VSS & Adjuncts - Parameters

Question 1

Temperature

Answer 1

Between 36 - 37.3

Question 2

PSA

Answer 2

ADEQUATE:
- Warm pink & dry
- Pulse: 60-100
- SBP > 100
- GCS: Alert, orientated

BORDERLINE PERFUSION:
- Cool, pale and clammy
- Pulse: 50-100
- SBP: 80-100
- GCS: Alert, orientated

INADEQUATE PERFUSION:
- Cool, pale and clammy
- Pulse: <50 OR >110
- SBP: 60-80
- GCS: Alert OR altered

EXTREMELY POOR PERFUSION:
- Cool, pale and clammy
- Pulse: <50 OR >110
- SBP: <60
- GCS: Alert OR altered
(only difference is SBP)

NO PERFUSION:
- Cool, pale and clammy
- Pulse: Nil
- SBP: Unrecordable
- GCS: Unconscious

**TIPS**
1. Skin not warm pink and dry = not adequate
2. Not alert & orientated = inadequate or less
3. Only difference between inadequate & poor is SBP

Question 3

GCS

Answer 3

GCS parameters are just the scoring system

Question 4

RSA

Answer 4

NORMAL
1. Calm, quiet
2. Speech: Clear, steady
3. Sound: Quiet
4. Rate: 12-16 breaths/min
5. Rhythm: Regular
6. Effort: Normal
7. Skin: Normal
8. Pulse: 60 - 100
9. GCS: Alert

MILD
1. Calm or anxious
2. Speech: Full sentences
3. Cough/mild wheeze / basal crackles
4. Rate: 16-20 breaths/min
5. Rhythm: Prolonged exp phase
6. Effort: Slight
7. Skin: Normal
8. Pulse: 60 - 100
9. GCS: Alert

MODERATE
1. Distressed, anxious
2. Speech: Short sentences
3. Cough, insp/exp wheeze or mid-zone crackles
4. Rate: >20 breaths/min
5. Rhythm: Prolonged exp phase
6. Effort: Marked
7. Skin: Pale, sweaty
8. Pulse: 100-120
9. GCS: Alert or altered

SEVERE
1. Exhausted / fighting to breathe
2. Speech: Words or none
3. No cough, insp/exp wheezes, full field crackles, no breath sounds
4. Rate: >20 or <8 breaths/min
5. Rhythm: Prolonged exp phase
6. Effort: Marked
7. Skin: Pale, sweaty, +/- cyanosis
8. Pulse: >120, <60
9. GCS: Altered / Unconscious

Question 5

BGL

Answer 5

Between 4 - 8

Question 6

Sp02

Answer 6

95% - 100%