EMR CHEAT SHEET
FRONTLINE FIRST AID & EMERGENCY TRAINING
250-470-0205
www.frontlinefirstaid.ca
Frontline First Aid EMR Cheat Sheet
Page 1 of 12 2018-03-29 www.frontlinefirstaid.ca | 250-470-0205 | [email protected]
Table of Contents Assessment Model ................................................................................................................................................................. 2
Glasgow Coma Scale ............................................................................................................................................................... 3
APGAR ..................................................................................................................................................................................... 3
CPR Compression: Ventilation Ratios .................................................................................................................................... 3
CPR with Airway Obstruction................................................................................................................................................. 3
CPR in transport - Treatable CPR ........................................................................................................................................... 4
Dynamic CPR / CPR on the Move ........................................................................................................................................... 4
Oxygen Cylinder Calculations................................................................................................................................................. 4
Oxygen Flow Rates ................................................................................................................................................................. 4
Common Units of Measurement ........................................................................................................................................... 4
6 “Rights” of Medication ........................................................................................................................................................ 5
ASA & Nitro ............................................................................................................................................................................. 5
KED Strapping Sequence ........................................................................................................................................................ 5
Simple Triage and Rapid Treatment (S.T.A.R.T.) ................................................................................................................... 6
Urgent Transport Critical Interventions Requiring History and/or Vital Signs .................................................................... 6
Critical Findings ...................................................................................................................................................................... 6
IV Drip Set Calculations .......................................................................................................................................................... 7
Common IV Solutions ............................................................................................................................................................. 7
Common IV Complications ..................................................................................................................................................... 7
Assisted Ventilations .............................................................................................................................................................. 7
Rescue Breathing .................................................................................................................................................................... 7
Cushing’s Triad ....................................................................................................................................................................... 7
Lund & Browder Burn Estimation Sheet ................................................................................................................................ 8
Relevant S-A-M-P-L-E and Mechanism of Injury Information .............................................................................................. 9
Head to Toe Assessment Mnemonics .................................................................................................................................... 9
Entonox Mnemonics ............................................................................................................................................................ 10
Entonox Protocol .................................................................................................................................................................. 10
Sager Traction Splint ............................................................................................................................................................ 11
Administration of Glucogel to an Unresponsive Patient .................................................................................................... 11
BCAS Treatment Guidelines compared to ........................................................................................................................... 12
PAC National Occupational Skill Competency Profiles ....................................................................................................... 12
Canadian Red Cross Certification & BC EMALB Licensing ................................................................................................... 12
Frontline First Aid EMR Cheat Sheet
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Assessment Model 1. SCENE SURVEY
H Hazards Is there anything in the area that could cause problems or injuries
E Environment Is the area hot…cold…toxic…unstable…etc
M Mechanism of Injury What happened to cause the injury or condition
P Number of Patients How many people require assistance or transport
A Additional Resources Are more personnel needed? Ambulance, FD, hazmat, poison control, tech rescue, etc
2. PRIMARY SURVEY
D Delicate Spine Is spinal motion restriction needed? Yes or No Critical Interventions Quickly manage life threatening problems as you find them
LOC AVPU Alert…Verbal stimulus…Pain stimulus…Unresponsive
A Airway With “Cheater Carotid Check” and OPA if unresponsive
B Breathing Oxygen or Assisted Ventilations if needed
C Circulation Radial Pulse, Skin and Rapid Body Survey - Blanket
Main Concerns What are the most potentially life-threatening problems?
Initial Transport Decision Urgent or Delayed…Notify Medical Control
3. SECONDARY SURVEY Interview
S Signs and Symptoms What is hurting or causing discomfort
O Onset Did this happen suddenly or gradually
P Provokes Is there anything that makes the pain better or worse
Q Quality Sharp…dull…throbbing…aching…stabbing…burning…crushing…squeezing…tingling…etc…
R Radiating Where is the pain; and does it stay in one spot or move to other areas
S Severity How bad is the pain on a scale of 1-10
T Timing When did the pain start; and does is come and go or stay constant
A Allergies Are you allergic to anything…and have you been recently exposed
M Medications Do you take medication…did you take too much…too little…missed…new ones
P Previous Medical History Medical conditions or past incidents; diabetes…high BP…asthma…COPD…etc
L Last Meal What and when did you last eat or drink…is that normal for you
E Events Leading Up To What were you doing when the pain or discomfort started
Vital Signs
LOC Glasgow Coma Scale
Respirations Rate…Rhythm…Character
Pulse Rate…Rhythm…Character
SpO2 Pulse Oximeter – Blood Oxygen Level
Blood Pressure Palpation…Systolic/P or Auscultation…Systolic/Diastolic
Skin Color…Temp…Moisture - Measure body core temperature if relevant
Cap Bgl? Measure Capillary Blood Glucose Level if relevant
Head to Toe
Pupils Pupils Equal and Reactive to Light – compare size and reactivity of each pupil
Palpation Feel for injuries
Auscultation Listen to the Chest if relevant
Distal Circulation Assess bilateral pulses and check motor and sensory function in extremities
4. ONGOING SURVEY
Record Data Ensure patient care report is complete and accurate…Pass information to higher levels of care
Reassess Vitals every 5 minutes if life-threatening…every 15 minutes if non-life-threatening
Communicate Notify Medical Control of significant decisions or changes
S-B-A-R Transfer S Situation B Background A Assessment R Results / Recommend
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Glasgow Coma Scale
Eye Opening
Best Verbal Response
Best Motor Response
6 Obeys commands
5 Oriented 5 Localizes to pain
4 Spontaneously 4 Confused 4 Withdraws to pain
3 To voice 3 Inappropriate words 3 Flex to pain (Decorticate)
2 To pain 2 Incomprehensible sounds 2 Extend to pain (Decerebrate)
1 No response 1 No response 1 No response
Eye + Verbal + Motor = GCS (3-15) GCS less than 13 is life threatening
APGAR 0 1 2
Activity Limp Some extremity flexion Active Movement
Pulse Absent Below 100 bpm 100 bpm or higher
Grimace No response Grimace Cough, sneeze, cry
Appearance Body/Extremities Blue/Pale Body Pink – Extremities Blue Completely pink
Respiration Absent Slow and Irregular Strong, crying
7-10 is “Normal … 4-6 is “Fairly Low” … 0-3 is “Critically Low”
CPR Compression: Ventilation Ratios Adult over 9 Child 1-8 Infant under 1
One Rescuer 30:2 30:2 30:2
Two Rescuer 30:2 15:2 15:2
Infant with pulse less than 60 bpm = Start CPR
Check pulse 30-45 seconds if patient is Hypothermic
CPR with Airway Obstruction CPR with Obstruction
CPR
1 Ventilation does not go in Attempt 2nd Breath
30 Compressions
AED as soon as Possible
Look in Mouth
Finger Sweep if object visible
Attempt Ventilation
Repeat until
• 2 Ventilations go in
• Or Signs of Life
30 Compressions
2 Ventilations
AED as soon as possible
Repeat until
• Signs of Life
Remove OPA
2 Ventilations go in
Re-insert OPA
•
Frontline First Aid EMR Cheat Sheet
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CPR in transport - Treatable CPR 3 Consecutive No-Shocks
Consult Medical Control
Hypothermia
Cardiac Tamponade
Pulmonary Embolism
Tension Pneumothorax
Severe Blood Loss
Overdose
Airway Obstruction
Dynamic CPR / CPR on the Move
• Plan your exit route on the way in
• Have suction ready in case of vomiting during turns or lifts
• Watch for subtle vomiting inside the mouth or mask
• Reassess patient after every move or pause
• Secure patient AND equipment before moving
• Pocket mask may be more reliable than BVM during movement
• Set stretcher at a height that allows for effective compressions
Oxygen Cylinder Calculations Duration of Flow = (gauge pressure -200 psi) x C
Flow Rate (lpm)
C = Cylinder Constant
D-Cylinder: C = 0.16 L/psi (most commonly used on scene)
E-Cylinder: C = 0.28 L/psi M-Cylinder: C = 1.56 L/psi
Oxygen Flow Rates
Device BC EMALB Paramedic Association of Canada
(Canadian Red Cross Emergency Care Manual) O2 %
Simple / Standard Mask 6 – 15 lpm N/A 35-55 %
Non-Rebreather Mask 8 – 15 lpm 10+ lpm 90+ %
Bag Valve Mask 15 lpm 10+ lpm 90+ %
Nasal Canula 2 – 4 lpm 1 – 4 lpm 24-36 %
Resuscitation Mask (Pocket Mask) N/A 6+ lpm 35-55 %
Normal Room Air
20.7 – 21 %
Exhaled Air 16%
Common Units of Measurement Unit Abbreviation Used for measuring…
Milligrams of Mercury mmHg Blood Pressure
Millimoles per Litre mmol/L Blood glucose levels
Milligrams mg Medications such as ASA and Nitro
Drips per millilitre or Drips per minute gtts/ml or gtts/minute Dripset sizes and IV solution drip rates
Litres per minute lpm Oxygen flow rates
Frontline First Aid EMR Cheat Sheet
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6 “Rights” of Medication 1 Person Does this person have a prescription
2 Medication Have they had it before…no Contraindications…is this their Medication
3 Time When was the last dose taken…is it needed now
4 Dose How much should they take
5 Route How should they take/use it
6 Documentation Record the time and effects of each dose
Emergency Medical Responders licensed in British Columbia
Administer… 1. Entonox 2. Oxygen 3. Nitroglycerin 4. Acetylsalicylic Acid (ASA) 5. Glucose
Do not Administer by might commonly Assist with… • Epinephrine
• Ventolin
• Salbutamol
• Atrovent
• Albuterol
KED Strapping Sequence My Middle strap first Yellow
Baby Bottom strap second Red
Looks Leg straps third Black
Hot Head straps fourth White
Tonight Top strap last Green
ASA & Nitro
ASA
NITRO Indications
(all must be “Yes” to administer)
Signs & Symptoms of a possible Heart Attack
Safely taken ASA in the past
Indications (all must be “Yes” to administer)
Signs & Symptoms of a possible Heart Attack
Prescribed Nitroglycerin
Contraindications (all must be “No” to administer)
Allergic to ASA
Asthma
Gastric Bleeding such as an ulcer
Unresponsive (ie…likely to choke on tablet)
Contraindications (all must be “No” to administer)
Systolic Blood Pressure below 90 mmHg
Cialis within the past 48 hours
Viagra/Levitra in the past 24 hours
Administer if…
• Indications are met (all “Yes”) and
• Contraindications are ruled out (all “No”)
Administer if…
• Indications are met (all “Yes”) and
• Contraindications are ruled out (all “No”)
Chew…
• two 81 mg tablets or
• one 325 mg tablet
Administer as soon as possible…before Vital Signs
• 0.4 milligrams (one spray = 0.4mg)
• Q3-5 (every 3-5 minutes) confirming pain persists and Systolic BP remains > 90mmhg
Frontline First Aid EMR Cheat Sheet
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Simple Triage and Rapid Treatment (S.T.A.R.T.) Dead / Non-Salvageable (BLACK) Not Breathing
Immediate (RED)
Breathing > 30 per minute
Breathing with absent radial pulse
Decreased LOC
Delayed (YELLOW)
• Unable to walk
Minor (GREEN)
• Able to walk
Breathing Normal
Radial Pulse Present
Normal LOC
Urgent Transport Critical Interventions Requiring History and/or Vital Signs In some cases a patient may need Urgent Transport…AND…Critical Interventions which require information not normally acquired until the Secondary Survey.
In these cases…make an effort to efficiently gather the minimum information required without delaying transport any longer than necessary.
Intervention Information Required
Nitroglycerin for Chest Pains • Full set of vitals (particularly Blood Pressure)
• S-A-M-P-L-E and O-P-Q-R-S-T
ASA for Chest Pains • S-A-M-P-L-E and O-P-Q-R-S-T
• Administer as soon as possible…before Vital Signs
Glucogel for Unresponsive Diabetic • Full set of vitals (particularly CapBgl)
• S-A-M-P-L-E
Critical Findings Finding Implication Intervention
GCS less than 13 Decreased LOC OPA / NPA
Breathing over 30 times/minute Tachypnea Assist Ventilations
Breathing less than 10 times/minute Dyspnea Assist Ventilations
Blood Pressure less than 80 mmHg Systolic Hypo-tension Position Supine
Blood Glucose less than 4 mmol/L Hypoglycemia Glucose
Oxygen Saturation (SpO2) less than 95% Hypoxia / Hypoxemia Increase O2 intake
Infant pulse less than 60 bpm Equivalent to Absent Begin CPR
Body core temperature below 35 - 36 C Mild Hypothermia Rewarm slowly
Body core temperature below 30 - 34 C Moderate Hypothermia Rewarm slowly
Body core temperature below <30 C Severe Hypothermia Rewarm slowly
Body core temperature above 37 C Hyperthermia Cool rapidly
APGAR below 4 Unresponsive Load and Go
Pulseless, angulated limb Limb Threatening Load and Go Attempt to realign
Adult Pulse Rate over 160 bpm Urgent Tachycardia Load and Go
Frontline First Aid EMR Cheat Sheet
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IV Drip Set Calculations
Drip Set Sizes • gtts = “drips”
• ml = “milliliters”
• gtts / ml = “how many drips add up to one milliliter”
Standard (Regular) 15 gtts / ml
Macro (Adult) 10 gtts / ml
Micro (Mini) 60 gtts / ml
gtts / minute (drips per minute) = volume (expressed in milliliters) to be infused X gtts / ml
Infusion time (expressed in minutes)
Common IV Solutions
Solution Commonly Used For…
Ringer’s Lactate Blood loss
D5W / D10W Hypoglycaemia
Normal Saline Dehydration
2/3 – 1/3 Dehydration
Common IV Complications Interstitial
Circulatory Overload
Thrombosis and Thrombophlebitis
Catheter Embolism
Infection of Catheter Site
Allergic Reaction
Air Embolism
Assisted Ventilations
Problem Ventilation Rate
Adult Child / Infant
Timed between or
with patient’s
own breaths
Breathing too Fast
• greater than 30 breaths per minute 1 breath
every
5-6 seconds
1 breath
every
3-5 seconds
Breathing too Slow
• less than 10 breaths per minute
Signs of Hypoxia
Signs of Respiratory distress
Rescue Breathing
Problem Ventilation Rate
Adult Child / Infant
Respiratory Arrest…but PULSE PRESENT 1 breath every 5-6 seconds 1 breath every 3-5 seconds
Cushing’s Triad 3 concurrent conditions commonly associated with Congestive Heart Failure or Head Injury
1 Increased Systolic Blood Pressure while Diastolic Blood Pressure remains “Normal”
2 Slow Heart Rate 3 Irregular Breathing
Frontline First Aid EMR Cheat Sheet
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Lund & Browder Burn Estimation Sheet
Area Age
0 (infant) 1 year 5 years 10 years 15 years Adult
A = half of head 9.5% 8.5% 6.5% 5.5% 4.5% 3.5%
B = half of one thigh 2.75% 3.25% 4% 4.5% 4.5% 4.75%
C = half of one lower leg
2.5% 2.5% 2.75% 3% 3.25% 3.5%
Frontline First Aid EMR Cheat Sheet
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Relevant S-A-M-P-L-E and Mechanism of Injury Information MVA
Location of patient Which vehicle patient was in How many vehicles involved
Impact speed Exterior damage Interior damage
Type of restraints Initial position of patient Condition of patient
Loss of consciousness Condition of other patients Wearing a seat belt?
Fall
Where from Height Free fall or hit other objects
Landing surface Position of patient at impact What hit first
Position Found Loss of consciousness Cause of fall
Pedestrian Struck
What hit them Size and weight of object Velocity of vehicle
Vehicle part that hit patient Damage to vehicle Distance patient thrown
Loss of consciousness Condition of patient Condition of Vehicle Occupants
Shooting
Type of firearm Range and Angle Loss of consciousness
Type of bullet Entrance and exit wounds Initial position and condition of patient
Stabbing
Type and size of weapon Loss of consciousness Type of wound
Number of wounds Other injuries Initial position and condition
Head to Toe Assessment Mnemonics Why might a patient have an altered level of consciousness?
A Alcohol
T Trauma
E Epilepsy I Infection
I Insulin (Diabetic) P Psychiatric
O Overdose P Poison
U Uremia S Stroke
During a Head to Toe assessment…watch for:
B Burns
C Contusions
S Swelling
O Open Wounds A Abrasions C Crepitus
L Lacerations P Penetrations R Rigidity
D Deformity
I Instability
P Punctures
T Tenderness
S Subcutaneous Emphysema
Frontline First Aid EMR Cheat Sheet
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Entonox Mnemonics Contraindications Precautions
C Ability to COMPLY S SHOCK
D DECOMPRESSION sickness A ABDOMINAL distension
C Altered level of CONSCIOUSNESS D DEPRESSANT drugs
P PNEUMOTHORAX C COPD
A AIR emboli F FACIAL Injuries
I INHALATION injury
• Ruling out Contraindications involves Chest Auscultation
• Contraindications mean you cannot administer.
• Precautions mean you need to fix something first, or monitor closely to ensure the Entonox is not creating/exasperating any problems
• 2 Precautions = Contraindicated
N NITROGLYCERIN use within 5 minutes
Or…
D Decompression sickness
I Inhalation injuries
V Ventilation must be adquate
I Inability to comply with instructions
N Nitroglycerin spray in the last 5 minutes
E Embolisms in the lungs/chest/bloodstream
Entonox Protocol Indications Significant Pain
Rule out Contraindications
C-D-C-P-A-I-N or
D-I-V-I-N-E
Note Precautions S-A-D-C-F
Completed before administration
Primary Survey
Contraindications ruled out (requires Chest Auscultation)
Mix bottle if stored improperly
Adequate ventilation secured (vehicle ventilation system activated if available)
Proper Storage Not left unused over long periods
Not stored below -6 Celcius
Not stored vertically
Instructions to Patient
Self-administered using mask/bite valve
“Pull” Entonox out of the bottle by inhaling through bite valve
Pain should be relieved
May begin to feel: o Light-headed o Giddy o Drowsy o Nauseous
Stop or start at any time
Use until pain is relieved or adverse effects are felt
After Discontinuing Entonox
Supplemental Oxygen with Non-Rebreather Mask at 15 lpm
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Sager Traction Splint
Utilized for suspected Femur Fractures not involving the hip or knee
Assess injured leg Distal Pulse – check for presence or absence
Motor-Sensory check
Look and feel to determine exact location and extent of injury
Apply Traction
Adjust saddle to ensure short side of saddle hinge is down
Nestle saddle against injured leg (short hinge down)
Have helper stabilize splint
Apply small thigh strap
Apply ankle harness above malleoli
Apply traction of 10% body weight o 15 lbs maximum per limb o 5 lbs maximum for open fractures and upper or lower third fractures o 5 lbs maximum for Pediatric patients o 30 lbs maximum for Bi-Lateral fractures (15 lbs per leg)
Secure Splint
Ensure adequate padding
3 straps around splint…above and below injury
Secure thigh strap…then the other two straps
Secure Figure 8 Strap
Reassess Injury
Reassess all splint straps and Traction Gauge
Ensure Leg in line with body…same length as other leg
Recheck presence or absence of Distal Pulse
Ensure no movement / aggravation of injured limb
Administration of Glucogel to an Unresponsive Patient
Assess Patient
If Hypoglycaemia is suspected or possible….Measure Capillary Blood Glucose Level as part of Vital Signs
CapBgl below 4 mmol/L requires administration of Glucogel
Protect Airway
Assemble Suction Unit and keep it ready
Place Patient in Recovery (Semi-Prone) Position
Remove OPA
Administer Glucogel
Place approximately half the tube of Glucogel on the inside of the lower cheek (Buccal Pouch)
• A tongue depressor may be utilized
Continue slowly until the entire tube of Glucogel has been absorbed
Monitor
Advise Medical Control
Monitor for changes
Re-measure CapBgl in 5 minutes
If CapBgl remains below 4 mmol/L
• Advise Medical Control and request permission to administer second tube
Frontline First Aid EMR Cheat Sheet
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BCAS Treatment Guidelines compared to PAC National Occupational Skill Competency Profiles
Guideline BCAS Treatment Guidelines
(BC EMALB) These are ones we follow in BC
PAC NOSCP (Red Cross Emergency Care Manual)
Minimum Systolic B.P. to give Nitro 90 mmHg 100 mmHg
Nitro Dose Frequency Every 3-5 minutes (Q3-5) Every 5 minutes (Q5)
Nitro…Maximum Dosage No limit as long as Systolic BP>90 Limit of 3 doses in 30 minute span
Hyperglycaemia 11 mmol/L or higher 8 mmol/L or higher
Burn Percentage Calculations Lund & Browder Chart Rule of Nines
Burn Cooling On Scene 1-2 minutes Varies with extent of burns
CPR with Hypothermia Check Pulse for 30 seconds Check pulse for 45 seconds
Canadian Red Cross Certification & BC EMALB Licensing
3. License Application and Maintenance
Submit online License Application
Pay $450 Licensing Fee to EMALB after passing evaluations
EMALB will mail your License to the
address listed on your application
License valid for up to 5 years with
yearly “Continuing Competence”
Submit 20 Patient Contacts per year
Submit 20 Continuing
Education Credits per year
2. Complete BC EMALB EMR Evaluations (must be within ONE year)
You must submit an online
Request for Evaluation
You must select and confirm
Practical Evaluation dates
You must ask Red Cross to email
your Certificate to EMALB
1-877-356-3226
You must create an Online BCeID
You must complete the Jurisprudence Exam online
You must complete the Written Exam
online
You must successfully
complete
1 “Medical”
&
1 "Trauma"
Scenario
1. Complete Canadian Red Cross EMR Course & Certification
Frontline will notify you within 10 days that you have been
submitted to Red Cross
You’ll also get an email from Red Cross. Follow our instructions: frontlinefirstaid.ca/certificates
Access and print your Canadian Red Cross EMR Certificate through your MyRC profile
EMALB will only accept a PDF copy emailed directly from Red
Cross