2013 pocket paramedic

1

PocketParamedic.org [email protected]

Pocket Paramedic 2013

By Jason Houghton

A collaboration of useful guidelines In a quick reference pocket book;

tailored for pre-hospital care.

2

Pocket Paramedic 2013 “An elegant solution to a simple problem” A collaboration of useful guidelines in a quick reference pocket book tailored for pre-hospital care. This handy pocket book resulted from my quest to consolidate the most relevant and useful guidance into a single source; something that can be carried in your pocket at all times - whenever you may need it. Pocket Paramedic is 100% non-profit. Sold at cost. Hopefully, this will mean more people can benefit from it. Download the FREE electronic edition from: PocketParamedic.org I hope you find it useful. Jason Houghton - Paramedic [email protected]

user

Typewriter

http://www.pocketparamedic.org/PocketParamedic2013.pdf

3

Contents

Adults Algorithms and Charts

4

Paediatrics Algorithms and Charts

19

Obstetrics Useful Information and Charts

32

Equipment Instructions and Guidance

37

Assessment & History Taking Aid memoirs, Acronyms and Diagnosis

45

Trauma & Medical Emergencies Useful Information and Charts

53

Anatomy Diagrams and Terminology

62

ECG & ETCO2 Interpretation Examples and Explanations

68

Major Incidents Acronyms and Plan of Action

77

Infection Prevention & Control Useful Information

91

Key Contacts Phone Numbers

96

Notes Extra Space

97

References Credits and Information Sources

99

4

Adults Algorithms and Charts

Adult Basic Life Support 5

Adult Advanced Life Support 6

Adult Cardiac Arrest 7

Adult Bradycardia 8

Adult Tachycardia (With Pulse) 9

Adult Chocking Treatment 10

In Hospital Resuscitation 11

AED Algorithm 12

Adult Glasgow Coma Scale 13

Adult Normal Ranges & Drug Dosages 14

Normal Peak Flow Readings 15

Normal Peak Flow Readings Chart - Men 16

Normal Peak Flow Readings Chart - Women 17

Adult Analgesic Ladder 18

5

Adult Basic Life Support 10

Ad

ult

s

6

Adult Advanced Life Support 10 A

du

lts

7

Adult Cardiac Arrest 10

Ad

ult

s

8

Adult Bradycardia 10 A

du

lts

9

Ad

ult

s

A

du

lt Tachyca

rdia (W

ith P

ulse

) 10

10

Adult Choking Treatment 10 A

du

lts

11

In Hospital Resuscitation 10

Ad

ult

s

12

AED Algorithm 10 A

du

lts

13

Adult Glasgow Coma Scale

Eyes

Verbal

Motor

4 Opens Eyes Spontaneously

3 Opens Eyes in Response to Voice

2 Opens Eyes in Response to Painful Stimuli

1 Does Not Open Eyes

5 Oriented, Converses Normally

4 Confused, Disoriented

3 Utters Inappropriate Words

2 Incomprehensible Sounds

1 Makes No Sounds

6 Obeys Commands

5 Localizes Painful Stimuli

4 Flexion / Withdrawal to Painful Stimuli

3 Abnormal Flexion to Painful Stimuli (Decorticate)

2 Extension to Painful Stimuli (Decerebrate)

1 Makes No Movements

Ad

ult

s

14

Adult Normal Ranges & Dosages

Parameter Unit Value

Heart Rate BPM 60 - 100

Respiratory Rate BPM 12 - 19

SpO2 % ≥ 95

BP Systolic mmHg 100 - 170

BP Diastolic mmHg 60 - 80

Blood Glucose (BM) mmol/L 5 - 10.9

Energy 1st Shock Joules 200

Energy 2nd Shock Joules 300

Energy 3rd Shock Joules 360

Adrenaline 1:10000 mg (ml) 1 (10)

Amiodarone mg (ml) 300 (10)

Amiodarone (Refractory VF/VT) mg (ml) 150 (5)

Ad

ult

s

15

Normal Peak Flow Readings 8 EU/EN13826 PEF Meters Only

Ad

ult

s

16

Ad

ult

s

No

rmal

Pe

ak F

low

Re

adin

gs C

har

t -

Me

n 8

17

Ad

ult

s

N

orm

al Pe

ak Flow

Re

adin

gs Ch

art - Wo

me

n 8

18

Adult Analgesic Ladder (12 Years and Older)

Pain Score Medical Pain

Trauma, Orthopaedic,

Musculoskeletal & Soft tissue Pain

0 – 3 Mild Pain

Consider Entonox +/-

Ibuprofen 400MG


Ibuprofen 400MG

4 – 6 Moderate Pain


Morphine 2.5 to 5mg

(Max 20mg)


Ibuprofen 400MG

7 – 10 Severe

Pain


Morphine 2.5 to 5mg

(Max 20mg)


Ibuprofen 400MG +/-

Morphine 2.5 to 5mg

(Max 20mg)

For Cardiac Related Chest Pain Morphine Should be Considered in the First Instance

Ad

ult

s

19

Paediatrics

Paediatric Basic Life Support 20

Paediatric Advanced Life Support 21

Paediatric Cardiac Arrest 22

Newborn Advanced Life Support 23

Paediatric Chocking Treatment 24

Paediatric Glasgow Coma Scale 25

Paediatric Arrest Calculations 26

Paediatric Normal Ranges & Arrest Dosages 27

Normal Peak Flow Readings Chart - Paediatric 28

Pain Assessment Faces 29

FLACC Scale Pain Assessment 30

Paediatric Analgesic Ladder 31

20

Paediatric Basic Life Support 10 P

aed

iatr

ics

21

Paediatric Advanced Life Support 10

Pa

edia

tric

s

22

Paediatric Cardiac Arrest 10 P

aed

iatr

ics

23

Newborn Life Support 10

Pa

edia

tric

s

24

Paediatric Choking Treatment 10 P

aed

iatr

ics

25

Paediatric Glasgow Coma Scale

Eyes

Verbal

Motor

4 Opens Eyes Spontaneously

3 Opens Eyes in Response to Speech

2 Opens Eyes in Response to Painful Stimuli

1 Does Not Open Eyes

5 Smiles, Orients to Sounds, Objects, Interacts

4 Cries but Consolable, Inappropriate Interactions

3 Inconsistently Inconsolable, Moaning

2 Inconsolable, Agitated

1 No Verbal Response

6 Infant Moves Spontaneously or Purposefully

5 Infant Withdraws from Touch

4 Infant Withdraws from Pain

3 Abnormal Flexion to Pain for Infant (Decorticate)

2 Extension to Pain (Decerebrate)

1 No motor response

Pa

edia

tric

s

26

Paediatric Arrest Calculations 10 WEIGHT

ENERGY

TUBE SIZE

FLUID

ADRENALINE AMIODARONE

GLUCOSE

Age Formula 0 – 12 Months Weight (kg) = (Age in Months x 0.5) + 4 1 – 5 Years Weight (kg) = (Age in Years x 2) + 8 6 – 12 Years Weight (kg) = (Age in Years x 3) + 7

Age Formula 0 – 12 Years Joules = Weight (kg) x 4j

Age Formula Pre Term 2.5mm Neonates 3 – 3.5mm

1 – 10 Years Internal diameter (mm) = (Age/4) + 4 Length (cm) = (Age/2) + 12

Type Formula (0 – 12 Years) Medical Bolus (ml) = Weight (kg) x 20ml Trauma Bolus (ml) = Weight (kg) x 10ml Concealed Haem Bolus (ml) = Weight (kg) x 5ml

Formula (1:10,000) (0 – 12 Years) Formula (300mg in 10ml) (0 – 12 Years)

Dose (mcg) = Weight (kg) x 10mcg (0.1ml)

Dose (mg) = Weight (kg) x 5mg …Then ml’s = Dose (mg) / 30)

Age Formula 0 – 12 Years Dose (ml) 10% Glucose = Weight (kg) x 2ml

Resuscitation Council UK 2010

Pa

edia

tric

s

27

Age

HR

(BP

M)

RR

(PM

) B

P (Systo

lic) W

eigh

t (kg)

Ene

rgy (Jo

ule

s) Tu

be

(mm

) Flu

ids

(ml)

Ad

ren

aline

(ml) (m

cg) A

mio

daro

ne

(ml) (m

g) G

luco

se (m

l) B

irth 1

10

-16

0 3

0-4

0 7

0-9

0 4

20

3 8

0 0

.40

(40

) 0

.67

(20

) 8

1 M

1

10

-16

0 3

0-4

0 7

0-9

0 4

.5 2

0 3

90

0.4

5 (4

5)

0.7

5 (2

2.5

) 9

3 M

1

10

-16

0 3

0-4

0 7

0-9

0 5

.5 2

5 3

.5 1

10

0.5

5 (5

5)

0.9

2 (2

7.5

) 1

1 6

M

11

0-1

60

30

-40

70

-90

7 4

0 4

14

0 0

.70

(70

) 1

.17

(35

) 1

4 9

M

11

0-1

60

30

-40

70

-90

8.5

40

4 1

70

0.8

5 (8

5)

1.4

2 (4

2.5

) 1

7 1

2 M

1

10

-15

0 2

5-3

5 8

0-9

5 1

0 4

0 4

.5 2

00

1.0

(10

0)

1.6

7 (5

0)

20

18

M

10

0-1

50

25

-35

80

-95

11

50

4.5

22

0 1

.1 (1

10

) 1

.83

(55

) 2

2 2

Yr

95

-14

0 2

5-3

0 8

0-1

00

12

50

5 2

40

1.2

(12

0)

2.0

0 (6

0)

24

3 Y

r 9

5-1

40

25

-30

80

-10

0 1

4 6

0 5

28

0 1

.4 (1

40

) 2

.30

(70

) 2

8 4

Yr

95

-14

0 2

5-3

0 8

0-1

00

16

70

5 3

20

1.6

(16

0)

2.6

6 (8

0)

32

5 Y

r 8

0-1

20

20

-25

90

-10

0 1

8 8

0 5

.5 3

60

1.8

(18

0)

3.0

0 (9

0)

36

6 Y

r 8

0-1

20

20

-25

80

-11

0 2

5 8

0 6

50

0 2

.5 (2

50

) 4

.20

(12

5)

50

7 Y

r 8

0-1

20

20

-25

90

-11

0 2

8 1

00

6 5

60

2.8

(28

0)

4.6

7 (1

40

) 5

6 8

Yr

80

-12

0 2

0-2

5 9

0-1

10

31

10

0 6

.5 6

20

3.1

(31

0)

5.1

2 (1

55

) 6

2 9

Yr

80

-12

0 2

0-2

5 9

0-1

10

34

12

0 6

.5 6

80

3.4

(34

0)

5.6

7 (1

70

) 6

8 1

0 Y

r 8

0-1

20

20

-25

90

-11

0 3

7 1

30

7 7

40

3.7

(37

0)

6.1

7 (1

85

) 7

4 1

1 Y

r 8

0-1

20

20

-25

90

-11

0 4

0 1

40

7 8

00

4.0

(40

0)

6.6

7 (2

00

) 8

0

P

aed

iatric No

rmal R

ange

s & A

rrest D

rug D

osage

s 2

01

3

Pa

edia

tric

s

28

N

orm

al P

eak

Flo

w C

ha

rt -

Pae

dia

tric

s 8

Pa

edia

tric

s

29

Pae

diatric P

ain A

ssessm

en

t Faces

Pa

edia

tric

s

30

Cri

teri

a 0

1

2

Face

N

o p

arti

cula

r ex

pre

ssio

n o

r sm

ile

Occ

asio

nal

gri

mac

e o

r fr

ow

n,

wit

hd

raw

n, u

nin

tere

sted

Fr

equ

ent

to c

on

stan

t q

uiv

erin

g ch

in, c

len

ched

jaw

Legs

N

orm

al p

osi

tio

n o

r re

laxe

d

Un

easy

, res

tles

s, t

ense

K

icki

ng,

or

legs

dra

wn

up

Acti

vity

Ly

ing

qu

ietl

y, n

orm

al

po

siti

on

, mo

ves

easi

ly

Squ

irm

ing,

sh

iftin

g b

ack

and

fo

rth

, ten

se

Arc

hed

, rig

id o

r je

rkin

g

Cry

N

o c

ry (

awak

e o

r as

leep

) M

oan

s o

r w

him

per

s;

occ

asio

nal

co

mp

lain

t C

ryin

g st

ead

ily, s

crea

ms

or

sob

s, f

req

uen

t co

mp

lain

ts

Co

nso

lab

ility

C

on

ten

t, r

elax

ed

Rea

ssu

red

by

occ

asio

nal

to

uch

ing,

hu

ggin

g o

r b

ein

g ta

lked

to

, dis

trac

tib

le

Diffi

cult

to

co

nso

le o

r co

mfo

rt

FL

AC

C S

cale

P

aed

iatr

ic N

on

-Ver

ba

l Pa

in A

sses

smen

t To

ol

Pa

edia

tric

s

31

Paediatric Analgesic Ladder (Under 12 Years)

Pain Score Medical Pain

Trauma, Orthopaedic,

Musculoskeletal & Soft tissue Pain

0 – 3 Mild Pain


Ibuprofen &/or Paracetamol



4 – 6 Moderate

Pain


Morphine



7 – 10 Severe

Pain


Morphine



+/- Morphine

For Cardiac Related Chest Pain Morphine Should be Considered in the First Instance

Pa

edia

tric

s

32

Obstetrics Algorithms and Charts

APGAR Score for Newborns 33

Mechanics of Normal Birth 34

Shoulder Dystocia 35

Breech Birth Delivery 36

33

APGAR Score for Newborns Appearance

Pulse

Grimace

Activity

Respiration

1 Blue or Pale All Over

2 Blue at Extremities, Body Pink

3 No Cyanosis, Body and Extremities Pink

1 Absent

2 <100

3 ≥100

1 No Response to Stimulation

2 Grimace/Feeble Cry when Stimulated

3 Cry or Pull Away when Stimulated

1 None

2 Some Flexion

3 Flexed Arms and Legs that Resist Extension

1 Absent

2 Weak, Irregular, Gasping

3 Strong, Lusty Cry

Ob

stet

rics

34

Mechanics of Normal Birth 5 O

bst

etri

cs

35

Shoulder Dystocia 4

The McRoberts' manoeuvre is a procedure performed to release a baby's impacted shoulder during shoulder dystocia. The mother's legs are held back in a flexed position and pulled to her chest to further open the pelvis and allow the baby's shoulder to be released. At the same time suprapubic pressure is applied to the mother's lower abdomen over the pubic bone.

Ob

stet

rics

36

Breech Birth Delivery 5

1

4

2

5

3

6

Ob

stet

rics

37

Equipment Instructions and Guidance

Laerdal Suction Unit 38

ParaPAC Operation 39

Fitting a Collar 40

Fitting a Donway 41

Fitting a Donway Continued 42

Fitting a KED 43

Fitting a KED Continued 44

38

Laerdal Suction Unit 6

Procedure for Daily Test. 1 Ensure that tubing is unwound and un-occluded

2 Ensure the suction catheter adapter is removed from the holder (if applicable)

3 Ensure the canister lid, T-bar, angled connector and tubing are securely fastened.

4

To run the test, press and hold the test button while setting the operating switch to 500+mmHg. Do not release the test button until a minimum of 2 seconds after the operating switch has been set to 500mmHg. The test will start immediately.

5

As soon as LED 2 from the bottom of the battery status indicator comes on (takes approximately 1 second) fully occlude the patient suction tubing until all 4 LED’s have illuminated and LED 1 lights up again.

6 Keep the tubing blocked while LED 2, 3 and 4 lights up. 7 Release the tubing when LED 1 comes on again. 8 Evaluate the test results.

9 After evaluating the test results, turn the operating switch to “0” to exit the device test.

Equ

ipm

ent

39

ParaPA

C O

pe

ratio

n 1

1

Equ

ipm

ent

40

Fi

ttin

g a

Ce

rvic

al C

olla

r 9

Equ

ipm

ent

41

Fittin

g a Do

nw

ay 9

Equ

ipm

ent

42

Fi

ttin

g a

Do

nw

ay C

on

tin

ue

d 9

Equ

ipm

ent

43

Fittin

g a KED

9

Equ

ipm

ent

44

Fi

ttin

g a

KED

Co

nti

nu

ed

9

Equ

ipm

ent

45

Assessment & History Taking Aid memoirs, Acronyms and Diagnosis

Patient Assessment Triangle 46

Body Assessment - DCAPBTLS 47

Neurological Assessment - 5Ps 47

Chest Assessment - TWELVEFLAPS 48

Chest Assessment – ATOMFC 49

Chest Trauma 49

Chest Pain - History Taking 50

Abdominal Pain - History Taking 51

Abdominal Pain Locations 52

46

Patient Assessment Triangle

Airway &

Appearance

Circulation/Skin

Breathing

Effort

General Impression (First View of Patient)

Normal Abnormal

A

Normal cry or speech. Responds to parents or to environmental stimuli such as lights, keys, or toys. Good muscle tone. Moves extremities well.

Abnormal or absent cry or speech. Decreased response to parents or environmental stimuli. Floppy or rigid muscle tone or not moving.

B

Breathing appears regular without excessive respiratory muscle effort or audible respiratory sounds.

Increased/excessive (nasal flaring, retractions or abdominal muscle use) or decreased/absent respiratory effort or noisy breathing.

C Colour appears normal for racial group of child. No significant bleeding.

Cyanosis, mottling, paleness/pallor or obvious significant bleeding.

Initial Assessment (Primary Survey)

Normal Abnormal

A Clear and maintainable. Alert on AVPU scale.

Obstruction to airflow. Gurgling, stridor or noisy breathing. Verbal, Pain or Unresponsive on AVPU scale.

B Easy, quiet respirations. Respiratory rate within normal range. No central cyanosis.

Presence of retractions, nasal flaring, stridor, wheezes, grunting, gasping or gurgling. Respiratory rate outside normal range. Central cyanosis.

C

Colour normal. Capillary refill at palms, soles, forehead or central body ≤2 sec. Strong peripheral and central pulses with regular rhythm.

Cyanosis, mottling, or pallor. Absent or weak peripheral or central pulses; Pulse or systolic BP outside normal range; Capillary refill > 2 sec with other abnormal findings.

Ass

essm

ent

47

Body Assessment

Body Assessment

DCAPBTLS

D Deformity

C Contusions

A Abrasions

P Penetrations

B Burns

T Tenderness

L Lacerations

S Swelling

5Ps

P Pain

P Paralysis (Movement)

P Paraesthesia (Sensation)

P Pulses and Capillary Refill

P Pallor (Skin Colour and Temperature)

S Swelling

Ass

essm

ent

48

Chest Assessment

TWELVEFLAPS

T Tracheal deviation (Is it central?)

W Wounds / Bleeding (Check the neck, must be sealed to prevent air embolus / haemorrhage)

E Emphysema (Surgical, may indicate tension pneumothorax)

L Laryngeal Injury (Is there crepitus, indicating injury?)

V Veins (Distended?, if so may indicate a tension pneumothorax or cardiac tamponade)

E Expose & Examine the thorax

F Feel (Flail segments, wounds, symmetrical expansion, crepitus, fractures)

L Look (Equal rise and fall, paradoxical breathing, bruising, wounds)

A Auscultation (Equal sounds, absent, diminished, added sounds?)

P Percussion (Dullness, hyper-resonance, symmetry)

S Search sides and back

Ass

essm

ent

49

Chest Assessment

ATOMFC

A Airway obstruction (Tongue, trauma, foreign object, vomit etc)

T Tension Pneumothorax

O Open sucking wound (Open Pneumothroax)

M Massive Haemorrhage (Haemothroax)

F Flail Chest

C Cardiac Tamponade

Chest Trauma

Differential Diagnosis

Condition Chest

Expansion Trachea Percussion

Breath Sounds

Pneumothorax Decreased Unchanged Resonant Reduced

Tension Pneumothorax

Hyper expanded

Deviated away from tension

Hyper Resonant

Absent of affected side

Haemothorax Possibly reduced

Undeviated Dullness Reduced or absent

Collapse / consolidation

Reduced

May deviate towards collapse

May be dull Reduced or bronchial breathing

Pleural effusion Possibly reduced

Undeviated Dullness Reduced or absent

Ass

essm

ent

50

Chest Pain - History Taking

SOCRATES

S Site - Where is the pain or discomfort? Can you point to the area with one finger?

O Onset - What were you doing when the pain first started? What do you think may have caused this pain or discomfort?

C Character - Can you describe the type of pain? Is it: dull ache, sharp, stabbing, cramping, tearing, tightness, crushing, burning? Is it there all the time or does it in waves?

R Radiating - Does the pain stay in one place or does it radiate? Does it follow a certain pattern?

A

Associated Symptoms - Pale, clammy, dyspnoea, tachypnoea, SOB, dizzy, syncope, lethargy, confusion, vomiting, haemoptysis, productive cough, fever, haematemesis, pulse abnormalities, impending doom. Have you had a recent cough or been vomiting? When did you last eat? Have you had any difficulty swallowing?

T Time - How long have you had the pain? Has it been there ever since? Have you ever had a similar episode like this before?

E

Exacerbate / Relieve - Does anything ease the pain? (Analgesia, patient positioning, resting. Does anything make the pain worse? (Walking, leaning forward, lying down, coughing, movement, inhalation or expiration.

S Severity - If you were to score the pain out of 10, 1 being no pain and 10 being the worst imaginable, what would you score it?

Previous History - Recent trauma, chest infection or coughing, asthma, angina, COPD, heart failure, dyspepsia, dysphagia,

Risk Factors - Family history, smoker, overweight, heavy drinker, sedentary life style, hypertension, hypercholesterolemia, long travel / pregnancy, diabetes.

Ass

essm

ent

51

Abdominal Pain - History Taking

SOCRATES

S Site - Where is the pain or discomfort? Can you point to the area with one finger?

O Onset - What were you doing when the pain first started? What do you think may have caused this pain or discomfort?

C Character - Can you describe the type of pain? Is it: dull ache, sharp, stabbing, cramping, tearing, tightness, crushing, burning? Is it there all the time or does it in waves?

R Radiating - Does the pain stay in one place or does it radiate? Does it follow a certain pattern?

A

Associated Symptoms - Pale, clammy, dyspnoea, tachypnoea, SOB, dizzy, syncope, lethargy, confusion, nausea, vomiting, diarrhoea? Have you noticed anything abnormal when passing water? For example: Increased or reduced frequency, dark or off colour urine. Does it have a strong odour, burning sensation? Have you noticed anything abnormal when passing a bowel motion? Increased or reduced frequency, pain, loose or hard stools, dark coloured or bright red.

T Time - How long have you had the pain? Has it been there ever since? Have you ever had a similar episode like this before?

E

Exacerbate / Relieve - Does anything ease the pain? (Analgesia, patient positioning, resting, applying pressure, passing wind or bowel motion?) Does anything make the pain worse? (Lying down, coughing, movement, inhalation, expiration, palpation, passing water or bowel motion?)

S Severity - If you were to score the pain out of 10, 1 being no pain and 10 being the worst imaginable, what would you score it?

Birth Bearing Age - Any chance you could be pregnant? Are there any changes to your menstruation cycle: early, late, abnormal colour, odours, increased pain? Have you had any vaginal discharge?

Previous History - Recent trauma, chest infection or coughing, asthma, angina, COPD, heart failure, dyspepsia, dysphagia,

Risk Factors - Family history, overweight, heavy drinker, sedentary life style, hypertension, hypercholesterolemia, long travel / pregnancy, diabetes.

Ass

essm

ent

52

Abdominal Pain Locations 1

Ass

essm

ent

53

Trauma & Medical Emergencies Useful Information and Charts

Rule of Nines 54

Submersion/Immersion Drowning 55

Key Points - Submersion/Immersion 55

Shock Comparison 56

Stages of Shock 57

Catastrophic Haemorrhage Tourniquet 58

Removing a Helmet 59

Fitting a Triangular Bandage 60

Routes of Drug Administration 61

54

Rule of Nines Paediatric & Adult

Tra

um

a &

Med

ica

l

55

Submersion/Immersion Drowning

The pulse may be extremely slow if hypothermia is present, and external cardiac compression may be required. Bradycardia often responds to improved ventilation and oxygenation. Drugs such as adrenaline and atropine are less effective in HYPOTHERMIA, and must not be repeatedly used. These drugs may pool in the static circulation of the drowned casualty, and then, after re-warming and circulation has been restored, act as a dangerous bolus of drug as they are circulated. In hypothermic cardiac arrest, defibrillation will be unsuccessful where the core temperature remains low. At 28C the ventricle may spontaneously fibrillate. Defibrillation may not succeed until the core temperature rises above 30-32C.

Tra

um

a &

Med

ica

l

Key Points – Submersion/Immersion

Ensure own personal safety

Successful resuscitations have occurred after prolonged submersion/immersion.

Near drowning is often associated with hypothermia.

Special considerations in cardiac arrest treatment in the presence of hypothermia.

Severe complications may develop several hours after submersion/immersion.

56

Tra

um

a &

Med

ica

l

Typ

e

RR

H

R

BP

C

ap R

efill

Sk

in

Hyp

ovo

laem

ia

>2

Se

con

ds

Pal

e

Cla

mm

y Sw

eaty

Car

dio

gen

ic

>2

Se

con

ds

Pal

e

Cla

mm

y Sw

eaty

Sep

tic

<2

Se

con

ds

Flu

shed

H

ot

Swea

ty

An

aph

ylac

tic

<2

Se

con

ds

Flu

shed

H

ot

Swea

ty

Ne

uro

gen

ic

----

<2

Se

con

ds

Flu

shed

H

ot

Swea

ty

Sh

ock

Co

mp

aris

on

57

Tra

um

a &

Med

ica

l

Stage

s of Sh

ock

Stage

Blo

od

Loss

ml

Signs an

d Sym

pto

ms

1

<15

%

75

0

No

rmal B

loo

d P

ressure &

Resp

Rate,

Slight P

allor &

An

xiety

2

15

- 30

%

75

0 - 1

50

0

Tachycard

ia, Increased

Resp

Rate &

D

iastolic P

ressure, N

arrow

Pu

lse P

ressure, Sw

eatin

g, Mild

ly An

xiou

s/R

estless

3

30

- 40

%

15

00

- 2

00

0

Marked

Tachycard

ia >12

0 b

pm

&

Tachyp

no

ea >30

bp

m, D

ecreased

Systo

lic Pre

ssure, A

ltered M

en

tal Statu

s, Sweati

ng, C

oo

l & P

ale Skin

4

>40

%

>20

00

Extreme Tach

ycardia &

Tachyp

no

ea, W

eak Pu

lse, Decreased

LOC

& Systo

lic B

P <7

0, Skin

is Sweaty, C

oo

l and

Pallo

r

58

C

atas

tro

ph

ic H

aem

orr

hag

e T

ou

rniq

uet

9

Tra

um

a &

Med

ica

l

59

Re

mo

ving a H

elm

et 9

Tra

um

a &

Med

ica

l

60

Fi

ttin

g a

Tria

ngu

lar

Ban

dag

e 9

Tra

um

a &

Med

ica

l

61

Routes of Drug Administration

Code Route Description

BUC Buccal Administration directed toward the cheek, from within the mouth.

ET Endotracheal Administration down the ET tube.

IM Intramuscular Administration within a muscle.

INH Inhaled Administration by breathing.

IO Intraosseous Administration within the bone marrow.

IV Intravenus Administration within or into a vein or veins.

NASAL Nasal Administration to the nose; administered by way of the nose.

NEB Nebulised Administration in the form of mist.

PO Oral Administration to or by way of the mouth.

PR Rectal Administration to the rectum.

SC Subcutaneous Administration beneath the skin; hypodermic.

SL Sublingual Administration beneath the tongue.

TOPIC topical Administration to a particular spot on the outer surface of the body.

Tra

um

a &

Med

ica

l

62

Anatomy Diagrams and Terminology

Palpable Pulse Locations 63

Bones - General 64

Bones – Spinal Colum 65

Anatomical Terms of Location 66

Patient Positioning 67

63

Palpable Pulse Locations

An

ato

my

64

Bones - General A

na

tom

y

65

Bones – Spinal Colum

An

ato

my

66

Anatomical Terms of Location

Term Definition

Anterior Posterior

From front (Anterior) to back (Posterior).

Dorsal Ventral

From top (Dorsal) to bottom opposite end of body (Ventral).

Lateral (Left) Lateral (Right)

From left to right side of the body.

Medial (Left/Right)

From centre of organism to one or other side

Proximal Distal

from tip of an appendage (distal) to where it joins the body (proximal)

An

ato

my

67

Patient Positioning 7

An

ato

my

68

ECG & ETCO2 Interpretation Examples and Explanations

ECG Lead Placement 69

Normal ECG 70

ECG Assessment Guide 71

ECG Arrhythmias 1 72




Interpretation of ETCO2 Waveform 76

69

ECG Lead Placements 9

ECG

& E

TCO

2

70

Normal ECG 3

I Lateral aVR V1 Septal V4 Anterior

II Inferior aVL Lateral V2 Septal V5 Lateral

III Inferior aVF Inferior V3 Anterior V6 Lateral

Interval Time in Seconds

PR Interval 0.12 to 0.22

QRS Complex 0.08 to 0.12

QT Interval 0.35 to 0.42

ECG

& E

TCO

2

71

ECG Assessment Guide 3 Point Description

What is the rhythm? Regular, Irregular

What is the Rate? Fast, Normal, Slow

Are there P Waves Present?

YES - Atrial Foci NO - Junctional or Ventricle Foci

Are all the P Waves the Same?

YES - Then Same Foci No - Then Different Foci

Is there a P Wave before each QRS?

YES - Atrial Foci NO - Junctional or Ventricle Foci

Is there a QRS after every P Wave?

NO - Ventricular Standstill or Possible Heart Block

Is the P-R Interval Normal?

YES - 0.12 to 0.20 Seconds (3-5 small squares) NO - If >0.0 seconds its First Degree Heart Block

Is the QRS Normal? YES - 0.04 to 0.12 secconds (1-3 small squares) NO – Bundle Branch Block

Is the ST Segment Isoelectric?

If Elevated its Myocardial Infarction If Depressed its Ischemia or Angina

Is the T Wave Normal?

YES – 3 Times the Height of the P Wave NO – Inverted?

ECG

& E

TCO

2

72

ECG Arrhythmias 1 3

Normal Sinus

1st Degree Heart Block

Missing QRS Complex

2nd Degree Heart Block

Type 1

Multiple Missing QRS Complexes

2nd Degree Heart Block

Type 2

3rd Degree Heart Block

ECG

& E

TCO

2

73

ECG Arrhythmias 2 3

ECG

& E

TCO

2

Atrial Fibrillation

Atrial Flutter

Asystole

Bundle Branch (Determine

Left/Right from 12 Lead)

Sinus Bradycardia

74

ECG Arrhythmias 3 3 EC

G &

ETC

O2

Idioventricular Rhythm

Junctional Rhythm

Multifocal Premature Ventricular Contraction

Compensatory Pause

Premature Atrial

Contraction

Paced Rhythm

75

ECG Arrhythmias 4 3

Compensatory Pause

Premature Junctional

Contraction

Super Ventricular Tachycardia

Unifocal Premature Ventricular Contraction

Ventricular Fibrillation

Ventricular Tachycardia

ECG

& E

TCO

2

76

Interpretation of ETCO2 Waveform

Sudden loss of waveform, ETCO₂ near zero. ET Tube,

disconnected, dislodged, kinked or obstructed.

Loss of circulatory function.

Decreasing ETCO₂ with loss of plateau. ET tube cuff leak or deflated cuff ET tube in

hypopharynx Partial obstruction

CPR Assessment. Attempt to maintain

minimum of 10mmHg

Sudden Increase in ETCO2. Return of

spontaneous circulation

ECG

& E

TCO

2

77

Major Incidents Acronyms and Plan of Action

Approach - Think STEP 123 78

Approach - Scene Assessment - CSCATTT 78

Dynamic Operational Risk Assessment 79

Plan of Action - SitRep - METHANE 80

Plan of Action - Briefing Structure - IIMARC 80

Primary Triage 81

Triage Categories 82

Pre-Alert - ASHICE 83

Handover - Trauma MIST 84

Handover –Medical MIST 84

EH20 Escape Hood 85

NAAK Presentation 86

NAAK Indications 87

NAAK Directions for Use 88

Electronic Personal Dosimeter (EPD) 89

EPD Alarm Descriptions 90

78

Approach

Think STEP 123

S Safety

T Triggers for

E Emergency

P Personnel

1 Casualty, approach using normal procedures

2 Casualties, approach with caution, consider all options

3 Casualties or more, without obvious cause, do not approach scene

Scene Assessment - CSCATTT

C Command and Control

S Safety

C Communication

A Assessment

T Triage

T Treatment

T Transport

Ma

jor

Inci

den

ts

79

Dynamic Operational Risk Assessment

A dynamic risk assessment is undertaken and applied to tasks or situations that are in the main unforeseeable or

unpredictable or during which the circumstances, environment or behaviour of the patient or those at

scene may be subject to rapid change.

Ma

jor

Inci

den

ts

80

Plan of Action

Situation Report to Control - METHANE

M Major Incident – Standby or Declared

E Extraction Location

T Type of Incident

H Hazards (Present and Potential)

A Access (Egress)

N Number of Casualties

E Emergency Services (On Scene or Required)

Briefing Structure - IIMARC

I Information – Overview of incident, location, what is involved and when it happened

I Intention – What are we going to do

M Method – How are we going to achieve it

A Administration – What records are required

R Risks – DORA, hazards, Minimising them and contingency plans

C Talk groups, mobile phones, de-brief arrangements

Ma

jor

Inci

den

ts

81

Primary Triage

Ma

jor

Inci

den

ts

82

Triage Categories

Tag Colour Definition

EXPECTANT / DEAD

Victim unlikely to survive given severity of injuries, level of available care, or both.

Palliative care and pain relief should be provided

Priority 1

Victim can be helped by immediate intervention and transport

Required medical attention within minutes for survival (up to 60)

Includes compromises to patients Airway, Breathing, Circulation

Priority 2

Victim’s transport can be delayed Includes serious and potentially life

threatening injuries, but status not expected to deteriorate significantly over several hours

Priority 3

Victim with relatively minor injuries Unlikely to deteriorate over days May be able to assist in own care Walking wounded

Ma

jor

Inci

den

ts

83

Pre-Alert

ASHICE

A Age

S Sex

H History

I Illness / Injuries / Intervention

C Condition – HR, RR, SpO2 Air / O2, BP, BM, Temp, GCS, ECG.

E Estimated Time of Arrival

RED

Cardiac Arrest. Peri-Arrest. Any patient eliciting MTC outcome using Major Trauma Pathfinder. Currently fitting. GCS 12 or less. PPCI.

AMBER

Cardiac chest pain New Stroke (regardless of symptom time). Any other clinical concern.

Ma

jor

Inci

den

ts

84

Handover

Trauma - MIST

M Mechanism of Injury

I Injuries

S Signs (Vitals)

T Treatment

Medical - MIST

M Medical History (PMH/Allergies)

I Illnesses (PC/HPC)

S Signs (Vitals)

T Treatment

Ma

jor

Inci

den

ts

85

EH20 Escape Hood 2

For use when the crew believe that they have been potentially exposed to a form of hazardous contamination. One size fits all. It will provide 20 minutes of respiratory protection to escape the scene.

Ma

jor

Inci

den

ts

86

NAAK Presentation

Services carry a supply of 10 packs of Nerve Agent Antidote Kits on every Emergency ambulance for self-administration by the crew in the event of accidental exposure to nerve agents.

They consist of 2 prefilled automatic intramuscular injection devices linked by a plastic clip and housed in a foam pouch. Atropen containing 2.0mg of Atropine and a Combopen containing 600mg Pralidoxime Chloride.

Ma

jor

Inci

den

ts

87

NAAK Indications

The Nerve Agent Antidote Kit (NAAK) should be self-administered or assisted by their crew mate if they are incapacitated on occasions where they suspect that they have been accidentally exposed to nerve agents such as Organo Phosphates (deliberate or accidental release), and are suffering the effects listed below.

Clinical Diagnosis:

History of exposure Miosis Respiratory distress Bronchorrhoea Depressed level of consciousness Bronchospasm Muscle Twitching Convulsion

Including one or more of the following:

Bronchorrhoea Bronchospasm Severe Bradycardia (<40 bpm)

User may experience the following side effects:

Impairment of psychomotor function Disorientation Loss visual accommodation Photophobia Transient bradycardia then tachycardia

Palpitations Arrhythmias CNS depression Circulatory/respiratory failure

Ma

jor

Inci

den

ts

88

NAAK Directions for Use

1

Remove Pen No 1 marked ATROPINE from the plastic holder this removes the safety cap and extreme care must be taken.

2

Place the GREEN cap of the auto injector against the upper quadrant of the thigh making sure that that it is clear of anything in the trouser pocket. Press hard until the injector functions, count to ten slowly and then withdraw. Bend the needle on any hard surface until it breaks off. Record time of administration.

3

Remove Pen No 2 marked PRALIDOXIME from the plastic holder this removes the safety cap and extreme care must be taken.

4

Place the BLACK cap of the auto injector against the upper quadrant of the thigh making sure that that it is clear of anything in the trouser pocket. Press hard until the injector functions, count to ten slowly and then withdraw. Bend the needle on a hard surface until it snaps off. Record time of administration. Hold both injectors in your hand until help arrives.

Ma

jor

Inci

den

ts

89

Electronic Personal Dosimeter (EPD)

An Electronic Personal Dosimeter (EPD) is a small pager sized device that will monitor for the presence of ionising radiation. It is designed to allow for normal every day background levels of radiation, but should it detect a rise in levels of radiation in the vicinity of the wearer it will activate an internal audible alarm to alert the wearer to look at the display and take action according to the reading and the perceived local circumstances.

Default Screen

This example shows the Dose Rate on the display screen in micro-Sieverts/hour (µSv/h).

Test Display Screen

At the beginning of every shift the wearer should perform a confidence test. From the default display screen press and hold the operating button until “TEST” is displayed.

Confidence Test Display

Double press the operating button to initiate the confidence test, which confirms operation of visual display and the visual and audible alarms. The display screen will show all icons at once, the audible alarm will sound and the visual indicator will flash.

Ma

jor

Inci

den

ts

90

EPD Alarm Descriptions Alert Description Low Battery Warning

There is a low battery warning, which is an intermittent slow tone. This indicated there is about ten hours battery life left. This will be the most common warning heard (the data in the EPD will be stored for about a month without a battery).

Alarm 1 Primary Alert Signal

The first tone or Primary Alert Signal is an intermittent double “fast” chirp and the LED will illuminate RED and indicates the presence of a level of radiation just above background. This tone will also sound whenever the battery is replaced and is a function of the auto test process. It also acts as a reminder of the alerts for the wearer. The user should be aware of this facility and is NOT to change batteries at incident sites. The Primary Alert Signal should be the only activation alarm the wearer will ever hear whilst performing their duties, the most common will be the low battery warning.

Alarm 2 Secondary Alert Signal

The second tone, the Secondary Alert Signal is a slow two-tone alarm and indicated a level of radiation approximately equivalent to that received annually by normal means. Under normal circumstances where this level of radiation is present, Ambulance staff will not be deployed forward to assist casualties.

Alarm 3 Tertiary Alert Signal

The third alert tone, the Tertiary Alert Signal is a continuous single high tone. This tone indicated that the wearer has been exposed to a potentially significant or high dose.

Ma

jor

Inci

den

ts

91

Infection Prevention & Control Useful Information

Mops and Buckets 92

Hand Washing Technique 93

Hand Hygiene 94

Protective Clothing 94

Sharp/Splash Injury Procedure 95

92

Mops and Buckets

Mops and their corresponding colour coded buckets must not be interchanged. If any mop becomes contaminated with blood or body fluids, then the head should be discarded as clinical waste and a replacement fitted immediately. All mop heads should be routinely replaced every month.

Infe

ctio

n C

on

tro

l

93

Hand Washing Technique 12

Good and efficient hand hygiene is the single most important factor in the prevention and control of the spread of infection.

Second to hand washing, consistent use of barrier methods, especially wearing gloves, is the most important step in preventing cross-contamination of staff and patients.

Infe

ctio

n C

on

tro

l

94

Hand Hygiene 12 Use the hand washing technique:

Protective Clothing Circumstance/Activity Appropriate PPE

Circumstance/Activity Appropriate PPE

Circumstance/Activity Appropriate PPE

Exposure to blood/body fluids anticipated, but low

risk of splashing.

Wear gloves, plastic apron and sleeve protectors.



Infe

ctio

n C

on

tro

l

95

Sharp/Splash Injury Procedure Inoculation/blood splash injuries include any sharp

object that pierces the skin, bites or any other exposure to blood or body fluids.

Bleed it – Apply pressure, but “DO NOT” suck the wound.

Wash it – Wash with soap under warm running water for 2 minutes.

Dry it – Do not scrub the injury or pat it dry.

Dress it – Cover the injury with a dressing.

For splashes to the eyes – Irrigate with saline or water.

For splashes to the mouth – Rinse with copious amounts of water and wash your face. Donor – Identify and document the source of the inoculation injury include: Name, DOB and home address if possible.

Inform – Contact EOC and inform them of the situation.

Attend – Go to the nearest Emergency Department without delay.

Report it – Report the incident to occupational health as soon as possible. Telephone your local Occupational health service. Write Numbers Below:

Infe

ctio

n C

on

tro

l

96

Key Contacts Phone Numbers and Addresses

97

Notes

98

Notes

99

1. Ansari, P (2012) Acute Abdominal Pain [Online] URL: http://www.merckmanuals.com/professional/gastrointestinal_disorders/acute_abdomen_and_surgical_gastroenterology/acute_abdominal_pain.html

2. Avon Protection Systems (2011) EH20 Data Sheet, Melksham/England: Avon Protection Systems.

3. Evans, S (2004) A Guide Through the Maze of ECGs, 3rd Edition, Somerset/England: Association of Professional Ambulance Personnel.

4. Fikac, L (2000) Shoulder Dystocia [Online] URL: http://www.capefearvalley.com/outreach/outreach/peapods/obemergencies/shoulderdystocia.htm

5. Kochenour, N (1997) The Mechanism of Normal Labor [Online] URL: http://library.med.utah.edu/kw/human_reprod/lectures/physiology_labor/#2

6. Laerdal (2013) Laerdal Suction Unit: Instruction Manual, Kent/England: Laerdal Medical Limited

7. Medtrng (2012) Postures and Direction of Movement [Online] URL: http://www.medtrng.com/posturesdirection.htm

8. Peak Flow (2004) Mini-Wright Peak Flow Meter: Predictive Normal Values (Nomogram, EU scale), Essex/England: Clement Clarke International.

9. Queensland Ambulance Service (2011) Clinical Practice Manual [Online] URL: http://www.ambulance.qld.gov.au/medical/CPM.asp

10. Resuscitation Council UK (2010) Resuscitation Guidelines 2010, London/England: RCUK.

11. Smiths Medical (2008) Emergency Transport and Ventilation [Online] URL: http://www.smiths-medical.com/Upload/products/product_relateddocs/EmergencyTransport.pdf

12. World Health Organisation (2009) Clean Care is Safer Care: Clean Your Hands, Geneva/Switzerland: WHO.

References and Credits

100

Handover

A collaboration of useful guidelines in a quick reference pocket book tailored for pre-

hospital care.

This handy pocket book resulted from my quest to consolidate the most relevant and useful

guidance into a single source; something that can be carried in your pocket at all times -

whenever you may need it.

Download the FREE electronic edition from: PocketParamedic.org

Thank you to everyone that has allowed their content to be included in Pocket Paramedic.

For more information visit PocketParamedic.org

Pocket Paramedic is a non profit venture. When Available, the A6 hard copies are sold at cost. For Information Purposes Only. Pocket Paramedic.org, and Jason Houghton, take absolutely zero responsibility for how you, as an individual, choose to make use of Pocket Paramedic.. The contents of this pocket book can in no way be guaranteed to be accurate and/or up to date. No credit is taken for the intellectual property of others highlighted in the references.

Where applicable, consent has been granted to reproduce all copyrighted material. Information provided in Pocket Paramedic may differ from other guidelines, protocols and

procedures; you must never use Pocket Paramedic as a substitute for them.

Version 1.1

Health & Medicine

2013 pocket paramedic