S.F.A, E.F.A, I.F.R, E.M.F.R.- March 2010 Compiled by: Joe Draper PCP Consent (ask permission ) Implied Consent ? Can I be sued ? Gross Negligence Abandonment ? Good Samaritan Act 2 Governing Bodies: Ministry of Health (MOH) Base hospitals Ambulance service LEVELS OF CARE • Primary Care Paramedic •Advanced Care Paramedic •Critical Care Paramedic **FLIGHT/LAND CTAS= Canadian Triage Acuity Scale Every patient is assigned a number between 1-5 regarding their level of severity. ie: VSA=1, hurt toe=5 1. Assume control of the situation/scene: E- Environment M- Mechanism of injury/illness C- Number of casualties A- Assistance from other resources 2. Introduction: Approach, and introduce yourself Obtain consent, and explain your procedures PROTECT C-SPINE UNTIL RULED OUT!!! 3. Establish a baseline level of awareness: AVPU- Alert Alert to VERBAL stimulus Alert to PAINFUL stimulus Unresponsive 4. Assess the Airway: Open and inspect the airway for obstructions, or potential obstructions, and listen for quality of the air exchange. 5. Assess the breathing: Inspect/listen/feel for chest wall movement Auscultation of air movement in all fields Inspect for signs of respiratory distress: cyanosis, tracheal movement, accessory muscle use, etc. 6. Assess the cervical spine: Palpate and inspect the posterior neck for deformity, pain, or spasm. 7. Assess the circulatory status: Palpation of radial or central pulse Obtain a blood pressure Inspection for any gross bleeds Determine need for defibrillate and cardiac monitoring ***Look for ANY “signs of life” 8. Assess the following for life threatening injuries/problems: Chest Abdomen Pelvis Femurs CLAPS(D)= TICS(D)= C- contusions L- lacerations A- abrasions P- penetrations S- symmetry D- deformity/distention T- tenderness I- instability C- crepitus S- subcutaneous emphysema D- deformity/distention Use these AFTER all life threatening Problems have been corrected!!! SIGN vs SYMPTOM? SAMPLE= S- signs and symptoms A- allergies M- medications P- past medical history L- last oral intake E- events preceding incident/illness What Happened / why ? Witnessed or Un-witnessed? Medical vs. Trauma? Trauma ? – C-Spine ! What is the patients chief complaint? Signs and Symptoms History of Illness or Injury 10 Head Tilt - Chin Lift or Modified jaw thrust One Hand on the Lower Jaw One Hand on the Forehead Insert oral airway or Nasal airway 11 Assess for rate, rhythm and quality of respirations. If not present: Head Tilt, Chin Lift Lift the jaw forward Take a normal breath Use a barrier device. Give two breaths of 1 second in duration with enough volume to make the chest rise. Don't over inflate TO AVOID GASTRIC DISTENTION 12 Lt Atrium Rt Atrium Rt Ventricle •Assess for rate, rhythm, quality of pulse •Check BP •If possible- listen for heart sounds •Stop any gross bleeds •If pulse not present- START CPR! Lt Ventricle Blood Pressure is the amount of pressure exerted from the heart, that is measured within the arteries. SYSTOLE: -The contraction phase -The UPPER number DIASTOLE: -The relaxation phase -The BOTTOM number WHAT IS A “NORMAL” BLOOD PRESSURE? Patient Adult Child Infant Age (yrs) Depth Ratio Of Chest 8+ 30 : 2 1½ to 2 inches 100/min 15 : 1 1/3 to 1/2 Depth of chest 100/min 1/3 to 1/2 28days – 15: 1 Depth of 1 chest REMEMBER- PUSH HARD! PUSH FAST! 120+/min 1–8 Rate Assess Head to Toe For: Severe Bleeding Check skin temperature Soft tissue injuries Burns Medic Alert Treat For Shock Anything assessed that looks abnormal! 16 SHOCK= a state when there is widespread reduction of tissue perfusion resulting in: decreased oxygenation of cells, and inadequate removal of toxic byproducts. PUMP Signs & Symptoms Anxiety Confusion Rapid breathing Nausea and vomiting Cool, clammy or mottled skin Rapid heart and breathing rate Unconscious ? SHOCK 02 VESSELS VOLUME17 Types of Shock Examples Septic:: Severe illness caused by overwhelming infection of the bloodstream Hemorrhagic:: Large amount of blood loss externally and/or internally Obstructive: Airway obstruction, Chest wound causing collapse of lung Cardiogenic: Heart attack, Sudden cardiac arrest. Anaphylaxis: Severe allergic reaction causing airway swelling. Neurological: Neurological system or spinal shock. M IL D M ODERATE SEV ER E F a st H R > 1 0 0 F a st H R > 1 2 0 S lo w H R < 6 0 F a st R R > 1 6 F a st R R > 2 0 S lo w R R < 1 2 N o rm a l s k in P a le , c o ld s k in P a le , c o ld , c la m m y R e stle ss C o n fu sio n U n c o n sc io u sn e ss 18 Upon completion of primary exam, and all life threats have been corrected… Assess the following: •Head •Neck/spine •Chest/back •Abdomen •Pelvis/hips •Arms •Legs IF AT ANY POINT THE PATIENTS CONDITION CHANGES RE-START YOUR PRIMARY EXAM!!! 19 AMI- Acute Myocardial Infarction AEMCA- Advanced Emergency Medical Care Assistant ALS- Advanced Life Support APGAR- American Pediatric Gross Assessment Record PRN- As required BVM- Bag Valve Mask BLS- Basic Life Support PO- By Mouth CA- Cancer CACC- Central Ambulance Communications Centre CNS- Central Nervous System CVA- Cerebrovascular Accident (stroke) COPD- Chronic Obstructive Pulmonary Disease CHF- Congestive Heart Failure CTAS- Canadian Triage & Acuity Scale DNR- Do Not Resuscitate GCS- Glascow Coma Scale JVD- Jugular Vein Distention LOA- Level Of Awareness MCI- Mass Casualty Incident PEARL- Pupils Equal And Reactive to Light ROSC- Return Of Spontaneous Circulation SAED- Semi Automatic External Defibulator TIA- Transient Ischemic Attack UTI- Urinary Tract Infection VSA- Vital Signs Absent Over 78,000 deaths per year in Canada, Progression of Atherosclerosis ages 40-65. (66% occur outside the hospital) 40,000 from Coronary Artery Disease 20,000 from Sudden Cardiac Arrest 16,000 from Strokes Risk Factors Smoking, High Blood Cholesterol, High BP, Stress, Heredity, Age, Diabetes & Lack of Regular Exercise Controllable Risk Factors ? 22 Cardiac Pain “crushing”, “heavy” pain Often radiates to neck/arm Pain does not change with palpation or inspiration Shortness of Breath Pale, sweaty Nausea/vomiting Agitated/anxious How do we treat these? NON- Cardiac Chest Pain Other descriptions ie: “stabbing”, “sharp” Usually localized pain Pain often changes with palpation/inspiration Often, no other symptoms beside the pain besides anxious So where is the pain coming from? Does being a woman change things??? Signs & Symptoms Sudden Headache Dizziness/Confusion Facial Drooping Slurred Speech Arm Drift Weakness/Paralysis T. I. A. ( Mini Stroke) Hemorrhage Emboli Thrombus Blood Flow from the heart 24 Signs & Symptoms Rate/Depth Accessory Muscles Pale, Bluish Skin Coughing, Choking Restlessness Shortness of Breath Noisy Breathing 25 1. 2. 3. 4. 5. Asthma Emphysema Bronchitis Pneumonia Congestive Heart Failure ALWAYS GIVE O2!!!!! HOW MUCH THOUGH? Allergens Peanuts Seafood Insect Bites Medications Latex Others? 27 Signs & Symptoms What does EPI do? Abdominal cramps, vomiting, diarrhea 28 Laceration Partial or full Amputation Contusion Avulsion Abrasion Bleeding Nose Impaled Object 29 When to suspect a Spinal Injury! Mechanism of Injury Amnesia to event Neck/Back Pain Paralysis Weakness Numbness Obvious Head Injury Loss of consciousness Priapism 7 12 5 30 Internal/External Types concussion scalp wound fractures intracranial hemorrhage 31 Mechanism of Injury Falls, blunt impact Signs & Symptoms Facial injuries, Bleeding or bruising to the head Vomiting Confusion Abnormal behavior Loss of, or changes in levels of Consciousness 32 Causes Epilepsy Stroke Febrile (children) Others? Signs & Symptoms 1. A taste or smell prior to. 2. may appear daydreaming. 3. uncontrollable muscle movement. 4. Loss of bowel/bladder D 33 Non-Shockable Rhythms Shockable Rythms NORMAL SINUS RHYTHM VENTRICULAR FIBRILLATION ASYSTOLE VENTRICULAR TACHYCARDIA 34 Signs & Symptoms Shortness of Breath Bleeding Coughing up blood. Pain at the injury site Engorged neck veins Treatment The Approach Cover holes Valve Reassure the patient! 35 Blunt or Penetrating Trauma may cause: Int./Ext. Bleeding Pain & Tenderness to the affected area Guarding Distention Painful urination Potential for significant blood loss PELVIS 36 : Rest Immobilize (splinting) Cold compress Elevate (if applicable) DS 37 Chemical? – Electrical? - Radiation? Flush the affected area with large amounts of water Look for entrance and exit wound Cool the burn area and treat accordingly 38 39 BRAIN S U G A R PANCREAS S U G A R INSULIN 40 Hypoglycemic or Hyperglycemic? Hypoglycemia: *Fast onset *Too much insulin/not enough sugar Signs and Symptoms: •Drunk in appearance •Pale and very sweaty •Seizures/agression •CBG <4 mmols Treatment: Conscious?- Give food, juice etc. Unconscious?- ABC’s, full assessment Hyperglycemia: *Slow onset *Too much sugar/not enough insulin Signs and Symptoms: •CBG >15mmols •Acetone breath •Fast breathing •Dry/Red skin Treatment? 41 Treatment Keep patient warm Remove wet cloths Give Warm Fluids Recovery Position Hyperthermia Treatment Cool Patient Remove From Sun Give Cool Fluids Recovery Position Hypothermia 42 CALL LOCAL POISON CONTROL OR CALL 911 OR CALL O FOR OPERATOR Do not administer anything by mouth unless advised to do so by a poison control center Poison Control 1-800-267-1373 English-French, toll- free Ontario 43 What Medications do BLS Medics carry? •Nitroglycerin •Ventolin •ASA •Glucagon •Oral Glucose •Dextrose •Epinephrine •Benadryl (diphenhydramine) •Gravol (dimenhydrinate) WHAT IS SYMPTOM ASSIST? The 5 Rights of Medication Administration • The right medication • The right person • The right dose/amount • The right route • The right time 45 As the baby's head comes out, support it with one hand. Do not pull on the baby. If the umbilical cord is around the baby's neck, gently loosen and unwrap it. Protect the baby's airway by keeping the mouth and nose clear of mucus or fluids. Allow the delivery to progress, but support the baby as they can be slippery upon complete delivery. Insure the baby has an airway, is breathing (or crying), and has a pulse. Do NOT cut the umbilical cord. Wrap the baby in clean clothes and keep the baby warm. Document the time of birth! If the baby has no pulse, proceed with the CPR guidelines for an infant! ***DON’T FORGET ABOUT MOM!