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