Study Day Module 5 Flashcards
What are the signs of severe croup?
- agitation/distress
- cyanosis
- SPO2 <92% on air or decreasing SPO2
- Increased use of accessory muscles
- Increasing lethargy
What are the elements of the croup severity table?
- Behaviour
- Stridor
- Resp rate
- Accessory muscle use
- Oxygen
MILD/MODERATE/SEVERE
What are the elements of the paediatric asthma severity table
- Conscious state
- Work of breathing
- Tachycardia
- Speech
MILD/MODERATE
SEVERE
CRITICAL
What defines MILD/MODERATE severity on the paed asthma chart?
Normal CS, some increased WOB, tachycardia, speaking in phrases/sentances
CS = Normal WOB = Increased TACHYCARDIA = Tachycardia SPEECH = Phrase/sentance
What defines SEVERE severity on the paed asthma chart?
CS = Distressed WOB = Markedly Increased TACHYCARDIA = Tachycardia SPEECH = Phrase/sentanceords
What defines CRITICAL severity on the paed asthma chart?
Agitated/distressed, markedly increased WOB including accessory muscle use/retraction, tachycardia, speaking in words
CS = Altered WOB = Maximal TACHYCARDIA = Marked Tachycardia SPEECH = Unable
What defines CRITICAL severity on the paed asthma chart?
Altered CS, maximal WOB, marked tachycardia, unable to talk
CS = Altered WOB = Maximal TACHYCARDIA = Marked Tachycardia SPEECH = Unable
What are the elements of MILD Croup on the Paed croup severity table?
Behavior: Normal
Stridor: Barking cough. Stridor only when active or upset
RR: Normal
Accessory muscle use: None or minimal
Oxygen: No oxygen required
What are the elements of MODERATE Croup on the Paed croup severity table?
Behavior: Some/intermittent irratability
Stridor: Stridor at rest
RR: Increased resp rate, Trachael tug, nasal flaring
Accessory muscle use: Moderate chest wall retraction
Oxygen: No oxygen required
What are the elements of SEVERE Croup on the Paed croup severity table?
Behavior: Increasing irritability and/or lethargy
Stridor: Stridor present at rest
RR: Marked increase or decrease in RR, Trachael tug, Nasal flaring
Accessory muscle use: Marked chest wall retraction
Oxygen: Hypoxaemia (late sign)
What are the key steps in the Normal Birth CPG?
- Imminent normal birth preparation
- Birth of head
- Umbilical cord check
- Head rotation
- Birth of shoulders and body
- Clamping and cutting the cord
- Birthing placenta (third stage)
What are the steps for ‘Imminent normal birth preparation’ in the normal birth guideline
- Reassure including cultural considerations
- Prepare equipment for normal birth
- Provide a warm and clean environment
- Provide analgesia as per pain relief guidelines
What are the steps for ‘birth of the head’ in the normal birth guideline
- As head advances encourage mother to push with each contraction
- If head is birthing too fast, ask mother to pant with an open mouth during contractions instead
- Place fingers on baby’s head to feel strength of descent of head
- Apply gentle pressure to the perineum to reduce the risk of perineal tears
- If precipitous, apply gentle backward and downward pressure to control sudden expulsion of the head. DO NOT HOLD BACK FORCIBLY
- Note time once head delivered.
What are the steps for ‘Umbilical cord check’ in the normal birth guideline
- Following birth of head check for umbilical cord around the neck
- If loose and wrapped around neck:
- > slip over baby’s head with appropriate traction
- If tight:
- > mother should be encouraged to push
- > where the baby does not descend and cord still cannot be loosened, clamp and cut cord
What are the steps for ‘head rotation’ in the normal birth guideline
- with the next contraction the head will turn to face one of the mother’s thighs (restitution)
This indicates internal rotation of shoulders in preparation for the birth of the body
What are the steps for ‘birth of the shoulders and body’ in the normal birth guideline
- May be passive or guided birth
- Hold baby’s head between hands and if required apply gentle downwards pressure to deliver the anterior (top) shoulder
- Once the baby’s anterior shoulder is visible, if necessary to assist birth, apply gentle upward pressure to birth posterior shoulder - the body will follow quickly
- Support the baby
- Note time of birth
- Place baby skin to skin with mother on her chest to maintain warmth unless baby is not vigorous/requires resuscitation
- Following delivery of baby, gently palpate abdomen to ensure second baby is not present
What are the steps for ‘clamping and cutting the cord’ in the normal birth guideline
- there is no immediate urgency to cut the cord. Wait for the cord to stop pulsating, which commonly takes one to two minutes. Allow birthing partner to cut cord if they wish. Cord cutting should be undertaken prior to extrication
- To cut cord, clamp 10cm from baby and 5cm from the first clamp then cut between the two clamps
- For uncomplicated births, transport can be conducted without cutting the cord if it is the parental preference
What are the steps for ‘Birthing placenta’ in the normal birth guideline
PASSIVE (EXPECTANT) MX
- Allow placental separation to occur spontaneously without intervention
- may take 15 mins to an hour
- Position mother sitting or squatting to allow gravity to assist expulsion
- Breast feeding may assist separation or expulsion
- DO NOT PULL CORD - wait for signs of separation:
- > lengthening of cord
- > uterus becomes rounded, firmer, smaller
- > trickle or gush of blood from vagina
- > cramping/contractions return
- Placenta and membranes are birthed by maternal effort, ask mother to push
- Use two hands to support placenta and use a twisting motion to ease membranes out of vagina
- Noe time of placental delivery
- Place placenta and blood clots into container and transfer
- inspect for completeness
- inspect fundus is firm contracted and central
- continue to monitor fundus though do not massage once firm
- If fundus not firm or blood loss >500ml manager as per postpartum haemorrhage
What are the clinical signs of DKA/HSS
- Dehydration
- Tachypnoea
- Polydipsia
- Polyphagia
- Polyuria
- Kussmauls breathing
- Hx diabetes
what are the critical illnesses that get treated as o2 less than 85%
- CASKETS
- cardiac arrest
- anaphylaxis
- shock
- ketramine sedation
- status epilepticus
- major trauma/head injury
- severe sepsis
WHat are the conditions under chronic hypoxia that we titrate spo2 to 88-92%?
SOB CCN
- Severe kyphoscoliosis
- Obesity
- Bronchiectasis
- Cystic fibrosis
- COPD
- Neuromuscular disorder
What are the conditions that get 15L via non-rebreather regardless of spo2 readings?
- Toxic inhalation exposure
- Decompression illness
- Cluster headache
- Postpartum haemorrhage
- Shoulder dystocia
- Cord prolape
What is the treatment for Hyperglycaemia?
IF BGL >11
AND
Clinical features of DKA/HHS
AND
Less than adequate perfusion
- Normal saline 20ml/kg, titrated to perfusion status
- Consult if further doses required
- Consider reduced volume for elderly or impaired renal/cardiac function
- Consider antiemetic
What is the RASH criteria for anaphylaxis
- Sudden onset of symptoms (<30 min up to 4 hours)
AND
- 2 or more RASH +- confirmed exposure to antigen
OR
ISOLATED HYPOTENSION <90 FOLLOWING KNOW EXPOSURE
OR
Isolated resp distress following known exposure
What are the risk factors for refractory anaphylaxis or deterioration?
- Expected clinical course (Hx of refractory anaphylaxis/ICUY admissions/multiple adrenaline doses
- Hypotensive <90SBP
- Medication as precipitating cause (antibiotics, IV contrast)
- Respiratory symptoms/respiratory distress
- Hx of asthma or multiple co-morbidities/medications
OR
No response to initial dose of IM adrenaline
Why do we give glucagon for refractory anaphylaxis or non-responsive to IM adrenalin?
Glucagon has inotropic, chronotropic and antibronchospastic effects
When do we give glucagon in the setting of anaphylaxis?
Pt’s who remain hypotensive after 2 doses of adrenaline in the setting of:
- Past Hx of heart failure
OR
- Patients on beta-blocker medications
What is the treatment for adult anaphylaxis?
- 500mcg adrenaline IM
- repeat every 5 mins as required
No max
- Call MICA if risk factors or not responsive to adrenaline
- Insert IV
- O2 therapy
What additional therapies can we apply in the treatment of anaphylaxis in the adult?
- For airway odema
- Bronchospasm
- Hypotension
Airway Oedema:
- 5mg adrenaline nebulised
- consult for repeat doses if required
Bronchospasm:
- Salbutamol 5mg nebulised or pMDI 4-12 doses
- > repeat 20-minute intervals if required
- Ipratropium bromide 500mcg neb or pMDI 8 doses
- Dexamethasone 8mg IV/oral
Hypotension:
- Normal Saline (max 40ml/kg) titrated to response
- > consult for additional 20ml/kg if required
what is the definition for status epilepticus
> 5min continuous seizure activity
OR
multiple seizures without full recovery of consciousness between seizures
what is the treatment for adult seizures?
Generalised Convulsive SE:
- Midaz 10mg
(5mg if old or frail)
- repeat 10mg once only after 10 minutes
Seizure activity ceaed/Subtle SE/Other Se:
- monitor airway, ventilation, CS and BP
- is suspected subtle SE consult for midaz
what are the care objectives for the ACS guideline?
- Rapid identification of STEMI to facilitate rapid reperfusion
- Provision of antiplatelet treatment
- Reduce cardiac workload by treating associated symptoms
When do you contact ARV/PIPER regarding envenomation?
For suspected snake bites with a transport time >30 minutes to ED
WHat is the treatment for australian snake bites?
Bite to a limb:
- Apply PBI
- Splint limb
- Immobilise the patient on the stretcher
Bite to torso:
- Immobilise patient on stretcher
- Obtain 2x IV access
- Manage resp distress with supplemental O2 and supportive ventilation
What is the treatment for Spider bites?
Red back:
- No PBI
- Ice pack
Big black:
- DO not walk
- to limb apply PBI and immobilise pt on a stretcher
- to torso immobilise pt on a stretcher
- Manage pulmonary oedema with CPAP
What is the treatment for marine animal stings?
Non-tropical jellyfish:
- wash with seawater
- gently pick off remaining tentacles
- apply warm/hot water to the site, consider an ice pack if no hot water. DO NOT apply vinegar
Barbed fish/rays:
- Do not attempt to remove the barb
- Manage haemorrhage
- Immerse in warm/hot water
Blue ringed octopus:
- PBI and imobilise patient
- Prepare for pt deterioration with prolonged resus efforts
Undiffe
rentiated nausea and vomitting may include what:
- secondary to cardiac chest pain
- secondary to opiod analgesia
- secondary to cytotoxic drugs or radiation
- severe gastro
WHat are the clinical signs of dehydration according to the nausea and vomitting CPG
- Postural perfusion changes including tachycardia, hypotension or dizziness
- decreased sweating and urination
- poor skin turgor, dry mouth, dry tongue
- fatigue, altered conscious state
- evidence of poor fluid intake compared to fluid loss
What is the preferred treatment for nausea and vomiting in the pregnant patient with signs of dehydration?
Fluid rehydration
What is the treatment for undifferentiated nausea and vomiting per the N&V guideline
Ondans 4mg ODT
- repeat 4mg after 5-10 mins if symptoims persist (max 8mg)
or 8mg IV
If know allergy or C/I to Ondans and under 21 give stemetil
What is the treatment for dehydration per the N&V guideline
Less than adequate perfusion:
- NS max 40ml/kg
- consult for additional 20ml/kg (if consult unavailable just do the 20)
Adequate perfusion but significant dehydration:
- NS 20ml/kg over 30 mins
What is the treatment for vestibular nausea per the N&V guideline
Pt >21
- Stemetil 12.5mg
Pt <21
- Ondans
WHat are the care objectives for prehospital management of fractures/dislocations?
- Control external haemorrhage
- Apply good splinting practices
- Resolve neurological or vascular compromise where possible
- Use judicious analgesia
WHen should a pelvic splint be applied?
- If there is suspicion of pelvic injury
- If pt has inadequate perfusion and/or altered conscious state following significant mechanism that may result in pelvic injury
WHat are the principles of reducing a fracture?
- Provide procedural analgesia
- Irrigate with 500ml - 1L of NS if compound fracture
- Apply traction and gentle counter-traction in the line of the limb
- If required further manipulation should be done whilst the limb is still under tractions
- Splint limb following reduction
What are the signs of epiglottitis
stridor, increased WOB, drooling and absence of cough
- Can also include low pitched expiratory stridor (often snoring) and the pt preferring to sit in a tripod position
What is the treatment for Upper airway obstruction - Paed?
Partial obstruction (effective cough):
- Encourage cough
- Utilise gravity
- Maintain BLS
Partial obstruction (ineffective cough):
- Utilise gravity
- Back slaps alternating with chest thrusts
IF unconscious or pt becomes unconscious
- Chest compressions
- Suction
- Magils
- Forced ventilation
what is the treatment for Mild/Moderate asthma for paeds?
2-5 years = 2-6 doses salbutamol via PMDI
>6 years = 4-12 doses salbutamol via PMDI
4 breatsh each dose
repeat 20 minutes
what is the treatment for Severe asthma for paeds?
Salbutamol Nebulised:
Small children (2-4 years) = 2.5mg (1.25ml) Medium child (4-11 years) = 2.5 - 5mg (2.25 - 2.5 ml)
Repeat salbutamol 20 minutes
+
Ipratropium bromide 250mcg in 1 ml nebulised
what is the treatment for Critical asthma for paeds?
Salbutamol 10mg in 5 ml nebulised
- repeat 5 min intervals as required
Ipratropium bromide 250 mcg in 1 ml Nebulised
Dexamethasone 600mcg/kg oral (max 12mg)
Adreanline 10mcg/kg
- repeat 5-10 mins
- max 30mcg/kg
What are the car objectives for burns?
- identify and manage potential airway burns as a priority
- minimise the impact of injury by maintaining tissue and organ reperfusion, minimising pain, appropriate burn would cooling and minimising heat loss during transfer to hospital.
what are the signs or airways burns?
- evidence of burns to upper torso and neck
- facial and upper airway odema
- sooty sputum
- burns that occured in an enclosed space
- singed facial hair
- respiratory distress
Hypoxia
when should cooling of burns be ceased?
after 20 mins
or
if pt startes shivering
or temo drops below 35
how long should chemical burns be irrigated for?
As long as pain persists
what is the treatment for paediatric burns?
Partial or full thickness burns >10% TBA
- Need MICA to give 3x %TBSA X pt weight NS
ALL BURNS:
- Pain relief
- Cool the burn
- Warm the patient
- Apply dressing
- Transport
what is the adult pain relief treatment for SEVERE pain
FIRST LINE
- IV morph or IV fent
AND - IN Ket
Consult for IV Ket if pain remains following 2-3X doses
SECOND LINE (if IV access unsuccessful or delayed):
- Fent IN
- Ket IN
- Methox
- Morph IM
what is the adult pain relief treatment for MODERATE pain
FIRST LINE:
- Morph IV or Fent IV
If access delayed of unsuccessfuk
- Fent IN
OR - Ket IN
All pts get paracetamol unless C/I
SECOND LINE:
- Ket IN
- Morph IM
THIRD LINE:
- Methox
What is the IM dose for morph and fent
Morphine:
10mg
- repeat 5mg after 15 mins ONCE ONLY
Or
- 1 mg for old cunts
- no repeat
Fentanyl:
100mcg
- repeat 50mcg @ 15 mins once only
- 1cg/kg for old cunts
WHat is the dose for IN Ket
75mg
- repeat 50mg after 20 mins
- No max dose
Old/frail:
50mg
- 25mg at 20 mins
no max
what is the paed dose for paracetamol
15mg/kg
what is the treatment for moderate pain in the paed pain management guideline?
Fentanyl IN:
- Small child (10-17kg) = 25mcg IN
- Medium child (18-39kg) = 25-50mcg IN
Repeat initial dose at 5-10 min
Consult after 3 doses.
- Consult with RCH for doses in children under 10kg
- Consider paracetamol in combo with opioids
UNABLE to administer fent OR in moderate sever pain procedural pain:
- Methox 3ml
- repeat 3ml
what is the treatment for severe pain in the paed pain management guideline?
- Fent IN +- Methox
Fentanyl IN:
- Small child (10-17kg) = 25mcg IN
- Medium child (18-39kg) = 25-50mcg IN
Repeat initial dose at 5-10 min
Consult after 3 doses.
- Consult with RCH for doses in children under 10kg
- Consider paracetamol in combo with opioids
UNABLE to administer fent OR in moderate sever pain procedural pain:
- Methox 3ml
- repeat 3ml
Presentation of morphine
10mg in 1ml
precautions of morphine
- elderly/frail
- hypotension
- resp depression
- current asthma
- resp tract burns
- known addiction. to opiods
- acute alcoholism
- pts on MAOIs
side effects of morphine
- Drowsiness
- resp depression
- euphoria
- nausea
- vomitting
- addiction
- pin-point pupils
- Hypotension
- bradycardia
Presentation of fentanyl
100mcg in 2 ml
precautions of fentanyl
- elderly/frail
- impaired hepatic function
- resp depression (COPD)
- current asthma
- pts on MAOIs
- known addiction to opioids
- Rhinitis, rhinorrhea or facial trauma
side effects of fentanyl
- resp depression
- apnoea
- rigidity of the diaphragm
- bradycardia
presentation of ketamine
200mg in 2 mlk
precautions of ketamine
may exacerbate cardiovascular conditions
side effects of ketamine
- hypertension
- tachycardia
- emergence reactions
- increased skeletal tone
- hypersalivation
- diplopia
- nystagmus
- respiratory depressions
- apnoea
- nausea
- vomiting
presentation of paracetamol
500mg tablet
120mg in 5ml
precautions of paracetamol
- impaired hepatic function
- elderly/frail
- malnourished
side effects of paracetamol
- hypersensitivity reactions
- haematological reactions
presentation of methox
3ml glass ampule
precautions of methoxy
- must be held by the patient
- pre-eclampsia
- concurrent use with oxytocin
side effects of methoxy
- drowsiness
- decrease in BP
- bradycardia
presentation of dextrose
25g in 250ml infusion pack
presentation of glucagon
1 IU (mg) in 1 mL hypokit
side effects of glucagon
nausea
vomiting
presentation of adrenaline
1mg in 1ml
precautions of adrenaline
Consider lower doses for:
- elderly/frail
- pts with cardiovascular disease
- pts on MAOIs
- higher doses may be required for pts on Beta blockers
side effects of adrenaline
- ST
- supraventricular arrythmias
- ventricular arrythmias
- HTN
- pupillary dilation
- May increase size of MI
- Anxiety/palpitations
Presentation of midazolam
5mg in 1 ml
precautions of midaz
- reduced doses may required for eldery/frail, CCF, chronic renal failure, shock
- CNS depressant effects enhances in presence of alcohol, narcotics and other tranquilisers
- Can cause severe resp depression in pts with COPD
- Pts with myasthenia gravis
side effects of midaz
- depressed level of consciousness
- resp depression
- loss of airway contorl
- hyoptension
presentation of GTN
300mcg or 600mcg tabs
50mg patch
precautions of GTN
- no previous admin
- elderly frail
- recent MI
- concurrent use with other tocolytics
side effects of GTN
- tachycardia
- Hypotension
- Headache
- Skin flushing
- Bradycardia
presentation of aspirin
300mg tab
precautions of aspirin
- peptic ulcer
- asthma
- pts on anticoagulants
side effects of aspirin
- Heartburn
- nausea
- GIT bleeding
- Increased bleeding time
- Hyper sensitive reactions
presentation of salbutamol
5mg in 2.5ml
precautions of salbutamol
large doses can cause metabolic acidosis
side effects of salbutamol
- ST
- Muscle tremor
presentationm of ipratropium bromide
250mcg in 1 ml
precautions for ipratropium bromide
- glaucoma
- avoid contact with eyes
side effects of ipratropium bromide
- headache
- nausea
- dry mouth
- skin rash
- tachy cardia
- palpitations
- acute angle glaucome
presentation of dexamethasone
8mg in 2 ml
precautions for dex
solutions which are not clear should be discarded
presentation of ondansetron
4mg oral tab
8mg in 4ml
side effects of ondansetron
COMMON
- headache
- constiptaion
- Fever
- Dizziness
- Rise in liver enzymes
RARE
- hypersensitivity reactions
- QT prolongation
- Widened QRS
- tachyarrythmias
- seizures
- extrapyramidal reactions
- visual disturbances
precautions of ondansetron
- pts with liver disease should not recieve more than 8mg in 24 hours
- pts on diuretics could have electrolyte imbalance
- ondans contains aspartame and should not be given to pts with phenylketouria
- concurrent use of tramadol
- pregnancy
presentation of prochlorperazine
12.5 mg in 1 ml
precautions of prochlorperazine
- hypotension
- epilepsy
]- pts affected by alcohol or on anti-depressants
side effects of prochlorperazine
- drowsiness
- blurred vision
- hypotension
- ST
- skin rash
- Extrapyramidal reactions
what is the fluid burns calculations
OVER 15
%TBSA x Pt weight
- Overf 2 hours from time of burn
12-15
3 X %TBSA X Weight
- over 24 hours form time of burn
- first half in first 8 hours
WHat are the 6P’s of neurovascular checks?
- Pain
- Pulse
- Pallor
- Parasthesia (pins and needles)
- Paralysis
- Temperature
WHat are the 5HEDS in head trauma
- LOC exceeding 5 mins
- Head/skull fracture
- Emesis more than once
- Neurological defecit
- Seizure
what are the actual TCG criteria
HR <60 or >120
RR <10 or >30
BP <90
O2 <90
GCS
if <16 - GCS <15
If >16 - GCS <13
What are the emergent TCG criteria
Blunt injuries:
- Serious injury to single body region requiring specialised care or that is life or limb threatening
- Significant injuries involving more than one body region
Specific injuries:
- Limb amputation or limb threatening
- Suspect spinal cord injury
- Burns >20% TBSA (>10 if less than 15)
- Respiratory tract burns
- High voltage burns
- Serious crush injury
- Major compound fracture or open dislocation
- Fracture to 2 or more of femur/tibia/humerous
- Fractured pelvis
What are the potential TCG crietria
- Motor/cyclist impact >30kmh
- MVA >60kmh
- Pedestrian impact
- Ejection from vehicle
- Prolonged extrication
- Fall from 3m
- struck in head by object falling >3m
- Explosion
AND Co-mobidities
- Age <12 or >55 OR
- Preggers OR
- Significant underlying medical condition
Indications for pelvic splint as per CWI
- suspected pelvic fracture
- awake pt complaining of pain to pelvic area including lower back, groin, hips
- unconscious pt with significant mechanism of injury
- Traumatic arrest
contras for pelvic splint as per CWI
- impailed object preventing application
Precautions for pelvic splint as per CWI
- should be appropriately sized. Smalled pts may require sheet/towel/pillow case
- traction splint to limbs should not be applied until after pelvis has been stabalised
indications for CT6 as per CWI
- Middle third femur fracture
- upper 2/3 tib fib fracture
contras for CT6 as per CWI
knee or ankle/foot trauma
precautions for CT6 as per CWI
- Pelvic trauma is higher clinical priority, pelvis must be splinted first. can cause more damage to pelvis, anatomical splinting may be more appropriate
- realign long bone fractures in as close to normal position as possible
- open fractures with exposed bone should be irrigated with a sterile isotonic solution prior to realignment
