin (blue, pink, mottled)
- state of veins (under filled or collapsed = hypovolaemia)
- capillary refill >3s
- sweating
- distended neck veins
- internal and external bleeding
- reduced consciousness
Feel:
- cool, moist extremities
- pulse rate, strength, regularity
- damp clothing (sweat/blood)
- tenderness or guarding of abdo
Listen:
- heart sounds (normal? Muffled? Difficult to hear?)
- is the audible HR correspond to the pulse rate?
Testing capillary return in adults and infants/small children.
How to do and record
Adult: press nail bed for 5s then release
Infant/child: press on chest or abdo for 5s then release
Record as > or < 2s (I.e. time to say “capillary return”)
Signs of end-organ hypoperfusion (hypovolaemic shock)
Decreased urine output, acidosis, altered LOC and elevated lactate level
4 Common causes of unconsciousness
- profound hypoxia
- hypercapnia
- cerebral hypoperfusion
- recent administration of sedatives or analgesic drugs
What scale can be used as a quick assessment of disability in addition to checking the pupil size, symmetry and reactivity
AVPU -
Alert
Responsive to voice
Responsive to pain
Completely unresponsive
What does a deteriorating AVPU require of the clinician?
Reassessment of the ABCs and interventions to maximise brain perfusion and oxygenation and avoid secondary brain injury
In the presence of other evidence for head injury (e.g. altered AVPU/GCS) a dilated pupil is usually a sign of what?
A haematoma on the same side
What 3 things make up Disability assessment?
- LOC - using AVPU
- Check pupils
- Check BGL
Trauma clients are prone to hypothermia. What should be done after completing the primary survey?
Cover them in dry warm blankets
In trauma, why must the whole body including the back and genitals be examined?
- to exclude life-threatening injuries
- to check for signs that would indicate a contraindication to inserting an IUC
Reminder: the WHOLE body, including the following body parts, should be examined during Exposure/Environmental control to prevent life-threatening injuries to be missed.
However, most commonly the client is log rolled in the secondary survey so only do this during the primary if:
Back of head
Buttocks
Back
Perineum
Axillae
Skin folds
If the condition of the client requires it to be done during the primary survey (e.g. large amounts of blood underneath the client, disruption to sensation or movement) or there are enough people to do a log roll
Why should clients be re-evaluated at regular intervals?
Deterioration in a client’s clinical condition can be swift. If in doubt, repeat ABCDE
What is involved in a full set of vital signs?
- RR
- Pulse
- Temp
- manual BP (+/- both arms)
- BGL (if not done previously)
- GCS and neurovascular observations if appropriate
When should you do neurovascular observations?
On any client in which there is concern about the status of a limb. E.g. any pale, cool limb, any limb with an obvious fracture or deformity and any limb subject to trauma either blunt or penetrating
When should you include a GCS in secondary survey?
On any client with a suspected head injury or altered LOC. however it is easy to do a baseline GCS regardless of MOI.
What is one of the earliest signs of shock? What are other signs?
Earliest - narrowing pulse pressure (systolic minus diastolic)
- Incr. HR
- Decr. BP
- Incr. RR
- Decr. SpO2
- central cap refill of >2s
What should you do if at the secondary survey there is any deterioration in a parameter?
Re-assessment of ABC.
6 focused interventions of secondary survey
- pulse oximetry
- cardiac monitoring
- IDC (if not contraindicated)
- gastric tube (oro or naso)
- point of care pathology investigations (CG4, chem 8, troponin if indicated)
- lab specimens (urine, blood, swabs)
Physical pain relief measures
- Splint fractures (back slabs, box splints, inflatable splints, bits of wood, pillows, rolled up paper)
- Cool/hot packs, cold water
- Dressings to open wounds/burns
- Touch (stroking, massage)
- TENS
Others (used in Resus phase):
- provide reassurance
- provide info and explanation
- presence of family/friends allowing choices and control where possible
- diversion/relaxation strategies (deep breathing, meditation, imagery, music)
6 pieces of info that should be included when obtaining a History
- MOI (for probable injuries)
- Use of protective devices (e.g. seat belt, helmet, child seat)
- Time elapsed before the client received medical attention
- Injuries sustained or suspected by first responders. Initial responsiveness, any loss of consciousness, any seizure activity. Vital signs. Treatment (received prior to arriving at the clinic and response to those)
- Medic alert bracelet or other medical identification. If you are at the client’s home, look for medication bottles.
- The client’s age and previous general state of health
Head to Toe assessment:
What are you looking, listening and feeling for?
Deformities, contusions, abrasions, rashes, punctures, pain, pulses, burns, tenderness/pain, lacerations/leaks, swelling, needle marks, loss of peripheral pulses, swelling, deformity, impaired movement.
Sequence of Head-to-Toe assessment.
Use PPE:
Head
Neck
Chest
Abdomen
Pelvic region and genitals
Upper and lower limbs
Followed by Inspection of posterior surfaces (log-roll)
What is included in Inspection of posterior surfaces?
What to do if there are insufficient people for a log roll?
- Look for abrasions, lacerations, bleeding or penetrating injuries.
- Listen to lung fields
- Palpate the spine for any tenderness or steps between the vertebrae
Slip a gloved hand under the back of the neck, the small of the back and under the knees. Check for blood on withdrawing the hands. Take care in the presence of glass or other sharp objects.
Jot it down: what should documentation include?
- Date and time
- Demographic information (name, DOB, address, gender, etc.)
- A short history from DeMIST and AMPLE
- Primary survey (findings and interventions)
- Secondary survey (findings and interventions)
What 3 things are address in the secondary survey?
- Injuries are detected and accurately documented
- Urgent treatments, such as covering wounds and splinting fractures are provided
- Appropriate analgesia, antibiotics or tetanus immunisations are ordered
3 things to do following the secondary survey
- Reassess ABCDE and vital signs, ongoing
- Continual monitoring
- priorities for further investigation and treatment may now be considered and a plan for definitive care established
Four basic principles for best outcomes in any emergency situation
- Preparation:
- prepare for the worst; focus on communication, role delegation, working within your scope of practice and local protocols;
- early notification to a retrieval network - Assessment and response:
- Send for extra help early, consider calling for assistance from colleagues, ambulance backup, emergency services, or activating emergency response teams if available
- Always consider MOI
- Seek info from the scene, bystanders and emergency responders, and the client
- treat life-threatening injuries as you identify them
- Fluid resus to preserve vital organ function until bleeding can be controlled
- control temp to avoid hypothermia
Review and Monitor:
- Complete primary survey, quickly recap the info you have and reassess ABCDE
- At completion of the secondary survey, reassess ABCDE and vital signs (ongoing)
- Document and complete Early Warning Tools
Transfer to Definitive care
- effective and efficient communication is critical
Which body region is commonly injured in major trauma but is difficult to diagnose and manage?
Abdomen. A high index of suspicion should be maintain for any multi-trauma client.
What are 6 examples of blunt trauma?
MVAs, falls, assault, industrial accidents, blast force and sports-related injuries
What are patterns of injury influenced by? (4)
- Age (>55 or a child <16)
- MOI
- Pregnancy
- Significant comorbidity (e.g. 1+ of diabetes, epilepsy, cardiac failure, angina, acute MI, symptomatic chronic obstructive airway disease, renal/liver failure, chronic liver disease, congenital coagulopathy)
Which MOIs indicate the need for careful evaluation of the client (due to high energy transfer)? (10)
- Vehicle crash over 60km/h
- Major deformation of the vehicle, entrapment >30mins
- Fatal injury in the same vehicle, ejection from the vehicle
- Fall from over 3m
- Unrestrained child in a MV crash
- Any mechanism causing injuries to multiple body regions
- Cyclist or pedestrian hit by a vehicle at over 30km/h, driveway run-over injuries
- CHILDREN: drive-way run-over injuries
- CHILDREN: caustic ingestion - liquid or powder
- Motorcyclist accident
What injuries would you expect from a fall of 5m from a building by a 42y/o male?
- Spinal injuries
- Fractures to lower or upper extremities
- Fractured ribs
- Fractured pelvis/hip
- Pulmonary injuries (pneumothorax/haemothorax or pulmonary contusion)
- abdo injuries
Types of energy (5) related to MOI
Kinetic, thermal, electrical, chemical, nuclear.
Paediatric considerations with respect to MOI
- Different injuries due to size and anatomy
- Hit by car: abdo injuries vs fractured long bones (adult) due to height
- Blunt trauma: significant injury to underlying tissues w/out fracture (due to cartilaginous bones) vs fracture in adults. NB lack of # does not mean absence of injury, esp. in chest trauma
3 types of compressive forces involved in MVAs
- Vehicle collides with an object
- Occupant collides with the car interior
- Internal organs/tissues of the occupant collide causing rupture, shearing and bruising
When approaching an MVA scene, what should you observe to provide cues that may indicate the MOI? What should you pay attention to? (5) With children, what should you pay attention to? (3)
- Approaching scene, observe any skid marks and the situation of the car. Use all senses to notice any hazards and any victims that have been ejected or thrown from the vehicle
- Pay attention to: speed of vehicle, point of impact, type of impact, position of vehicle, use/non-use of restraints
- Children: wearing protective equipment such as helmets, knee guards, etc? Correct helmet size? Correct size car restraint for age/weight?
Predictable injuries: restrained driver or front seat passenger in MVA
Clavicle, sternum, cardiac injuries, diaphragmatic rupture, bruising/laceration of the liver/spleen/pancreas, pelvic injuries and bruising of the lower abdo, breast and shoulder.
Predictable injuries: unrestrained driver or front seat passenger in MVA
Head injury, facial injuries, cervical spine injury, larynx, clavicle, sternum, abdominal injuries, cardiac contusion, pelvic and lower limb injuries
Adult pedestrian hit by car - potential injury sites
Patella, tibia, fibula
Potential injuries resulting from side impact of someone in car in MVA
- Head jerked laterally (towards side of impact)
- Fractured clavicle
- Flail chest
- Fractured femur
