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Mechanism of Injury (MOI) ‐ trauma
In order for ECP to be able to provide best possible treatment, you need to have understanding of injuries are sustained by look at MOI. You are required to “search for clues” and be vigilant E.g. MVA’s Steering wheel that is buckled or bent o Thoracic trauma / fractures, neck, spinal, head trauma / fractures / injuries Front windshield damaged with a target looking shatter / crack / broken where windshield is damaged o Head, neck, spinal, thoracic trauma / fractures Dashboard is damaged or crumbled o Leg and pelvic fractures Kinetic force: When a car is driving at 120 km/p/h and has a head on collision with a brick wall, the car collides with the wall at approximately 240km/p/h
Nature of illness (NOI) ‐ medical
You are required to “search for clues” and be vigilant for clues on how the incident happened / occurred. Pt. home – general appearance of living quarters can provide many clues. Run‐down messy apartment with liquor bottles scattered everywhere could give an indication of the type of pt. you are about to treat.
Primary survey consists of o BSI and then o HHH ABC (conscious pt.) alternatively o HHH CAB (unconscious pt.) Primary survey – most important starting point in pre‐hospital pt. assessment in emergency care Even as you walking towards pt. and scene – critical assessment of ABC / CAB will determine pt. outcome Before primary survey – there are vital steps to be taken before pt. can be touched or treated o That is Body Substance Isolation
Body Substance Isolation (BSI)
Practice regarding ALL bodily fluids as being potentially infectious Always use BSI to protect yourself & partner from exposure to infectious disease/s Various ways to protect yourself from exposure to infectious disease/s o Masks o Gloves and eye protection o Hand washing o Disposal of used supplies NEVER leave medical equipment / dressing / bandages or anything used while treating the pt. behind!!!!!!
Once BSI taken care of – primary survey can begin Primary survey includes rapid assessment of pt. level of consciousness
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In almost every situation – following steps are excellent guidelines to follow: H Hazards Is the scene safe to approach the pt. H Help Send for help if needed – e.g. fire brigade H Hello A Airway Is pt. airway clear and free of debris? B Breathing Is pt. breathing? C Circulation Does pt. have pulse? And or obvious bleeding? After primary survey is complete and all life‐threatening injuries taken care of o Proceed to finding out pt. history Primary survey must be continuously assessed on same pt. o If ABC not re‐assessed continuously – pt. condition may deteriorate without you being aware of it. SPEAK to your pt. NON‐STOP o GSC can easily be completed if pt. is speaking o If pt. stops speaking you are immediately aware that the pt. has deteriorated.
Integral part of the pt. overall approach Secondary survey has sequence and manner – follow this
My provide clue in providing a diagnoses e.g. cold and clammy Foetal position could mean they are guarding an acute abdomen Trauma patients may lie in various positions depending on injuries sustained Pt. in pain may be crying or have various facial expressions Anxious pt. may look scared and wary of surroundings Be prepared for signs of restlessness o May indicate pt. becoming hypoxic or has internal bleeding o Restlessness in pt. must never be overlooked – can often indicate serious / potentially serious condition. Look for areas of blood soaked clothing Or deformed / unnatural positioned extremities Always observe the colour, temperature and abnormalities This will give you a good idea of the pt. perfusion Bright red skin – could be indication of: o carbon monoxide poisoning – (gas heater, attempted suicide by exhaust fumes) o allergic rash o dilation of blood vessels Pale skin o often associated with pt. in shock or normally pt. as being cold and clammy Bluish tinged skin o can be indication of hypoxia / hypothermia Yellow skin o Usually indication of jaundice – best seen in “whites” of eyes o Jaundice most often due to liver disease – e.g. hepatitis Hives and urticarial – indication of allergic reaction
OBVIOUS WOUNDS AND DEFORMITIES
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Module 6 2.1 Pt. History
S A M P L E Signs and Symptoms Allergies Medication Past medical history
Last meal Events leading up to the event
Signs is something you see Symptoms is what the pt. tells you Ask – are you allergic to anything like medication like aspirin or food like peanuts Are you on chronic medication or taking medication for anything like flu or heart problems This question needs to include the pt. as well as the pt. family (pt. may not have past heart problems but pt. parents or family may have heart problems) When was the last time the pt. ate or had something to eat What was the pt. doing before the pain started
This is main symptom that causes pt. to call for assistance e.g. difficulty breathing Always be alert to more serious underlying conditions even though Pt. might be complaining about specific wound e.g. pedestrian involved in MVA may complain of injured arm Physically examination may reveal internal abdominal bleed – possible ruptured spleen
History of Chief Complaint
Obtain full as possible history from pt. Ask the flowing questions: O P Q R S T Onset When did the pain start / begin? Provokes What provokes the pain? E.g. was the pt. exercising? Quality What is the quality of pain? Crushing / stabling / feels like someone is sitting on their chest Radiation / Radiating Is the pain radiating? i.e. to the jaw, arms, abdomen, back Severity How sever is the pain? Scale of 1 – 10? 10 being the worse the pt. has ever felt Time How long has the pain lasted? 1 hour And is the pain constant or does it come and go and for how long
At this point vitals MUST be taken Signs – something you can see, hear, feel Pt. may not be aware of them e.g. rate / rhythm / strength of pulse Pulse Respiration Air entry Haemoglucose test (HGT) Blood pressure Pupils Glasgow coma scale Revised trauma score Skin colour and temperature Capillary refill
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Module 6 2.3 Pulse
Palpated where an artery lies – close to surface skin – e.g. radial artery When evaluating pulse: (things to consider) Rate Number of beats per minute Rhythm Regularity of beats Volume / strength Force / amplitude of each beat Normal pulse rates per minute: Adults 60 – 100 bpm Children 80 – 100 bpm Toddlers 100 – 120 bpm New‐borns 120 – 140 bpm Extremely fit adult can have pulse rate as low as 40 – 60 bpm (unfit person has faster pulse) Pulse rate only tell us little Pulse rate with rhythm and strength could tell us lots E.g. pt. pulse rate 120 bpm – regular but weak Could indicate pt. that is in shock E.g. pt. pulse rate 120bpm – regular but strong Could indicate health pt. after exercising When describing pulse – ALWAYS include rhythm, rate and strength / volume Pulse can be located in many areas of the body:
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Module 6 2.4 Respiration
When describing respiration rate – ALWAYS include rhythm, rate and depth and ANY abnormal sounds / smells if present Normal respiration rate: Adult 12 – 20 bpm Child 15 – 30 bpm Infant 25 – 50 bpm Groups of children Ages Normal respiratory rates New‐borns and infants Up to 6 months old 30‐60 breaths/min Infants 6 to 12 months old 24‐30 breaths/min Toddlers and children 1 to 5 years old 20‐30 breaths/min Children 6 to 12 years 12‐20 breaths/min Cheyne stokes respiration o Usually a sign of severe brain injury o Breathing gets deeper and deeper then stops for some time and the cycle then repeats Depths of breaths may be affected by many factors o Pt. rib fractures – pt. will find it difficult to breath and therefore decrease breathing in order to lessen pain o Overdose of narcotic drugs (respiration depressants) – may have shallow breathing Abnormal breathing sounds o Snoring – obstructed airway o Stridor – high pitched squeaking noise heard on IN‐halation – caused by narrowing of airway Usually around larynx o Gurgling – indicated collection of fluids in upper airway Total lung capacity o 6000ml: Forced deep breathe ‐ Volume of air in lung after a forceful inspiration Tidal volume o 500ml: Normal breathing – volume of air inspire / expire during each respiratory cycle o Normal breathing 12‐20 breathes per minute) Dead air space o 150ml: Air remaining in passages Minute volume o Amount of air that moves in and out of the lungs per minute o Tidal Volume x respiratory rate (12‐20 bpm) = minute volume o VT or tidal volume is the amount of air the lungs breathe in one breath, o VE or minute volume is the number of breaths o RR (respiratory rate or f=frequency) breathed in one minute times the tidal volume. o Thus VT x RR = VE. 350ml x 12 breaths per minute = 4,2 L/min.
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Signs of abnormal breathing
Slower the 8 breaths/min OR faster than 24 breaths/min Muscles retractions Pale / cyanotic skin (bluish coloured skin) Cool, damp (clammy) skin Shallow / irregular respirations Pursed lips Nasal flaring
Air entry is determined by auscultating both the left and right sides of the thoracic cavity Auscultating the thorax with a stethoscope It is used to determine equality of breath sounds on both sides of the chest o Unequal air entry may suggest pneumothorax
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Auscultation: Sound Expansion Effort Normal Present & equal Adequate & equal Unlaboured / normal
Abnormal Diminished / unequal / absent Inadequate / unequal Laboured / increased effort / uses accessory muscles / flail rib fractures / subcutaneous emphysema
Two components to blood pressure measurements: Systolic (contraction of the heart) Diastolic (relaxation of the heart) Blood Pressure = Cardiac Output x Peripheral resistance Cardiac output = Stroke volume x Heart rate Blood pressure is recorded: systolic over diastolic e.g. 120/80 Normal blood pressures: Systolic: 100 – 140mmHG Diastolic: 65 – 90mmHG Male pt. Adult Age + 100 = Systolic BP 40 + 100 = 140 Diastolic BP = 2/3 of systolic BP 90 ‐ 100 Female pt. Adult Age + 90 = Systolic BP 30 + 90 = 120 Diastolic BP = 2/3 of systolic BP 80 Blood pressure can be estimated by finding different pulses: Pedal pulse: 90mmHG Radial pulse: 80mmHG Femoral pulse: 70mmHG Carotid pulse: 60mmHG RMB: BP only of many vital signs and must not be used in isolation e.g. pt. that has lost lots of blood may have normal BP o this due to response of vasoconstriction by vessels and increase in heart rate and output to maintain pressure o By the time the pt. BP falls – pt. is already in sever hypovolaemic shock
Remember: PEARL Pupils equal and reactive to light +‐ Normal size pupil 4mm State of pupils may be indicator of cerebral perfusion and oxygenation of brain Two main parameters: Size of pupils Reaction of pupils to light In normal healthy person – pupils are equal size and shape
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Size of pupil is usually determined by amount of light entering the eye Bright light causes pupil to constrict Darkness causes pupils to dilate When brain deprived of oxygen – pupils dilate Use of drugs may affect pupils Pt. who have dilated pupils but are alert and responsive – DON’T have problem with oxygenation to brain Drug may have caused papillary response Rate of reaction to light may give clues to states of brain Pupils slow to react – usually mean the brain or portion of the brain is hypoxic
Glasgow coma scale (value out of 15)
Derived from various responses to stimuli: Responses are: o Opening of eyes o Use of speech o Ability to move /15 Visual Response 1 Eyes don’t open 2 Pain causes eyes to open 3 Voices cause eyes to open 4 Spontaneous 5 ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ 6 ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ Lowest score is 3
Verbal Ability None Incomprehensible words / sounds Inappropriate words Minimal / confused Orientated ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Motor Skills No movement Abnormal extension to pain Abnormal flexion to pain Withdraws from pain Localizes pain Moves on command
2.9 Revised Trauma Score /12 GCS Systolic BP Resp. Rate 4 13 – 15 >90 10‐29 3 9 – 12 76 – 89 >29 2 6 – 8 50 – 75 6 – 9 1 4 – 5 1 – 49 1 ‐ 5 0 3 0 0 Lowest score is 3 2.10 Capillary refill
2 seconds to refill Press nail bed – release and determine time it takes for nail bed to return to initial colour.
2.11 Haemoglucose test (HGT)
Haemoglucose test – done by assessing blood sugar level of pt. Normal blood sugar level – 3.5 – 6.7 (or 7.4) mmol/L
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Module 6 2.12 Head – to ‐ Toe
Slide hands from neck upwards – to feel posterior scalp. Be extremely careful in trauma pt. NOT to move head DO NOT press hard on deformities – may push fragments of broken bone into brain Feel for deformities, swelling and blood Ears Look for ear damage Blood and CSF (cerebra‐spinal fluid) – may be oozing from ears ‐ May be indication of skull fracture Battle signs (bruising over mastoid process ‐ May be indication of skull fracture Nose Look for swelling, deformity or bruising Blood and CSF (cerebra‐spinal fluid) draining from nose ‐ May be indication of skull fracture Eyes Check external trauma – eyes and eyelids Raccoon eyes (bruising around the eyes) – May sometimes be indication of skull fracture Mouth 1st feel jaw for signs of fractures Open mouth – check there is no foreign matter within e.g. broken teeth/dentures, vomits, blood etc. Neck DO NOT move neck in trauma pt. Gently examine neck for wounds, bruises, palpate for subcutaneous emphysema Examine trachea – deviated or midline Examine posterior and anterior aspects of neck for swelling and deformities. Completion of neck examination – immobilize neck with neck brace Chest Fully expose pt. chest when necessary. – be respectful and allow pt. to keep their dignity Examine chest for stability, unity, bruising and wounds Auscultate chest for unequal breath sounds or any abnormal breath sounds e.g. wheezing, rales Lookout for medic‐alert bracelet Abdomen Ensure abdomen is exposed Look for bruising, lacerations, bowel eviscerations Palpate abdomen for tenderness, rigidity or guarding Pelvis Locate crests of ilium (hips) and gently exert pressure Instability or pain from this compression may indicated fracture of the pelvis Genitalia Should not normally be done – unless obvious signs of injury i.e. blood soaking through clothing, impalement of object Always be sensitive and cautious when exposing genitalia – allow pt. maintain dignity – provide privacy Very legal problems may be caused by this type of examination Extremities Expose legs and arms if injury is expected Examine for bleeding, deformity, bruising, abnormalities or abnormal positioning of limbs Test pt. sensation – response to touch – BADINSKI REFLEX – normal movement toes curl – abnormal movement toes pull up and away for touch. Medical pt. look for swelling – sacral oedema and pericardial oedema and poor circulation (pulse) Lookout for medic‐alert bracelet Completion of examining legs – examine arms in the same manor.
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Triage is a French word – meaning sorting Defined as categorizing and sorting of pt. according to degree / severity of injuries / illness Assessment of injuries is conducted briefly – establishing o Type of injuries sustained o How severe injuries are o Who is to receive priority in primary care o And transportation to medical facility During this assessment ABC principle is applied o Screaming, hysterical pt. usually NOT highest priority Pt. is conscious and has open airway o Silent pt. usually have depressed level of consciousness Possible airway obstruction Possible breathing difficulty Possible haemorrhage – resulting in shock ECP responsible for triage MUST overcome desire to stop and treat individual pt. – ECP must complete ABC ECP should continue categorizing each pt. To enable arriving team to quickly identify pt. needs of immediate treatment
Prioritization of pts.
ECP responsible for triage must ensure all pt. are closely monitored – triaging pt. may change Attention must be directed to priority 1 (/ highest priority) before treatment is administered to priority two pt. (/ lower priority pt.) Call centre must be updated of ALL events on continuous basis and any further assistance required Triage MUST be performed repeatedly (does not consist of one assessment)
Highest priority Life threatening emergencies Pt. in danger of asphyxia / hypoxia Obstructed airway Apnea Sucking chest wounds Tension pneumothorax Pt. in shock / impending shock Major external / internal bleeding Burns over more than 20% of body surface Cardiac tamponade
Second priority Pt. seriously injured Visceral injuries WITHOUT shock Burns – less than 20% o Including face / hands / feet / genitalia Spinal cord injuries Compound fractures / dislocations
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Module 6 18.104.22.168 Priority 3
Third priority Pt. with moderate to light injuries Soft tissue injuries WITHOUT shock Musculoskeletal injuries WITHOUT shock / WITHOUT loss of pulse / WITHOUT loss in sensation Minor injuries of the eyes Burns of other locations – less than 20%
These are dead pt. Priority 4 pt. should be left where they are found and covered SAPS will take over responsibility for removal of these victims
Pt. Effective interaction / communication
Effective interaction with patients
Make and keep eye contact Use pt. proper name (if you forget pt. name – use sir/ma’am) Tell pt. truth Use language pt. can understand Be careful of what you say about pt. to others Be aware of own body language Speak slowly, clearly, distinctly (always) If pt. hearing impaired, speak clearly and face pt. when speaking Allow time for pt. to answer questions Act in calm, confident manner
Communicating with elderly pt.
Determine pt. function age DO NOT assume elderly pt. senile / confused Allow pt. ample time to respond Watch for confusion, anxiety, impaired hearing / vision ALWAYS explain what is being done
Communicating with children
Children are aware of what’s going on Allow people / objects that provide comfort to remain close Explain procedures to children truthfully Position yourself on their level
Communicating with hearing impaired pt.
Always assume pt. has NORMAL intelligence Make sure you have paper and pen Face pt. and speak slowly, clearly and distinctly NEVER shout Learn simple phrases used in sign language
Communicating with visually impaired pt.
Ask pt. if they can see at all Explain all procedures truthfully as being performed If guide dog present – transport guide dog also.
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Module 6 4.6
Use short, simple questions and answers Points to specific parts of body as you ask questions Learn common words and phrases – non‐English language areas
Mentally disturbed pt.
Interaction with mentally disturbed can be difficult at best of times Should be kept in mind – abnormal behaviour may be part and parcel of medical diseases, reaction to severe stress, drug abuse NOT every pt. has specific mental (psychiatric) disorder. Pt. with hypoglycaemia or alcohol ingestion may appear mentally disturbed
Disruptive behaviour and drug abuse
Overview Drug defined as substance – can produce physical / mental effect on the body Every drug can have undesirable side effect or reaction Some reactions are life threatening and require emergency treatment Sometimes drugs misused and cause serious reactions Most drugs abused are done for mood altering effects Includes alcohol General misuse of drugs is termed as “substance abuse”
Drug defined as substance – can produce physical / mental effect on the body Drug abuse is worldwide Varies from Simple minor overdoses of medically prescribed drugs o Inhalation of intoxicating chemicals o To major narcotic usage Cocaine powerful CNS stimulant Heroin CNS depressant – does have mood elevating effects LSD ‐ One of most important and dangerous hallucinogenic drug o Alters pt. awareness of themselves – can cause fatal situations when pt. believes they can leap off buildings and fly.
Alcohol – powerful CNS depressant Chronic alcoholics may be suicidal Drunken pt. may show aggression, inappropriate behaviour, fall easily / be combative Pt. who abuses alcohol and drugs usually have underlying personality disorder o Pt. should always be approached in caring and understanding manner If pt. becomes too aggressive – call for assistance ‐ SAPS
Death and terminal illness
SIDS (Sudden Infants Death Syndrome)
Thousands of babies die from SIDS every year Usually occurs during sleep – in apparently healthy baby: 2 – 4 month old Also known as cot death Almost certainly encounter anguished, severely distressed pts. Always make effort to revive baby with basic life support – unless baby is cold and stiff
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Transport to hospital – even if baby seems dead to you o Be sure to examine baby o Signs of child abuse – DO NOT make this obvious to the parents Evidence of child abuse MUST be reported to doctor at receiving hospital
Often pt. will not have been previously ill / in danger – death will be a great shock to everyone Any doubts if the pt. is dead – full resuscitation should be carried out. o When person obviously dead – support should be given to the family and friends Keep family informed of what you are doing Close relatives and friends should be allowed to see the body if desired o BUT any mutilated areas should be covered NEVER raise false hopes – possible response to resuscitation if death is inevitable If possible, do not resuscitate pt. when family around; ask family to leave the room
Terminally ill pt. usually know / strongly suspect they are about to die May be little to do for terminally ill pt. – other than to make them comfortable Determine if pt. and family are aware that death is approaching Pt. should NOT die alone!!
Child abuse may take many forms o Beatings o Burns o Rape o Even attempted murder Anyone may be a victim of abuse – seen most often among family members Victims / pts. Of abuse may demonstrate anger / rage / withdrawal Victim may say little, appear not to care, may not want anyone near them If child abuse it suspected – make every effort to get child to hospital for doctors examination o RMB to express your feelings to doctor – avoid confronting parents with suspiciouns
Commonly known as “wife beating” / “husband beating” (abuse of husbands also recognised) May be possible at times to quietly discuss problem with victim alone – who will often refuse help However – issue must NOT be forced – best course of action o Attempt to persuade pt. to be taken to hospital
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