Emergency Patient Care

Report
S.F.A, E.F.A, I.F.R, E.M.F.R.- March 2010
Compiled by: Joe Draper PCP
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Consent (ask permission )
Implied Consent ?
Can I be sued ?
Gross Negligence
Abandonment ?
Good Samaritan Act
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Governing Bodies:
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Ministry of Health (MOH)
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Base hospitals
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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
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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
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Head Tilt - Chin Lift
or Modified jaw
thrust
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One Hand on the
Lower Jaw
One Hand on the
Forehead
Insert oral airway or
Nasal airway
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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
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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!
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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
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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!!!
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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 ?
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Cardiac Pain
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“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
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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
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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
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Signs & Symptoms
 Rate/Depth
 Accessory Muscles
 Pale, Bluish Skin
 Coughing, Choking
 Restlessness
 Shortness of Breath
 Noisy Breathing
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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?
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Signs & Symptoms
What does EPI do?
Abdominal cramps,
vomiting, diarrhea
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Laceration
Partial or full
Amputation
Contusion
Avulsion
Abrasion
Bleeding Nose
Impaled Object
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When to suspect a Spinal Injury!
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Mechanism of Injury
Amnesia to event
Neck/Back Pain
Paralysis
Weakness
Numbness
Obvious Head Injury
Loss of consciousness
Priapism
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5
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Internal/External Types
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concussion
scalp wound
fractures
intracranial hemorrhage
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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
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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
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Non-Shockable Rhythms
Shockable Rythms
NORMAL SINUS RHYTHM
VENTRICULAR FIBRILLATION
ASYSTOLE
VENTRICULAR TACHYCARDIA
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Signs & Symptoms
Shortness of Breath
Bleeding
Coughing up blood.
Pain at the injury site
Engorged neck veins
Treatment
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The Approach
Cover holes
Valve
Reassure the patient!
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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
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:
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Rest
Immobilize (splinting)
Cold compress
Elevate (if applicable)
DS
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Chemical? – Electrical? - Radiation?
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Flush the
affected area
with large
amounts of
water
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Look for
entrance
and exit
wound
Cool the
burn area
and treat
accordingly
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BRAIN
S
U
G
A
R
PANCREAS
S
U
G
A
R
INSULIN
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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?
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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
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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
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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
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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!

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