Skills Flashcards
101.02 Oropharyngeal Airway (OPA)
Aim:
Maintain patency of the upper airway in an unresponsive patient without a gag reflex.
Indications:
1. Unconscious patient
2. Loss of "cough and gag" reflex
3. Upper airway obstruction due to backward
displacement of the tongue.
Complications:
- Vomiting if intact gag reflex
- Laryngospasm: spasm of vocal chords
- Improper size or technique may obstruct airway.
NB
Measure incisors to angle of their jaw.
101.03 Nasopharyngeal Airway (NPA)
Indications:
Upper airway obstruction, especially where oral airway cannot be used:
1. Trismus
2. Seizures
3. Severely swollen tongue (Anaphylaxis)
4. Injuries to the mouth.
Complications:
- Epistaxis
- Nasal injury
- If suspect a base of skull fracture, use with caution,
NB
Measure earlobe to tip of nose.
Tolerated well where a slight gag exists such as drug or alcohol overdose.
Pass Y suction cathether down airway lumen to aspirate secretions from posterior pharynx.
101.04 Cricoid Pressure
Indications:
1. To prevent reflux of gastric contents and pulmonary
aspiration during endotracheal intubation.
2. To provide a clearer view of the vocal chords during
difficult intubation.
101.05 Intubation
Aim:
To provide artificial ventilation and protect against soiling in an unconscious patient.
Aim to intubate within 10sec, do not keep trying beyond 20sec.
Indications:
Unconscious patient with either:
1. Absent cough/gag reflex
2. Hypoventilation with hypoxia
Complications:
1. CO2 detector remains purple after 6 ventilations.
2. Patient remains hypoxic after intubation and ventilation
with 100% oxygen.
3. An air leak persists or excessive inflation of cuff is
necessary.
4. Absent breath sounds or inadequate chest movement.
5. Gastric distension.
6. Bag valve head has no expiratory noise.
If there is any doubt as to placement, deflate cuff and remove ETT.
- Dislodgement/Malposition into oesophagus, oro-pharynx
or right main bronchus. - Obstruction.
- Trauma
- Interference with physiological functions.
- If left chest does not expand ?pneumothorax or
?endobronchial placement. - Hyperventilation can lead to hypocapnia and
hypotension due to increased intrathoracic pressure
decreasing venous return.
NB
Paediatric tube size: (Age/4) + 4
Position Ear to Sternal Notch for non trauma patients.
Occipital pad and neutral position for trauma patients.
Padding under shoulders for paediatrics.
Ensure stylet does not protrude beyond tip of ETT or it may perforate trachea.
If chords are not readily visualised abort attempt and re-ventilate (2 min between attempts)
External Laryngeal Manipulation (ELM) may include Backwards Upwards Rightwards Pressure (BURP)
Prolonged attempts to intubate = hypoxic brain injury if the patient is not being ventilated and oxygenated by other means.
101.6.1 i-gel Supraglottic Airway
Aim:
To establish and maintain a clear airway in unconscious patients with absent cough/gag reflex and/or hypoventilating.
Complications:
1. Insert with care in cases of severe facial and airway
trauma.
2. Do not attempt insertion in cases of trismus or limited
mouth opening.
3. Do not use excessive force.
4. Insert with care in cases of fragile or vulnerable dental
work.
5. Remove ill-fitting dentures before attempting insertion.
Do NOT use gastric channel if:
- Excessive air leak through gastric channel.
- Oesophageal trauma
- History of upper gastro-intestinal surgery.
- Bleeding/Clotting abnormalities.
NB
Select an i-gel size commensurate with ideal body weight for height rather than actual body weight.
No more than three attempts in one patient.
101.07 Extubation
Indications:
If patient’s condition improves and indications for intubation are no longer present and the patient is physically trying to remove the tube then extubation must be considered.
NB
1. Patient in lateral position breathing 100% oxygen.
2. Suction with Yankauer sucker.
3. Fully deflate endotracheal cuff, check pilot balloon.
4. Suction trachea.
5. Cut tie-in tape.
6. Tube is gently withdrawn upon full inspiration assisted
by positive pressure on the Laerdal bag.
7. Oxygen therapy on high concentration mask.
101.08 Intragastric Tube
Indications:
Gastric distension with air or fluid eg near drowning or poorly performed EAR which can cause:
1. Increased risk of regurgitation.
2. Fluid absorption and consequent fluid overload.
3. Interference with breathing or IPPV especially in
children.
4. All intubated children about to receive IPPV.
5. Continuous vomiting.
6. Transport of neonates, spinal injuries, abdominal
problems - especially by air.
Contraindication:
With suspected fractured base of skull and facial injuries, the tube must be inserted through the mouth and not the nose.
NB
Measure distance from tip of nose to earlobe to xiphoid process (of sternum) which gives the approx. length required to enter the stomach.
101.09 Relief of Upper Airway Obstruction - Magill’s Forceps
Indication:
Removal of foreign body from airway where back blows and chest thrusts have failed.
Complications:
- Vomiting
- Laryngospasm
- Trauma to:
- Lips, teeth and tongue
- Pharynx, Larynx
- Epiglottis
Contraindications:
Conscious patient.
101.10 CO2 Detector
Indication:
Used to assist verification of Endo-Tracheal Tube (ETT) placement during endotracheal intubation.
NB
1. Detector must be purple when opened.
2. Attach viral filter to ETT and ventilate 6x to remove any
residual CO2.
3. Attach CO2 detector to viral filter then attach flexible
connector.
4. Colourimetric capnometers may be unreliable in very
low cardiac output states (ie oesophageal intubation
may not be detected in cardiac arrest).
5. Detector will only indicate CO2 for ~2hrs.
6. Detector may fail if it comes in contact with gastric
contents, secretions, fluids or drugs admin via ETT.
7. Pt who have consumed carbonated drinks may deliver
an erroneous reading, 6x ventilations to flush excess
CO2.
101.11 ETT Tracheal Suction
Indication:
To remove secretions from trachea.
Complications:
1. Hypoxia leading to potential cardiac arrhythmias and
fitting.
2. Tracheal mucosa trauma.
Contraindications:
Do suction pink frothy sputum within an ETT caused by cardiogenic pulmonary oedema, keep ventilating to maintain alveoli pressure and decrease pre-load.
101.12 Upper Airway Obstruction - Back Blows
Indication:
Upper airway obstruction due to foreign body in the conscious patient with an ineffective cough.
NB
1. Aim is to free the obstruction rather than give all back
blows.
2. Adults and larger children can be treated in the seated
or standing position.
3. Children and infants should be placed in a face down
position.
101.13 Upper Airway Obstruction - Chest Thrusts
Indication:
Upper airway obstruction due to foreign body in the conscious patient with an ineffective cough and back blows have been unsuccessful.
NB
1. Aim is to free the obstruction rather than give all chest
thrusts.
2. Adults and larger children can be treated in the seated
or standing position whilst conscious.
3. Children and infants must be placed in a face up
position.
101.14 Oral Suction
Aim: Remove fluid (saliva, vomit or blood) from the oropharynx.
Complications:
1. Hypoxia: be mindful of duration of suctioning (no more
than 10sec) and time between suction attempts.
2. Trauma to teeth, tongue, oropharynx and bleeding.
3. Vomiting or laryngospasm.
4. Increased intracranial pressure.
5. Bradycardia / Hypotension due to stimulation of the
vagal nerve.
NB
1. Maintain direct visualisation of the tip of the suction
catheter.
2. DAACC: MUST be swivelled to vertical and valve must
be ‘ON’.
3. Medi-Vac wall mount: turn ignition and master switch
‘ON’, activate suction pump on wall control panel, turn
white lever ‘ON’.
4. Head Injury: suctioning in a pt who already has a raised
intracranial pressure/intracranial bleed must be
performed with discretion and care.
5. Should a pt with CCF present with pink frothy sputum,
do not persist with suctioning, treat the cause instead
per protocol.
101.15 EMMA Capnograph
Aim:
To measure display and monitor End Tidal Carbon Dioxide (EtCO2) and respiratory rate during airway management:
- confirm correct placement of ETT
- Identify malposition
- titrate ventilations to maintain correct ETCO2 readings
NB
1. EMMA can be attached to ETT, LMA, BVM
2. Normal EtCO2 = 35 - 45mmHg
3. EtCO2 with effective ECC should display 15 - 20mmHg
4. Application of EMMA is mandatory for ALL intubated
patients.
5. Asthma/COPD post cardiac arrest or in respiratory
arrest EtCO2 may be high (greater than 80 - 100mmHg)
and ventilation may be difficult due to gas trapping.
These pt are prone to barotrauma and
pneumothoraces.
6. Normal tidal volume 7-10ml/kg. If pt is
hyper/hypocapnic maintain tidal volume but adjust RR
to compensate.
101.16.2 Video Laryngoscopy
Aim:
To provide visualisation of the glottis in unconscious patients for:
1. Removal of foreign body
2. Placement of oral endotracheal tube
3. Assist in insertion of intragastric tube
Complications:
1. Potential to alter multiple physiological parameters eg
vagal stimulation, intracranial pressure.
2. Trauma to the lips, teeth, tongue, pharynx, larynx and
trachea.
3. Hypoxia with prolonged laryngoscopy
4. Stimulation of gag reflex and vomiting.
5. Laryngospasm.
NB
Strongly consider this to be a two-clinician procedure: form an airway team.
Supine with sufficient ramping of the pt head to achieve ear to sternal notch alignment.
Remove dental prosthetics immediately prior to laryngoscopy (leaving them in situ will assist with mask seal in BVM).
To provide situational awareness to the team articulate as you perform the skill: Anatomy (posterior cartilages, interarytenoid notch, glottic opening, vocal chords), Issues (swelling, trauma, bleeding, fluids).
Establish and verbalise airway plan.
Laryngoscopy is an aerosol generating procedure!
102.1 Inspiratory Assistance
Indication:
- Hypoventilation
- Severe Pulmonary Oedema
Complications:
1. Gastric Distension
High pressure ventilation can lead to inflation of the
stomach by overcoming the resistance of the cardiac
sphincter. This can cause gastric regurgitation and
increase pressure on the diaphragm.
2. Barotrauma
High pressure ventilation can cause pressure injury to
the lung leading to subcutaneous emphysema and
pneumothorax. IPPV can convert a simple
pneumothorax to a tension pneumothorax in patients
with chest injuries.
3. Hypotension
IPPV raises intra-thoracic pressure and decreases
venous return especially if the pt is hypovolaemic.
NB Ventilation rates Adult 10-15 bpm or 1 breathe : 4-6 sec Children 20 bpm or 1 breathe : 3 sec Infant 40 bpm or 1 breath : 1.5 sec
102.1.1 Bag Valve Mask Resuscitation
Indication:
- Hypoventilation
- Severe Pulmonary Oedema
Complications:
1. Gastric Distension
High pressure ventilation can lead to inflation of the
stomach by overcoming the resistance of the cardiac
sphincter. This can cause gastric regurgitation and
increase pressure on the diaphragm.
2. Barotrauma
High pressure ventilation can cause pressure injury to
the lung leading to subcutaneous emphysema and
pneumothorax. IPPV can convert a simple
pneumothorax to a tension pneumothorax in patients
with chest injuries.
3. Hypotension
IPPV raises intra-thoracic pressure and decreases
venous return especially if the pt is hypovolaemic.
NB
Ventilation rates
Adult 10-15 bpm or 1 breathe : 4-6 sec
Children 20 bpm or 1 breathe : 3 sec
Infant 40 bpm or 1 breath : 1.5 sec
Viral/Bacterial (Heat and Moisture Exchange: HME) filter between bag and mask.
Pressure release valve uncapped.
Diverter turned away from operator.
Effectiveness: Observe both sides of chest rise and fall
Auscultate
Waveform capnography
102.02 Oxygen Administration
Indication:
1. Respiratory distress or hypoxia
2. Supplement in illness or injury to maintain tissue
oxygenation.
3. Simultaneous administration of other medications eg
Midazolam or Morphine
4. Obstetric and Diving Emergencies
5. Drive gas for the administration of nebulised
medications.
6. Hyperventilation.
Indications for 100% Oxygen Therapy:
1. Severe hypoxic states ie pt still confused, cyanosed on
15L/min via NRB.
2. Carbon Monoxide poisoning.
3. Venous air embolism.
4. Obstetric emergencies.
5. Diving emergencies.
Complications:
1. May cause hypoventilation in CAL pt dependent on a
hypoxic drive.
2. Increases risk of fire and/or explosion.
102.4 Decompression of Tension Pneumothorax
Aim:
Release of positive pleural pressure.
Indication:
1. Single tension pneumothorax: decompress injured
side.
2. Chest injuries with major trauma where pt is in a peri-
arrest state: urgent bilateral decompression.
3. Traumatic cardiac arrest with actual/suspected chest
injuries: urgent bilateral decompression.
Signs a pt with major chest trauma requires decompression:
1. Increasing respiratory effort and/or signs of
deteriorating respiratory function.
2. Haemodynamic instability.
3. Decreasing LOC - AVPU.
4. Increasing subcutaneous emphysema.
NB
Insertion point: mid-clavicular line, 2nd intercostal space above the 3rd rib.
Second rib articulates with sternum at angle of Louis.
Swab site then make 2-3mm long incision so Teflon sheath doesn’t catch on skin during insertion.
Advance while aspirating. When air/blood aspirated advance another 1cm then hold syringe and advance sheath to the hub.
Secure with Tegaderm or ECG electrode dots then withdraw needle.
All pt MUST have Heimlich valve (attach to blue end)
Once chest decompressed DO NOT remove cannula.
Even if misdiagnosis, leave cannula in-situ with connecting tube and Heimlich valve.
If catheter occludes and pt deteriorates, re-decompress beside existing site.
102.04.1 Decompression of Tension Pneumothorax - Russell Pneumofix
Aim:
Release of positive pleural pressure.
Indication:
1. Single tension pneumothorax with respiratory, cardiac
and/or haemodynamic compromise: decompress
injured side.
2. Chest injuries with major trauma where pt is peri-
arrest: immediate bilateral decompression.
3. Traumatic cardiac arrest with actual/suspected chest
injuries: immediate bilateral decompression (most
injured side first).
Signs a pt with major chest trauma requires decompression:
1. Increasing respiratory effort and/or signs of
deteriorating respiratory function.
2. Haemodynamic instability.
3. Decreasing LOC - AVPU.
4. Increasing subcutaneous emphysema.
NB
Insertion point: mid-clavicular line, 2nd intercostal space above the 3rd rib (to avoid intercostal neurovascular bundle)
Swab site then make 2-3mm long incision.
Insert at 90 degrees to chest.
Observe sudden movement of green indicator towards pt.
Push 1cm further into chest.
Aspirate syringe to detect air and confirm pleural space has been reached.
Advance catheter 2-3cm off end of needle.
Hold catheter in position (by hub marked “prometheus”) and withdraw needle.
Secure catheter to chest.
Once chest decompressed DO NOT remove cannula.
Bilateral decompression? Decompress most injured side first.
Use care in pt under 50kg.
Continual re-evaluation of cannula and site (recurrence of pneumothorax).
Heimlich valve not required!
102.07 Expiratory Assistance
Indication: Asthmatic patients presenting with severe dyspnoea: - chest will not deflate - extremely high inflation pressure - little or no air movement
Complications:
- Fractured ribs
- Hypotension
102.08 Peak Flow
Peak Expiratory Flow Rate (PEFR) :
1. Maximum speed of expiration and ability to expel air.
2. Measures airflow through bronchi and degree of
obstruction in the airway.
Performed on initial assessment and post medication administration.
Pt to stand/sit Deep full breath Lips tightly around mouthpiece Exhale forcefully Repeat twice (3x all up) Record highest score Allow to air dry after washing.
102.9 CPAP
Aim:
Increase residual functional capacity by providing continuous positive pressure during respiration.
Aids alveoli recruitment improving gas exchange.
Increases intra-thoracic pressure (reducing preload and afterload) to improve cardiac function in cardiogenic pulmonary oedema.
Indication:
1. Stable + basal crackles: if no response to O2, GTN +/-
Frusemide.
2. Increased WOB + mid zone to full field crackles:
concurrently with pharmacology.
Contraindications:
- LOC = P or U
- SBP < 90mmHg
- Hypoventilation
- Facial trauma
- Epistaxis
- Pneumothorax
- Active vomiting
Complications:
- Aspiration
- Gastric distension
- Hypotension
- Corneal drying
- Barotrauma
Warning:
1. Don’t with-hold treatment (GTN, O2) while initiating
CPAP.
2. Don’t occlude inlet of CPAP device where O2 tubing is
connected.
3. If pt increasingly distressed/agitated despite
reassurance and is unable to tolerate mask, it should be
removed and CPAP ceased.
NB Monitor: ETCO2 using nasal cannula capnography. SpO2 RR WOB Breath Sounds BP Mask : viral/bacterial filter : vectored flow valve : oxygen tubing. Discontinue if pt deteriorates (decr. LOC or ineffective ventilations) and commence IPPV 100% O2 via BVM.
102.10 PEEP
Positive End Expiratory Pressure PEEP:
maintains a small amount of pressure at end of expiration which increases functional residual capacity (FRC) reduces alveolar collapse and improves oxygenation.
Indication:
1. Acute Pulmonary Oedema - hypoventilating or poor
tidal volume.
2. CPAP Contraindicated (LOC= P or U)
Contraindications:
- Cardiac arrest
- SBP <90mmHg
- Pneumothorax
Complications:
- Aspiration (if using IPPV)
- Gastric distension
- Hypotension
- Barotrauma
- Pneumothorax
Warning:
1. Do not exceed 15cmH2O, PEEP greater than this =
significant risks for pt with compromised cardiac output.
2. PEEP may reduce venous return in shocked pt due to
increased pressure in the lungs.
3. Caution if PMHx of asthma or COPD, higher air
pressures can lead to gas trapping and barotrauma.
NB if SpO2 not improving increase PEEP every 3-5min to a max of 15cmH2O. Monitor: ETCO2 using inline capnography. SpO2 RR WOB Breath Sounds BP
103.1 Haemorrhage Control: Arterial Tourniquet
Indications:
Haemorrhage (Hhg) control where
1. Extreme life threatening arterial limb Hhg due to
penetrating trauma or limb amputation.
2. Limb arterial Hhg not controlled by direct pressure.
3. Hhg inaccessible and life-threatening arterial Hhg
suspected e.g. trapped.
4. Mass/Multiple casualties with life threatening arterial
Hhg in triage mode where direct pressure cannot be
provided without compromising other patients.
NB
Direct pressure (digital is better) : Elevation : Tourniquet
Tourniquet = pain, pt will require strong analgesia after application of tourniquet.
Reassess and tighten or add another proximal to first as required.
Tourniquet remains in place until arrival at definitive care. If loosened: possible reperfusion injury causing hypotension or pain causing hypertension.
Ensure appropriate PPE.
103.2 Cardiac Arrest Principles
Principles:
1. Immediate high-quality chest compressions + reduce
time to defibrillation = priority.
2. Minimise interrupts to compressions, rotate roles every
2min.
3. Teamwork + designate team lead.
4. Initial phase (up to 6min) of cardiac arrest with minimal
resources focus on effective chest compressions and
defibrillation.
Indications: Perform C-A-B (circulation, airway, breathing) 10s assessment. Cardiac Arrest Criteria: 1. Unconscious. 2. Absent / gasping respirations. 3. Absent central pulse.
NB
- 360degree access.
- Notify Control Centre Code 2 + request resources.
- Standardised equipment placement.
- Setting up defibrillator shouldn’t interfere with effective
chest compressions.
- 2 minute timer + metronome.
- Rotate compressor every 2 min.
- Tactile tap on / tap off.
- Chest pulse ONLY to differentiate between PEA/ROSC
with potentially perfusing rhythm.
- Bougie assisted intubation.
- Ventilate on room air if attaching O2 causes a delay.
- 2 person BVM only if difficulty achieving a seal.
- Compressions continue if any delay ventilating pt.
- BVM : pause compressions to allow ventilations.
- i-gel, ETT : no pause between compressions.
- Tidal volume: 4-6ml/kg. Minimal chest rise = good
indicator of adequate ventilations.
>=9y.o 30:2
0-9 15:2
Newborn 3:1
- Event mark medications.
- Use the HP-CPR checklist.
- Phase change: pause and reassess plans and task
allocation.
- Identify team leader: temporary delegation when
undertaking complex tasks.
- Closed loop exchange of information.
- Graded assertiveness.
REVERSIBLE CAUSES (HHHHTTTA): Hypoxia Hypovolaemia Hyperkalaemia Hyper/Hypothermia Tension Pneumothorax Thrombosis Toxins/poisons/drugs Anaphylaxis
ROSC:
- Palpable central pulse.
- Turn off metronome.
- Full primary assessment.
103.4 Chest Compressions
Indication:
1. Cardiac arrest (unconscious, absent or gasping
respirations and absent central pulse).
2. Children 1-8 : unconscious with pulse < 40.
3. Children < 1 : unconscious with pulse < 60.
Patients with ventricular assist devices VAD may not have pulses, perfusion determines treatment.
NB
Palms off chest to ensure full recoil. Coronary perfusion occurs during recoil phase of CPR.
Compression : Ventilation ratios
>= 9 yrs old is 30:2
0-8 yrs old is 15:2
Newborn is 3:1
103.5.4 Lifepak - Defibrillation
Aim:
Safe and effective defibrillation in cardiac arrest with shockable rhythms.
Indication:
Cardiac Arrest : unconscious, absent or gasping
respirations and absent central pulse.
NB
>=9 yrs : Anterior - Lateral pad placement
<8 yrs : Anterior - Posterior pad placement
>8cm from pacemaker / internal cardiac defibrillator [Consider Anterior - Posterior placement].
Person operating LifePak runs COACHED.
“Tap on” / “Tap off”
Use EVENT button to record interventions and medicine administration.
“print” “print” captures 3sec prior to memory.
peri-arrest? Apply pads but only connect to defibrillation cable if the pt arrests.
If unsure of rhythm with machine charged for shock and hands off chest, cancel charge, print 6s strip, recommence chest compressions while others interpret ECG printout…if VF/VT recharge and deliver shock, if not VF/VT continue CPR.
Deliver shock while looking at patient!.
103.5.5 Lifepak 15 Monitoring, Acquisition, Transmission
Aim:
Monitor patients with
1. Non cardiac pt using 4 leads e.g. trauma, asthma.
Progress to 12 lead where indicated.
2. All pt with suspected ACS.
NB
Transmit “Meets ST Elevation MI Criteria” and/or “Consider Acute Infarct”
DO NOT place limb leads on pt torso (deltoids and thigh)
Failed transmission (automatically redials 3x), check devices turned on and connected, transport and attempt another transmission from inside ambulance (10min later).
103.5.6 Lifepak 15 Non Invasive Monitoring
NIBP
NIBP measurement takes ~40sec
Initial default pressure is 160mmHg consider decreasing for paediatric pt.
Consider manual BP if NIBP reading appears unusually high/low.
ETCO2
Monitor performs auto zero routine as part of initialisation self-test, DO NOT connect ETCO2 FilterLine to pt ventilation system until monitor has completed self-test,
via nasal prongs, maximum flow rate 4L/min.
SpO2
Observe pulse bar fluctuation.
Preferred site: ring finger of non dominant hand.
Amplitude of pulse bar indicates relative signal quality.
Use HIGH sensitivity setting for low perfusion states.
Code summary will detail HR, ETCO2, SpO2 each time NIBP taken.
Caution:
- DO NOT apply cuff to limb with fistula.
- DO NOT apply cuff on same side as mastectomy.
Apply cuff to contralateral arm to the:
- SpO2 sensor
- IV fluid/medication infusion site.
103.06 Synchronised Cardioversion
Aim:
To safely and efficiently convert tachy-dysrhythmias causing haemodynamic compromise into sinus rhythm.
Indication: Confim patient: 1. Unconscious (LOC = P or U). 2. Rhythm SVT or VT. 3. Haemodynamically compromised. 4. >= 16 yrs : Heart rate >= 160 5. 1 - <16 yrs : Heart rate >=180
Contraindications:
1. LOC = A or V.
2. < 1 yr of age.
3. ECG indicates Sinus Tachycardia, rapid Atrial Fibrillation
or Atrial Flutter.
NB Print/Record pre-shock rhythms. Limb leads can remain in situ and connected. Check for Pacemaker/ICD. Apply pads >25mm from pacemaker. >= 9 yr old Antero-Lateral placement <9 yr old Antero-Posterior placement Confirm SYNC & sync marker appears on R wave.
Joules >= 16 yrs old:
1st shock - 100 joules
2nd shock - 150 joules
3rd shold - 200 joules
Joules 1 - < 16 yrs old
1st shock - 1 joule/kg
2nd shock - 2 joules/kg
3rd shock - 4 joules/kg
Immediate defibrillation if VF or pulseless VT.
Print/Record post-shock rhythms.
PMHx is important to differentiate SVT. Tachycardia with hypotension is more likely to present from: 1. Hypovolaemia 2. Anaphylaxis. 3. Sepsis 4. Tension Pneumothorax
Adult > 180 likely to be SVT.
Adult ~150 may be SVT but more likely to be a mimicker.
103.10 Valsalva Manoeuvre
Aim:
Management of SVT (rapid narrow QRS complex < 0.12s) in conscious pt (LOC=A or V) and symptomatic where other causes of tachycardia have been excluded.
Reversible causes of Tachycardia:
- Torsades de Pointes
- Anaphylaxis and Allergic reactions
- Sepsis
- Hypovolaemia (medical or trauma)
- Tension pneumothorax.
Contraindications:
Do not perform Carotid Sinus massage due to risk of brady-dysrhythmias or possible dislodgement of carotid plaque potentially leading to stroke.
NB Explain procedure. IV access. ECG continuous monitoring and document start/end of procedure on ECG. 45deg angle Syringe plunger 1/2 way Blow 15s Cease abruptly Elevate legs 45deg for 45s Repeat once.
Alternatively:
Interlock curled fingers.
Hold deep breath.
Try to pull hands apart for 15s
Beware SVT mimickers
- Dehydration
- Hypovolaemia
- Sepsis
- Exertion
- Medications/Drugs
103.11 Ventricular assist / Mechanical Heart devices
Aim:
Awareness for management of significant presentation, physiological and treatment differences with implanted devices.
NB
Default to pt/carers providing expert guidance/advice for treatment/management.
Confirm connections and battery status.
Default to primary treating hospital (bypassing others). Transport > 1-2hrs consult with AMRS.
Pt with LVAD/artificial heart not eligible for VOD by paramedics.
Primary Assessment: Perfusion determines treatment. 1. Check flow rate 2. Pulses may not be present. 3. Pulse oximetry may not be accurate. 4. Blood pressure cannot be measured. 5. Pt may be in VF but conscious.
Treatment Algorithm:
1. Commence CPR if flow < 1.5L/min
2. VF : DO NOT defibrillate if conscious! Only if
unconscious with prolonged VF and flow rate <
1.5L/min.
3. Do not sedate for cardioversion.
103.12 Lucas Mechanical Chest Compression Device
Aim:
Safe and efficient chest compressions in medical cardiac arrest.
Contraindications:
- Traumatic cardiac arrest.
- Pt has known “not for resuscitation” status.
- Pt <9 yrs old
- Pt >= 9yrs old and too small / large for Lucas to fit.
- Pt has Ventricular Assist Device VAD insitu.
103.13 Transcutaneous Pacing
Aim:
Management of haemodynamically unstable symptomatic bradycardia (>=16 yrs old) unresponsive to IV Atropine and Adrenaline Infusion.
Indications:
- > = 16 yrs old.
- HR < 40 bpm and haemodynamically unstable i.e.
- BP < 90mmHg
- Poor skin perfusion.
- Poor cerebral perfusion.
- Pt has failed to respond to pharmacology.
Contraindications:
- Pt in cardiac arrest in Asystole / PEA.
- Overdrive pacing of a ventricular dysrhythmia.
- <16 yrs old.
- Haemodynamically stable.
- HR >= 40
- Unable to complete Conscious Sedation Checklist.
NB
- 12 lead ECG, limb leads must remain in situ (if not
connect Lifepak will revert to Non Demand pacing).
- Check for pacemaker/ICD.
- Explain procedure.
- Pad placement: Antero-Lateral preferred, and >8cm
away from pacemaker/ICD.
- IV line (preferrably 2x)
- Medication for conscious sedation.
- IV fluids TKVO
- 1:10 000 Adrenaline drawn up in case of TCP failure.
- Complete Conscious Sedation Checklist.
- Do not cease Adrenaline infusion until confirmed
mechanical capture. - If TCP fails resume Adrenaline infusion and consider
Adrenaline IV bolus per pharmacology. - Starting rate 80PPM
- Starting current 30mA
- Increase current slowly to achieve electrical capture,
then increase as required to achieve mechanical
capture, then set current 10mA above minimum
mechanical capture threshold. - Electrical Capture: Wide QRS complex following the
pace marker. - Mechanical Capture: increased LOC, palpation of a
radial/femoral pulse, improvement in cardiac output /
SpO2.
Most common reasons for failure to pace:
1. Failure to increase current high enough to obtain
electrical capture.
2. Failure to confirm presence of mechanical capture
(increasing LOC and a radial/femoral pulse that
matches the speed of pacing).
3. Failure to monitor patient to ensure ongoing
mechanical capture.
Post initiating pacing provide analgesia as required/indicated. Pt should only require conscious sedation if distressed by the process.
103.15 Cardiac Arrest Principles - Trauma
Principles:
1. Three common causes of preventable early death in
trauma:
- Haemorrhage.
- Airway obstruction and inadequate ventilation.
- Tension pneumothorax.
2. In cardiac arrest due to trauma, correction of the
reversible causes (above) should have priority over
chest compressions. However, if sufficient resources
available then chest compressions can be performed
simultaneously provided they do not interfere with
treatment of suspected reversible causes.
3. Unless injuries are incompatible with life, resuscitation
of traumatic cardiac arrest is not always futile and
should be attempted.
NB
- Confirm traumatic cause of cardiac arrest.
- Provide MIST + “Mechanism & traumatic code 2”
- If drowning, hanging, asphyxia, hypoxia or isolated head
injury : treat per medical cardiac arrest.
- Prioritise treatment using MARCHE algorithm:
M assive (external) haemorrhage control
A irway management
R espiratory
C irculation
H ead injury / H ypothermia
E verything else
Massive (external) haemorrhage: Arterial tourniquet or direct, sustained and forceful wound pressure. Airway Triple airway management + suction Circulation Pelvic binding Large bore IV/IO as a priority if exsanguination is a likely cause of cardiac arrest. IV fluids + blood products from medical team / nearby ED. Chest compressions. Head injury/Hypothermia Ventilation/Oxygenation : SpO2, EtCO2 IV fluids Remove pt from cold/Remove cold (wet clothing) from pt & dry pt. Minimise heat loss and warm pt Everything else Burns Crush injury
Reason to cease resuscitation: no ROSC after 20min following treatment of likely reversible causes.
Early code 3 BEFORE departing scene.
Do not delay transport waiting for backup to arrive.
Traumatic cardiac arrest due to penetrating trauma: early code 3 with treatment enroute.
101.01 Upper Airway Management
Aim:
To clear and maintain a pt airway.
Causes:
- Tongue falling back : decreased LOC / supine
- Foreign bodies
- Swelling
- Laryngeal spasm
Diagnosis: - Open and inspect mouth for obstruction - Listen + Feel for movement of air (Silence: complete obstruction Stridor: incomplete obstruction Noisy breathing is obstructed breathing) - Look + Feel for chest rise and fall - Look for paradoxical see-saw breathing
Remove foreign bodies:
- Back blows / chest thrusts
- Position lateral / turn head to side
- Sweep with tip of Yankauer sucker
- Laryngoscope / Magill’s forceps
- Oral suction
Triple Airway Manoeuvre:
- Hand on forehead, extend head.
- Hold chin between thumb and index finger, lift verticall
allowing mouth to open slightly.
- In spinal injury minimise extension but airway takes
precedence.
- Jaw thrust in place of chin lift if preferred.
- Jaw thrust can be used on pt with suspected spinal
injury.
- Positioning lateral is an effective form of basic airway
manoeuvre.
Regurgitation is the passive flow of stomach contents into mouth and nose. It is often unrecognised because it is silent.
In infants the trachea is soft and pliable and may become occluded with excessive head tilt. Padding under the shoulders may assist to achieve a neutral head position.
104.1.3 Genitalia - Breast Examination
A chaperone must be present for children and is advisable for adults.
Consent for genital/breast examination must be obtained from patient/parent/person responsible if child <14 yrs old.
Discuss potential needs/benefits with your partner.
Document that assessment was performed; name of person who provided consent; examination findings.
Reasons for assessment:
1. Multi trauma: affecting multiple regions, reveal then
cover as you go.
2. Localised trauma to genitalia/breast
3. Localised complaint: eg. rash/burns
4. Use of equipment e.g. 12 lead ECG
Use simple/age specific language and allow pt to verbalise their concerns.
Provide reason for examination + expected findings as well as a description of the procedure.
104.02 Pulse Measurement
Newborn 120-160 Infant 120-140 1-3 yrs 100-120 3-5 yrs 80-100 10-15 yrs 60-90
104.03 Chest Measurements - Palpation and Auscultation
Indication:
As part of pt assessment where measurement of respiratory status is indicated.
NB
- Explain procedure and posture the pt
- Observe adequate respiratory rate and depth.
- Equality of chest movement: thumbs bilateral mid-
clavicular line and observe rise and fall of both sides of
the chest.
- Assess accessory muscle use.
- Look and feel for lacerations, swelling, deformity,
tenderness, flail segments.
- Auscultate: pt to breath through the mouth, compare
pairs of auscultation points, min 2x breath cycles per
auscultation point.
104.04 Abdominal Assessment
Indication:
Examination of abdomen during secondary assessment.
NB
- Reassure and explain procedure.
- Posture supine, expose abdoment.
- Looking for lacerations, swelling, deformity, presence of
penetrating injury, distension, rigidity, tenderness.
- The most reliable indicator of intra-abdominal bleeding
is unexplained shock.
- Use fingers in a kneading motion, palpate across
quadrants from top working downwards.
104.05 Blood pressure measurement
Indications:
Where blood pressure of a pt is required.
NB
- Reassure and explain procedure.
- Elbow slightly bent, palm up.
- Do not take blood pressure on an arm with an
arterio/venous fistula, mastectomy or haemophiliac pt.
- Arrows on cuff over brachial artery.
- Width of cuff should be 2/3 size of pt upper arm.
- Inflate 30mmHg above cessation of peripheral pulse
(brachial or radial).
- Deflate slowly until pulse sounds begin (systolic)
continue until pulse sounds cease (diastolic).
104.07 Jugular vein assessment
Indication:
As required
NB
- Reassure and explain procedure.
- Posture 45 degrees, pt to turn head away.
- When not distended: occlude jugular where it emerges
above clavicle then remove pressure to determine
whether it remains distended.
104.9 Pulse Oximetry
Aim:
To determine the percentage oxygen saturation SpO2 in a patient’s arterial blood.
NB
- LEDs emit light at red (660nm) and infrared (905nm)
through the capillary bed to a photodiode detector.
- The amount of light absorbed by oxyhaemoglobin and
carboxyhaemoglobin in the blood determines the oxygen
saturation.
- The pulse oximeters used by NSWA do not differentiate
between oxyhaemoglobin and carboxyhaemoglobin. Any
pt with suspected Carbon Monoxide poisoning should be
administered 100% O2 regardless of SpO2 readings.
