Study Day Module 8 Flashcards
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 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 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 paed anaphylaxis?
- 10mcg/kg adrenaline IM
- repeat every 5 mins as required
No max
- Call MICA if risk factors or not responsive to adrenaline
- O2 therapy
What additional therapies can we apply in the treatment of anaphylaxis in the paed?
- For airway odema
- Bronchospasm
- Hypotension
Airway Oedema:
- 5mg adrenaline nebulised
- consult RCH for repeat doses if required
- Notify
Bronchospasm:
- Salbutamol
- Aged 2-5: 2.5mg Neb or 2-6 doses PMDI
- Aged 6-11: 2.5-5mg Neb or 4-12 doses PMDI
- > repeat 20-minute intervals if required
- Ipratropium bromide 250mcg neb or pMDI (aged 6-11 = 8 doses, aged 2-5=4 doses)
- Dexamethasone 600mcg/kg oral Max 12 mg
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 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 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 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 adult burns?
Partial or full thickness burns >20% TBA if age >15
10%TBSA is age 12-15
Patients >15
= Normal Saline - TBSA x Pt weight
Adminiistered over 2 hours
If pt 12-15
Normal Saline - 3x TBSA% x Wieght
Over 24 hours. First half in 8 hours
Pain relief
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
SHED BS
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
what are the paediatric values? For a newborn and small infant
Age:
Newborn - under 24 hours
Small infant - under 3 months
Weight:
Newborn - 3.5kg
Small infant - 6kg
HR:
110- 170
BP:
>60
RR:
25 - 60
what are the paediatric values? For a large infant
Age:
3-12 months
Weight:
6 months - 8kg
12 months - 10kg
HR:
105 - 165
BP:
>65
RR:
25 - 55
what are the paediatric values? Small child
Age:
1-4
Weight:
age x 2 +8
HR:
85 - 150
BP:
>70
RR:
20 - 40
what are the paediatric values? Medium child
Age:
5-11
Weight:
5-9 = age x 2 +8
10-11 = age X3.3
HR:
70 - 135
BP:
>80
RR:
16 - 34
What is the treatment for SVT - Narrow complex tachycardia
IF SBP >90mmHg
- Record 12-lead prior to commencing mgmt
- Modified or Standard valsalva
- > repeat x2 @ 2 minute intervals (max 3 attempts)
How do you determine SVT?
- > 150bpm
- no or abnormal p waves
- narrow complex
what are the steps for the modified valsalva
- Position laying semi-recumbent (45degree angle)
- Forced expiration
- Immediately lay pt flat and raise legs rto 45 degree angle for 15 seconds
- return to semi-recumbent position
what is the target pressure of the valsalva?
40mmhg
what is the target pressure of the valsalva?
40mmhg
what should be recorded prior to any treatment for SVT?
12 lead unless the patient requires immediate treatment
how should you treat SVT and AF that is deteriorating to the point of cardiac arrest?
Cardioversion 200J
what are the signs and symptoms of an unstable/rapidly deteriorated patient in narrow complex tachycardia?
- inadequate perfusion/shock (hypotension, pallor, diaphoresis)
- Acutely altered conscious state or LOC
- Ischaemic chest pain
- APO
what. are stroke mimics?
SMITH MISSES
Seizure Migrane Inner Ear disorder Brain Tumour Hypo/hyperglycaemia
MS Intoxication Sepsis Syncope Electrolyte disturbance Subdural Haemotoma
how many strokes are ICH?
15-20%
WHat signs. indicate a stroke is most likely ICH?
- Rapid deterioration of CS and GCS<8
- Complaint of severe headache
- Nausea/Vomiting
- Bradycardia/Hypertension
Where do you transport suspected ICH patients?
Awake: Transport to nearest stroke hospital
Comatose: Transport to nearest neurosurgical centre
why should opioids. be used with cation in strpkoe patients?
Due to its impact in decreasing CS making assessment of deterioration difficult
what is the post intubation SBP target in stroke patients unable to maintain aurway?
SBP 120-140
if someone is:
MASS + >12 hours
and ACT FAST -
or Suspected TIA
Where do you transport to?
Non urgent transport to closest thrombolysing stroke centre
if someone is:
MASS + <12 hours
and ACT FAST -
Where do you transport to and how do you treat?
NON ECR Eligible stroke
- IV access 18g in large vein. with reflus valve
- Transport to thromolysing stroke centre
- Consider RV with MSU
- Pre notify hospital
if someone is:
MASS + <12 hours
and ACT FAST +
Where do you transport to and how do you treat?
ECR eligible stroke
- 18G in large vein
- consider RV with MSU
- Transport to ECR eligible facility if similar time from thrombolysing
- Otherwise to nearest stroke centre
- Pre notify
what is the MASS assessment for stroke
FACIAL DROOP
SPEECH
HAND GRIP
What is the ACT FAST Test for stroke
- Position arms at 45degrees. ENcourage patient to hold up
RIGHT ARM DROPS = CHAT
Severe leanguage defecit
LEFT ARM DROPS = TAP
Tap left shoulder and call pts name
- Both eyes deviate away or abnormal response
+ ELIGABILITY CRITEREA
= ACT FAST POSITIVE
What is the ACT FAST eligibility criteria?
- Defecits are new or significantly worse
- Known onset of symptoms <24 hours
- Living home independently with minor assistance
- No evidence of stroke mimics
- > pt is not comatose/near comatose
- > no seizure presceding symptom onset
- > BGL >2.8
- > No definitelt known (&active) malignant brain tumour
why is it that electrical. bruns may require more fluid than normal?
Often cause acute kidney injury secondary to profound muscle damange
What are the clinical features of DKA/HSS?
Confusion Dehydration Tachypnoea Polydipsia Polyuria Kussmauls breathing Hx of. diabetes
What are the S&S of meningococcal. septicaemia?
Typical pupuric rash
Septicaemia signs
- Fever, rigor, joing and muscle pain
- Cool hands and feet
- Tachycardia, hypotension
- Tachypnoea
Meningeal. signs
- Headache, photophobia, neck stiffness
- Nausea and vomiting
- Altered CS
- Irritable or whimpering
What is the treatment for meningococcal. septicaemia in paeds?
PPE
MICA
Ceftriaxone 50mg/kg IM (Max 1000mg)
Dilute 1000mg with 3.5ml Lignocaine 1%
- Administer to upper lateral thigh
Notify
What are the care objective for Narrow complex tachycardia
- Rapid termination of life threatening arrhythmia and transport to a facility capable of definitive care
- Rapid transport to facilitate the treatment of the arrhythmia where treatment is not available in the prehospital environment
- Early termination of stable SVT where possible, following ECG capture.
what populations should you be cautious of in giving IN KETAMINE
Adolescents/old frail/ pts with hx of anxiety or psychosis
what dose does optimal IN absorption occur with?
0.3 - 0.5 ml
what are indicators of neurovascular or vascular compromise in fractures that indicate a limb threatening injury?
altered sensation
loss of pulse
cold/dusky skin
