EMERGENCY PATIENT CARE

S.F.A, E.F.A, I.F.R, E.M.F.R.- March 2010Compiled by: Joe Draper PCP

The Law

Consent (ask permission )

Implied Consent ? Can I be sued ? Gross Negligence Abandonment ? Good Samaritan Act

2

Health System in OntarioGoverning 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 ScaleEvery patient is assigned a number between 1-5 regardingtheir level of severity. ie: VSA=1, hurt toe=5

Primary Assessment1. Assume control of the situation/scene:

E- EnvironmentM- Mechanism of injury/illnessC- Number of casualtiesA- Assistance from other resources

3. Establish a baseline level of awareness:

A- Alert V- Alert to VERBAL stimulusP- Alert to PAINFUL stimulusU- Unresponsive

PROTECT C-SPINE UNTIL RULED OUT!!!

2. Introduction:Approach, and introduce yourselfObtain consent, and explain your procedures

Primary Assessment Con’t

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 movementAuscultation of air movement in all fieldsInspect 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.

Primary Assessment Con’t

7. Assess the circulatory status:Palpation of radial or central pulseObtain a blood pressureInspection for any gross bleedsDetermine need for defibrillate and cardiac monitoring***Look for ANY “signs of life”

8. Assess the following for life threatening injuries/problems:ChestAbdomenPelvisFemurs

Assessment ToolsCLAPS(D)=

C- contusionsL- lacerationsA- abrasionsP- penetrationsS- symmetryD- deformity/distention

TICS(D)=

T- tendernessI- instabilityC- crepitusS- subcutaneous emphysemaD- deformity/distention

SAMPLE=S- signs and symptomsA- allergiesM- medicationsP- past medical historyL- last oral intakeE- events preceding incident/illness

Use these AFTER all life threateningProblems have been corrected!!!

SIGN vs SYMPTOM?

M.O.I.- Mechanism Of Injury/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

Injury10

AirwayHead 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

Breathing 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

12

TO AVOID GASTRIC DISTENTION

Circulation

•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!

Rt Atrium

Rt Ventricle

Lt Atrium

Lt Ventricle

BLOOD PRESSURES

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?

C.P.R. GuidelinesPatient Age

(yrs) Ratio Depth Of Chest Rate

Adult 8 + 30 : 2 1½ to 2 inches 100/min

Child 1 – 8 15 : 1 1/3 to 1/2 Depth of

chest 100/min

Infant 28days – 1 15: 1

1/3 to 1/2 Depth of chest

120+/min

REMEMBER- PUSH HARD! PUSH FAST!

Rapid Body SurveyAssess Head to Toe For: Severe Bleeding Check skin temperature Soft tissue injuries Burns Medic Alert Anything assessed that looks abnormal!

16

Treat For Shock

Shock

17

Signs & SymptomsAnxietyConfusionRapid breathingNausea and vomitingCool, clammy or mottled skinRapid heart and breathing rateUnconscious ?

SHOCK 02

VESSELS VOLUME

PUMP

SHOCK= a state when there is widespread reduction of tissue perfusion resulting in: decreased oxygenation of cells, and inadequate removal of toxic byproducts.

18

ShockTypes of Shock Examples

Septic:: Severe illness caused by overwhelming infection of the bloodstream Hemorrhagic:: Large amount of blood loss externally and/or internallyObstructive: Airway obstruction, Chest wound causing collapse of lungCardiogenic: Heart attack, Sudden cardiac arrest.Anaphylaxis: Severe allergic reaction causing airway swelling. Neurological: Neurological system or spinal shock.

MILD MODERATE SEVERE Fast HR >100 Fast HR>120 Slow HR <60 Fast RR >16 Fast RR >20 Slow RR <12 Normal skin Pale, cold skin Pale, cold, clammy

Restless Confusion Unconsciousness

Secondary Assesment

19

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 CHANGESRE-START YOUR PRIMARY EXAM!!!

Medical AbbreviationsAMI- Acute Myocardial InfarctionAEMCA- Advanced Emergency Medical Care AssistantALS- Advanced Life SupportAPGAR- American Pediatric Gross Assessment RecordPRN- As requiredBVM- Bag Valve MaskBLS- Basic Life SupportPO- By MouthCA- CancerCACC- Central Ambulance Communications CentreCNS- Central Nervous SystemCVA- Cerebrovascular Accident (stroke)COPD- Chronic Obstructive Pulmonary DiseaseCHF- Congestive Heart Failure

Medical Abbreviations Con’t

CTAS- Canadian Triage & Acuity ScaleDNR- Do Not ResuscitateGCS- Glascow Coma ScaleJVD- Jugular Vein DistentionLOA- Level Of AwarenessMCI- Mass Casualty IncidentPEARL- Pupils Equal And Reactive to LightROSC- Return Of Spontaneous CirculationSAED- Semi Automatic External DefibulatorTIA- Transient Ischemic AttackUTI- Urinary Tract InfectionVSA- Vital Signs Absent

Cardiovascular Disease Over 78,000 deaths per year in Canada, 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

Progression of Atherosclerosis

Chest PainCardiac 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

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?How do we treat these?

Does being a woman change things???

Stroke

24

Signs & Symptoms Sudden Headache Dizziness/Confusion Facial Drooping Slurred Speech Arm Drift Weakness/Paralysis T. I. A. ( Mini Stroke)

Emboli

ThrombusBlood Flow from the heart

Hemorrhage

Respiratory EmergenciesSigns & Symptoms Rate/Depth Accessory Muscles Pale, Bluish Skin Coughing, Choking Restlessness Shortness of Breath

Noisy Breathing25

Respiratory Diseases1. Asthma2. Emphysema3. Bronchitis4. Pneumonia5. Congestive Heart Failure

ALWAYS GIVE O2!!!!!HOW MUCH THOUGH?

Anaphylaxis

27

AllergensPeanutsSeafoodInsect BitesMedicationsLatexOthers?

Anaphylaxis

28

Abdominal cramps, vomiting, diarrhea

Signs & Symptoms

What does EPI do?

Bleeding and Wound Types

29

Laceration Contusion Abrasion

Partial or full Amputation Avulsion Impaled Object

Bleeding Nose

Spinal Cord Injury

Mechanism of Injury Amnesia to event Neck/Back Pain Paralysis Weakness Numbness Obvious Head Injury Loss of consciousness Priapism

30

When to suspect a Spinal Injury!

7

12

5

Head & Brain Injuries

Internal/External Types concussion scalp wound fractures intracranial hemorrhage

31

Head & Brain Injury

32

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

SeizuresCauses Epilepsy Stroke Febrile (children) Others?

Signs & Symptoms1. A taste or smell prior to. 2. may appear

daydreaming.3. uncontrollable muscle

movement.4. Loss of bowel/bladder

33D

Heart Rhythms

34

NORMAL SINUS RHYTHM VENTRICULAR FIBRILLATION

Shockable RythmsNon-Shockable Rhythms

VENTRICULAR TACHYCARDIAASYSTOLE

Penetrating chest wound: Pneumothorax

35

Treatment The Approach Cover holes Valve Reassure the patient!

Signs & SymptomsShortness of BreathBleedingCoughing up blood.Pain at the injury siteEngorged neck veins

Abdominal/Pelvic Injuries

36

PELVIS

Blunt or Penetrating Trauma may cause:Int./Ext. BleedingPain & Tenderness

to the affected areaGuardingDistentionPainful urination

Potential for significant blood loss

Musculoskeletal Injuries

: Rest Immobilize (splinting)

Cold compress Elevate (if applicable)

37D S

Burns Types

Flush the affected area with large amounts of water

Look for entrance and exit wound

38

Chemical? – Electrical? - Radiation?Cool the burn area and treat accordingly

Degree of Burns

39

Diabetes

40

BRAINB L O O D S U G A R

INSULIN

SUGAR

SUGAR

PANCREAS

Diabetic Emergencies

41

Hypoglycemic or Hyperglycemic?

Hypoglycemia:*Fast onset*Too much insulin/not enough sugarSigns and Symptoms:•Drunk in appearance•Pale and very sweaty•Seizures/agression•CBG <4 mmolsTreatment:Conscious?- Give food, juice etc.Unconscious?- ABC’s, full assessment

Hyperglycemia:*Slow onset*Too much sugar/not enough insulinSigns and Symptoms:•CBG >15mmols•Acetone breath•Fast breathing•Dry/Red skinTreatment?

Environmental Emergencies

42

Hyperthermia

Hypothermia

TreatmentKeep patient warmRemove wet clothsGive Warm FluidsRecovery Position

TreatmentCool PatientRemove From SunGive Cool FluidsRecovery Position

Poisoning

43

Poison Control1-800-267-1373  English-French, toll- free Ontario

CALL LOCAL POISON CONTROLOR CALL 911OR CALL O FOR OPERATORDo not administer anything by mouth unless advised to do so by a poison control center

EMS MEDICATIONSWhat Medications do BLS Medics carry?•Nitroglycerin•Ventolin•ASA•Glucagon•Oral Glucose•Dextrose•Epinephrine•Benadryl (diphenhydramine)•Gravol (dimenhydrinate)

WHAT IS SYMPTOM ASSIST?

Medication AssistanceThe 5 Rights of Medication

Administration• The right medication• The right person• The right dose/amount• The right route• The right time

45

Obstetrical Emergencies 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!