Workshop 1-3: Airway/Vitals and SAMPLE, Lifting and Moving/Spinal Immobilization Long Backboard, Spinal Immobilization KED/Hare Traction
Airway/Vitals and SAMPLE
Equipment Required:
suction unit with canister and tubing adult bag valve mask oxygen tank with regulator oral airways nasal airways blood-pressure cuff x2 stethoscope x2 pen light vitals and SAMPLE recording sheets
Competencies:
Preparatory competencies
4 Must demonstrate the ability to assess a patient for breathing difficulty 5 Must demonstrate ability to acquire a pulse providing rate, rhythm, and strength 6 Must demonstrate ability to assess the skin color, temp, and condition in an adult 7 Must demonstrate ability to assess capillary refill in pt. < 6 yo. 8 Must demonstrate ability to assess the pupils as to equality, size, reactivity 9 Must demonstrate ability to obtain a blood pressure 10 Must demonstrate ability to obtain a SAMPLE history
Airway competencies
1 Must demonstrate ability to perform a chin-lift during an airway scenario 3 Must demonstrate ability to perform suctioning during an airway scenario using soft/rigid suction devices 5 Must demonstrate ability to assemble, connect to O2 and ventilate during airway scenario using BVM 6 Must demonstrate ability to ventilate using a BVM for 1 min each demonstration 9 Demonstrate how to insert OP airway during an airway scenario 10 Demonstrate how to insert NP airway during an airway scenario 11 Correctly operate O2 tanks and regulator
Airway
Proctor guidelines:
1. Have the students practice airway skills using the Airway, Oxygen and Ventilation VPEG.
2. Use the Proctor teaching points below but give the students as much hands-on time as possible.
Proctor teaching points:
1. Suctioning equipment Types of Units Mounted Portable – electrical or hand operated Suction Catheters Hard (rigid , tonsil, Yankauer) – preferred for oral suctioning, especially in children Soft – primarily for nasal and ET tube suctioning
2. How to Suction Indications for use- fluids (blood, vomitus) in the throat; gurgling sound is heard when breathing or when performing artificial ventilations Contraindications – none Turn machine on to 200-300 mm Hg Measure suction tubing
3. Oral suctioning –measure same as oral airway
4. Nasal suctioning- measure same as nasal airway
5. Insertion Insert with no suction on the catheter, apply suction and withdraw with a twisting motion Maximum suction time- 15 seconds for adults, 10 seconds for children, 5 seconds for infants
6. Oropharyngeal (oral) Airway Indications for use- unresponsive with no gag reflex Contraindications –gag reflex Measurement- center of mouth to angle of jaw in position of function, or corner of mouth to bottom of earlobe inverted Insertion Adults – inverted, then rotate Infant/child – right side up with tongue depressor
7. Nasopharyngeal (nasal) Airway Indications for use – patient with gag reflex or oral injures unable to maintain airway Contraindications –nasal blockage, basilar skull fracture; a painful stimulus, use only if needed Measurement-tip of nose to ear lobe; also consider diameter Insertion – lubricate, bevel toward septum, attempt right nostril first
8. Assembly of BVM Select appropriate size mask Connect BVM to oxygen source with supply tubing If mask has inflatable collar, ensure collar is properly inflated Turn on oxygen and set flowmeter to at least 15 lpm
9. Positioning the BVM Take position at patients head and open the airway Insert airway adjunct if indicated Apply mask to patients face with the base of the mask in the groove between the lower lip and the chin and the apex over the bridge of the nose If mask has large round cuff surrounding the ventilation port, center the mask over the mouth
10. Hand positioning for two-person operation of BVM- place your thumb over the top half of mask, your index (and middle) fingers over the bottom half, and use your remaining fingers on the jaw to bring the jaw up to the mask; apply firm pressure to maintain an airtight seal; have your partner attach the BVM to the mask and squeeze the bag with two hands until the chest rises adequately
11. Hand positioning for one-person operation of BVM- place the thumb and index finger of one hand to form a "c" around the ventilation port, and use the remaining fingers on the jaw to bring the jaw up to the mask; apply firm pressure to maintain an airtight seal; attach the BVM to the mask and squeeze the bag with the other hand until the chest rises adequately
12. When no trauma is suspected, use the fingers to maintain head position with head tilt chin lift
13. When trauma is suspected, maintain C-spine stabilization and use the fingers to lift the jaw without tilting the head with jaw thrust
14. Ventilating the patient Choose the appropriate rate and observe for adequate chest rise and fall For the patient who is attempting to breathe, coordinate the ventilations with the patient's attempts to breathe Indications for use- patient not breathing or breathing inadequately Contraindications – facial trauma Two person operation more effective; use one person operation as a last resort
Vitals and SAMPLE
Proctor guidelines:
1. Have the students practice obtaining pulse, blood pressure, and respirations.
2. Discuss with the students how to assess a patient's breathing by looking at the patient as soon as they enter the room of the patient.
3. Have the students practice assessing mental status (AVPU), pupils, and skin color temperature and condition.
4. Have the students practice performing cap refill.
5. Have the students obtain SAMPLE history and OPQRST.
6. Have students record their findings on the Vitals and SAMPLE recording sheets.
7. Use the Proctor teaching points below but give the students as much hands-on time as possible.
Proctor teaching points:
General
1. Ages for emergency care purposes Infant- 0-1 years of age Child- 1-8 years of age or 1-signs of puberty Adult - >8 years of age or from signs of puberty
2. Baseline vital signs- the initial set of vital signs; consists of blood pressure, pulse, respirations
3. Other vital signs include- skin color temperature and condition, pupils, mental status
4. Other important patient information Chief complaint (CC) - why EMS was called, usually in the patient's words Sample history OPQRST when appropriate
Mental status or level of consciousness (LOC)
1. Assessed by observing the patient's level of responsiveness (AVPU) A- Alert V-Verbal P-Pain U-Unresponsive
2. Alert- patient is awake; must determine if they are oriented or disoriented oriented- they know their name, where they are, the time, interacting properly disoriented- do not know some or all of the above, not interacting properly, possibly asking repetitive questions
3. Verbal- patient is not awake but does respond to voice; for ex. You call their name 4. Pain- patient is not awake but does respond to painful stimuli; pinch their shoulders, No Sternal Rubs
5. Unresponsive- does not respond to anything; often loses cough and gag reflex and cannot control their airway
6. Glascow Coma Scale (GCS) is another way to measure mental status and is especially useful for the trauma patient with altered mental status; documented on every patient on patient care reports
Pulse
1. Pressure wave as heart contracts
2. Assess initially during primary by palpating the radial or carotid (if not breathing) pulse Use brachial or apical pulse in infants If radial pulse not palpable, assess carotid Never assess carotid on both sides at the same time Avoid excessive pressure on carotid, especially in geriatric patients
3. Rhythm - regular or irregular If irregular, count for a full minute
4. Quality - strong, weak or thready (weak and rapid)
5. Rate – fast, slow, normal 6. Assess during secondary by counting the number of beats in 30 seconds and multiplying by 2
7. Normal resting rates Adult - 60-100/min (athletes and some cardiac meds have lower rate) Child - 80-120/min Infant- 120-140/min Worry if adult <50 or > 120/min
Skin color, temperature, condition
1. Measure of perfusion, indication of shock
2. Assessment for color- look at the face, the nail beds, or inside the lips to determine peripheral perfusion to the skin; infants and small children, use palm of hand or sole of foot Normal skin color - pink Abnormal skin colors Pale (white) - poor perfusion Cyanotic (blue-gray) - inadequate oxygenation Flushed (red) - exposure to heat Jaundiced (yellow) - liver abnormalities Mottled (blotchy) - inadequate perfusion, especially in infants and children
3. Assessment for temperature- place back of hand on skin, usually on forehead or cheek Normal skin temperature - warm Abnormal skin temperatures (relative to ambient) Hot - indicating fever or extreme exposure to heat Cool - indicating poor perfusion or exposure to cold Cold - indicating extreme exposure to cold
4. Assessment for condition- place back of hand on skin, usually on forehead or cheek and observe and feel moisture (relative to ambient) Normal skin condition - dry Abnormal skin condition - wet, moist or inappropriately dry
5. Assessment of capillary refill - this sign most reliable in infants and children <6 yo Press on nail beds (palm of hand or sole of foot for infants) and measure the time for pink color to return Room temperature cap refill is normal if pink color returns in <2 sec for infants, children and adult males <3 sec for adult females <4 sec for geriatric patients Room temperature cap refill is delayed if pink color returns in >2 sec for infants, children and adult males >3 sec for adult females >4 sec for geriatric patients Absent for all patients if no pink return or if blue return Cap refill is unreliable in a cold environment and not generally used in patients >6 years old
Pupils
1. Evaluates perfusion to the brain
2. Assess by observing size and by briefly shining a light into the patient's eyes to determine reactivity Size - depends on ambient light level Dilated (large) Normal Constricted (small) Equal or unequal Reactivity - how the pupils change in response to light Reactive - change appropriately when exposed to light Unreactive - do not change when exposed to light Equally or unequally reactive to light PERL - Pupils are Equally Reactive to Light
3. Abnormalities can indicate traumatic brain injuries, stroke, drug overdoses, etc.
Blood pressure
1. Assess by using a BP cuff (sphygmomanometer) to obtain pressures BP should be taken on all patients >3 yo Wait at least 1 min before retaking BP on same arm Reported in even mmHg
2. Blood pressure Normals for adult Systolic For male - 100 + age up to 140 mmHg For female -90 + age up to 140 mmHg Diastolic - 60-90 mmHg for both High blood pressure (hypertension) Systolic >140 mmHg, or Diastolic >90 mmHg
3. Two methods of obtaining blood pressure Auscultation - listening with a stethoscope
Systolic - first distinct sound you hear as pressure in the BP cuff is slowly released Diastolic - last distinct sound you hear as pressure in the BP cuff is slowly released Palpation - systolic pressure determined by feeling the initial return of the radial pulse as pressure in the BP cuff is slowly released. BP by palpation typically 10 mmHg less than BP by auscultation
Respirations
1. Assess by observing the rise and fall of the chest and by listening to breath sounds
2. Rhythm - regular or irregular Irregular rhythm of more concern in a non-alert patient Count for a full minute if irregular in a non-alert patient
3. Quality - evaluate by observing and by listening to breath sounds, comparing side to side in at least 2 places Normal Chest expansion - equal with adequate tidal volume Respiratory effort (work of breathing) - minimal and unlabored Breath sounds - present and equal bilaterally with no unusual sounds Abnormal Chest expansion- shallow (slight chest and abdominal wall motion) with inadequate tidal volume (volume of air in a breath), shallow breathing of more concern in a non-alert patient Respiratory effort- increased and labored (working hard to breathe), accessory muscles use, nasal flaring or retractions, especially in infants and children Breath sounds- absent, unequal, noisy with increase in audible sound of breathing
4. Rate - fast, slow, normal
5. Assess during secondary by counting the number of breaths in 30 seconds and multiplying by 2 Normal resting rates Adult - 12-20/min (athletes lower) Child-15-30/min Infant - 25-50/min Worry if adult <12 or >20/min (limits for considering BVM) When determining respiration rate, do not let the patient know what you are doing to keep from affecting the results
SAMPLE
1. Signs/Symptoms Sign - any condition displayed by the patient and identified by you based on your own senses Symptom - any condition described by the patient
2. Allergies To medication - are you allergic to any medications? If none, enter NKDA (no known drug allergies) on patient care report To food or environmental - are you allergic to any other things? Look for medical ID tag if not alert
3. Medications Prescription - do you take any medications on a regular basis? Current and recent Birth control pills Non-prescription Current and recent Vitamin pills, supplements Recreational - ask under appropriate circumstances Look for medical ID tag if not alert
4. Pertinent past history Medical - are you under a doctor's care for any medical problems? Injuries - has this ever happened before? Doctor's name - who is your regular doctor? Look for medical ID tag if not alert
5. Last oral intake Solid or liquid When did you last eat or have something to drink?
6. Events leading to the injury or illness What were you doing just prior to ...? Were you doing anything that caused the injury, illness, or the symptoms?
OPQRST
1. Onset- What were you doing when this started? Is this a recurring issue or a new onset?
2. Provocation- Does anything make it feel better or worse?
3. Quality- How would you describe the pain or discomfort? For ex. squeezing, dull, pressure, sharp, etc.
4. Radiation- Does the pain or discomfort go anywhere else?
5. Severity- On a scale from 1 to 10, with 10 being the worst pain or discomfort you've ever felt, what number would you give this pain or discomfort?
6. Time- How long ago did this begin? Has the condition changed since it began?
Lifting and Moving/Spinal Immobilization Long Backboard
Equipment Required:
combi carrier (scoop stretcher) long backboard CID c-collars cravats backboard straps
Competencies:
Preparatory competencies
13 Move Patient using Spine board
Trauma competencies
29 Demonstrate stabilization of the cervical spine. (during scenario) 30 Demonstrate the four person log roll for a pt. with a suspected spinal cord injury (during scenario) 31 Demonstrate how to log roll a pt. with a suspected spinal cord injury using two people (during scenario) 32 Demonstrate securing a pt to a long spine board (during scenario)
Combi Carrier (scoop stretcher)
Proctor guidelines:
1. Discuss the uses of the Combi carrier (scoop stretcher).
2. Have the students place a patient on the Combi carrier (scoop stretcher).
3. Have the students move and prepare a patient for transport on the Combi carrier (scoop stretcher).
4. Use the Proctor teaching points below and answer the students questions but allow the students as much hands-on time as possible.
Proctor teaching points:
1. The Combi carrier (scoop stretcher) can be used for patients who have a suspect hip fracture, are unable to be moved from his or her location by other means, and are unable to be backboarded but require spinal immobilization.
Standing Backboard Proctor guidelines:
1. Have the students practice performing standing backboard immobilization. Use the Spinal Immobilization Supine Patient VPEG.
2. Ensure that the students are performing the skills safely.
3. Use the Proctor teaching points below and answer the students questions but allow the students as much hands-on time as possible.
Proctor teaching points:
1. The long backboard is used for spinal and full body immobilization.
2. The cervical immobilization device (CID) is used on long backboards to immobilize the head. Secure the head in the immobilizer, padding as necessary, after securing the body to the backboard.
3. The cervical collar (c-collar) is used for patients with suspected spinal injuries. The patient head should be in neutral in-line position before applying the collar.
4. Manual stabilization of C-spine must continue until the head is secured to a spine board even after the c-collar is applied.
5. If a proper size c-collar is unavailable or if a collar cannot be applied for any reason you can improvise and use towels, blankets, etc.
6. A standing backboard is used when a patient is found standing or walking around and has a suspected spinal injury. Do not ask the patient to sit down on a backboard, immediately immobilize the patient when you encounter him or her.
Spinal Immobilization Supine Patient VPEG
Proctor guidelines:
1. Have the students demonstrate proper back boarding techniques for a patient lying in the supine position using the Spinal Immobilization-Supine Patient VPEG.
2. Have the students demonstrate 2 and 4 person log rolls of patients with suspected spinal injuries when moving the patient to the long backboard.
3. Discuss with students how to safely move a patient on a backboard to and from the stretcher.
4. Use the Proctor teaching points listed below and answer the students questions but allow the students as much hands-on time as possible.
Proctor teaching points: 1. The long backboard is used for spinal and full body immobilization.
2. The cervical immobilization device (CID) is used on long backboards to immobilize the head. Secure the head in the immobilizer, padding as necessary, after securing the body to the backboard.
3. The cervical collar (c-collar) is used for patients with suspected spinal injuries. The patient head should be in neutral in-line position before applying the collar.
4. Manual stabilization of C-spine must continue until the head is secured to a spine board even after the c-collar is applied.
5. If a proper size c-collar is unavailable or if a collar cannot be applied for any reason you can improvise and use towels, blankets, etc.
6. The person holding C-spine is always in control of patient movement. He or she will signal when to begin the log roll of the patient.
7. Always log roll the patient towards you.
8. Suspect a spinal cord injury if the patient has; altered sensation in the extremities, loss of sensation or paralysis, loss of control of bladder/rectum, obvious deformity of the spine, pain upon palpation of spine, neck and/or back pain, and/or MOI.
9. PMS is pulse, motor (wiggle/move fingers and toes), sensation (feel fingers and toes). No strength testing
Spinal Immobilization KED/Hare Traction
Equipment Required:
KED c-collars cravats Hare traction splint
Competencies:
Trauma competencies
23 Demonstrate care of pt. with painful swollen deformed thigh 29 Demonstrate stabilization of the cervical spine. (during scenario) 33 Demonstrate using the short board technique
KED
Proctor guidelines:
1. Introduce the students to the Spinal Immobilization- Seated Patient VPEG.
2. Have the students demonstrate proper back boarding techniques for a patient in the seated position using the Spinal Immobilization- Seated Patient VPEG.
3. Use the Proctor teaching points listed below and answer the students questions but allow the students as much hands-on time as possible.
Proctor teaching points:
1. The short spine board (KED) is used for spinal immobilization of the stable seated patient.
2. After the patient is secured in the KED the patient is then moved onto a long backboard and secured to it for transport.
3. The cervical collar (c-collar) is used for patients with suspected spinal injuries. The patient head should be in neutral in-line position before applying the collar.
4. Manual stabilization of C-spine must continue until the head is secured to a spine board, long or short, even after the c-collar is applied.
5. If a proper size c-collar is unavailable or if a collar cannot be applied for any reason you can improvise and use towels, blankets, etc.
Hare Traction Splint
Proctor guidelines:
1. Introduce the students to the Immobilization Skills-Traction Splint VPEG.
2. Have the students practice splinting skills using the Immobilization Skills-Traction Splint VPEG.
3. Use the Proctor teaching points below and answer the students questions but give the students as much hands-on time as possible.
Proctor teaching points:
1. Types of Bone and Joint Injuries - open (skin broken) vs closed
Fracture - break in the continuity of a bone Sprain - stretching or tearing of ligaments Dislocation - displacement of bone ends that form a joint - usually Involves a sprain Strain - stretching or tearing of muscles or tendons Any of the above injuries may present as painful, swollen or deformed
2. Signs and Symptoms of Musculoskeletal Injuries
Pain/point tenderness - most reliable indication of injury Swelling/bruising (ecchymosis) Deformity - shortened, rotated, angulated Guarding/loss of normal movement/locked joint Grating (crepitus)/false motion on movement
3. Reasons for Splinting
Prevent motion of injured bones/joints Minimize additional damage to soft tissues from broken bones Decrease pain and discomfort
4. General Principles
Stabilize above and below the injury site Evaluate neurovascular function (PMS) Expose the injury site and remove interfering jewelry Control any bleeding and dress open wounds Immobilize (splint) as appropriate Do not intentionally replace protruding bones Pad to fill voids with rigid splints Reevaluate neurovascular function (PMS) When in doubt, splint 5. Traction Splinting of Femur
Indications for use are single, closed, mid-thigh femur injury Contraindications for use include injury to the hip or pelvis; injury to the knee or close to the knee; injury to the lower leg, foot or ankle Never use on an unstable patient; utilize backboard as splint