Pre Hospital Care Protocol 2

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Introduction When anyone is severely injured, resuscitation must begin as soon as possible preferably at the scene. Early and effective support of airway, ventilation, oxygenation, and perfusion is vital. In trauma resuscitation rescuers perform a “Primary Survey” to rapidly identify and immediately treat life-threatening conditions that will interfere with establishing an effective airway, oxygenation, ventilation, and circulation. After completion of the Primary Survey, the rescuer than perform the “Secondary Survey” to complete the assessment. In Secondary Survey, history is focused and physical examination is more detailed. Cardiopulmonary deterioration and arrest associated with trauma has several possible causes: • • • • • • • Severe central neurologic injury with secondary cardiovascular collapse. Hypoxia secondary to respiratory insufficiency, resulting from neurologic injury, airway obstruction, large open pneumothorax, or severe tracheobronchial laceration or crush. Direct and severe injury to vital structures such as the heart, aorta, or pulmonary arteries. Underlying medical problems or other conditions that led to the injury, such as cardiac arrest or stroke in the driver of a motor vehicle. Severely diminished cardiac output from tension pneumothorax or pericardial tamponade. Exsanguination leading to hypovolemia and severely diminished oxygen delivery. Injuries in a cold environment (eg. fractured leg) complicated by secondary severe hypothermia. Despite rapid and effective scene response, survival is poor in patients with out-of-hospital cardiopulmonary arrest due to blunt trauma. Patients who do survive out-of-hospital cardiopulmonary arrest associated with trauma generally are young, have penetrating injuries, receive early (at the scene) tracheal intubation, and receive prompt transport (rather than prolonged resuscitative attempts in the field) to the Emergency Department. Trauma Care Concept Treat the greatest threat to life first ! The Aim Of Care Trauma Life support emphasizes the first hour initial assessment and primary management of the injured patient, starting at the point in time of injury and continuing throughout initial assessment, life-saving interventions, reevaluation, stabilization and transportation. Perils Ambulance Service / Prehospital Care SOP / Azizi. 71 Protocol 6 PERFORMING PRIMARY SURVEY Perils Ambulance Service / Prehospital Care SOP / Azizi. 72 PRIMARY SURVEY FLOW CHART Assessment On Arrival Determine Responsiveness Establish Airway Patency With Cervical Spine Control Check Breathing For Effectiveness Check Circulation With Hemorrhage Control Briefly Illicit Disability Expose Patient To View Injuries Proceed To Secondary Survey Perils Ambulance Service / Prehospital Care SOP / Azizi. 73 WORK PROCESS Primary Survey DESCRIPTION During primary survey life-threatening conditions are identified and management begun simultaneously. Corrections of lifethreatening condition is carried out without any delay or further investigation. The patient should be completely undressed to facilitate examination and assessment. You must observe and listen as you quickly, but safely, reach the patient. Gather information that may provide clues as to the patient’s problems eg: • • • • The scene - Is it safe or hazardous? Does the patient have to be moved? Are conditions harsh? The patient - Is he alert, trying to tell you something or pointing to a part of his body. Bystanders - Are they trying to tell you something. Listen to them. Mechanisms of injury - Has something fallen on the patient? Is this burn injury? Has the patient been thrown against the steering column? Is the steering wheel bent, the dashboard dented, or the windshield broken? Deformities or injuries - Does the patient’s body appear to be lying in a strange position? Is there blood around the patient? Are there burns, crushed limbs, or any other obvious wounds? Behavioral changes - Is he aggressive or disruptive which may be due to trauma to the brain and nervous system. Signs - What do you quickly see, smell or hear when approaching the patient? Is there blood around the patient? Has he vomited? Is the patient having convulsions? Is there obvious pain? INSTRUCTION / TOOLS Assessment On Arrival • • • Determine Responsiveness Call-out ‘Are you O.K.’ while tapping the shoulder gently. Unconsciousness may be due to head trauma, shock, or respiratory arrest. If the spinal cord injury is present, the victim may be conscious but unable to move. Perils Ambulance Service / Prehospital Care SOP / Azizi. 74 Throughout initial assessment and stabilization, the rescuer should monitor the victim’s responsiveness. Deterioration could indicate either neurologic compromise or cardio respiratory failure. Airway Patency With Cervical Spine Control Cervical spine immobilization • Assume cervical injury in the following:  Head or neck injury.  multisystem trauma.  severe neck pain  numbness, parasthesia or tingling sensation of the hands  weakness of upper limbs. • Maintain the cervical spine in a neutral position with manual immobilization (best performed by a second person) while rapidly assess for airway obstruction:  Open airway by jaw-thrust.  Clear the mouth of blood, vomitus, and other secretions, manually (gloved-finger sweep or gauze-wipe) or suction.  look, listen and feel for breathing.  while suctioning, check for gag reflex. If gag reflex is absent, insert airway or intubate. • Inspect neck for signs of blunt and penetrating injury, tracheal deviation, distended neck veins, and use of accessory breathing muscles. Palpate for tenderness, deformity, swelling, subcutaneous emphysema, and tracheal deviation. Dress any wounds and apply hard cervical collar. • • Note: If there is a risk of cervical spine injury, maintain cervical immobilization throughout the rescue attempt until spinal immobilization equipment is applied. Breathing 1. Expose the chest. 2. Determine the rate and depth of respiration. Inspect and palpate the chest for tracheal deviation, unilateral and bilateral chest movement, distended chest wall, use of accessory muscles, any signs of injury. 3. Percuss the chest for presence of dullness or hyperresonnance. Perils Ambulance Service / Prehospital Care SOP / Azizi. 75 4. Auscultate the chest bilaterally, noting the lung sound. 5. Note apex beat displacement. 6. Perform ‘springing test’. 7. Identify the following and consider the treatment:  Tension pneumothorax - needle thoracocentesis.  Open chest wound - seal wound.  Cardiac tamponade - pericardiocentesis.  Flail chest - stabilize.  Massive haemothorax - chest tube drainage. 8. General management • • Administer high concentration of oxygen even if the victim’s oxygenation appears to be adequate. If breathing is absent or grossly inadequate ( eg. agonal or slow and extremely shallow), provide ventilation (deliver slowly) by:  Mouth-to-barrier device, OR  Bag-mask.  Tracheal intubation, ONLY when indicated and no contraindication. Circulation With Hemorrhage Control 1. Generally assess for • Source of external, exsanguinating hemorrhage. • Skin color and temperature. • Pulse: rate, volume and regularity. • Blood pressure, if time permits. • Capillary refill (nail-bed blanch test) to assess adequacy of perfusion. Normal 100 mmHg. If blood pressure remains low after 2-liter infusion, there is a possibility of continuing internal bleeding that needs surgical exploration in the hospital. • Monitor cardiac rhythm. • Prevent hypothermia. Remove wet clothes. • Insert urinary catheter and orogastric tube unless contraindicated and only when time allows. 1. Determine the level of consciousness using AVPU:  A - alert  V - respond to verbal command  P - respond to pain.  U - unresponsive. 2. Assess pupils for size, equality and reaction. 3. Illicit neurologic deficit:  Test for sensation - light touch or pinch the skin.  Test for motor function - lifting extremities, grasp objects, make a fist, move toes and fingers. Exposure Proceed To Secondary Survey Undress the patient region by region during examination in order not to miss any injury that may not be so obvious. Once stabilize, perform secondary survey i.e. a complete examination from head to toe, and manage appropriately before transporting the patient Cardiac monitor / defibrillator. Urinary catheter and gastric tube. Disability Reference – Advanced Trauma Life Support Course For Physicians; ABC Of Major Trauma; Malaysian Trauma Life Support Manual; CPR 2000 Guidelines For CPR & ECC – International Consensus On Science; ACLS Textbook; Emergency Medicine Companion Handbook; Brady Emergency Care; Protocols for Prehospital Emergency Medical Care; The Paramedic Manual; New South Wales Ambulance Service Paramedic Protocol; Senarai Ubat-Ubatan Kementerian Kesihatan Malaysia. Perils Ambulance Service / Prehospital Care SOP / Azizi. 77 Perils Ambulance Service / Prehospital Care SOP / Azizi. 78 Protocol 7 PERFORMING SECONDARY SURVEY Perils Ambulance Service / Prehospital Care SOP / Azizi. 79 SECONDARY SURVEY FLOW CHART Complete The Primary Survey First. Look And Feel From ‘Nose To Toes’. Use Your Tools Obtain History Documentation Transport Patient To Emergency Department Perform Secondary Triage Hand Case To Attending Doctor Perils Ambulance Service / Prehospital Care SOP / Azizi. 80 WORK PROCESS Secondary Survey DESCRIPTION It is the systematic assessment of the entire patient after completing the primary survey. The purpose of the secondary survey is to uncover problems which are not life-threatening but which could be injurious or could become life-threatening to the patient. In the field, perform secondary survey only when time allows. Do not delay transportation. The earlier the better! INSTRUCTION / TOOLS Look And Feel From ‘Nose To Toes’. 1. Head: a. Scalp - check for lacerations, swellings and depressions. Palpate for fractures at the base of lacerations. Stop profuse bleeding. b. Level of consciousness - use Glasgow Coma Scale. Deterioration may not be due to the primary injury to the brain but may reflect hypoxia or hypoperfusion. c. Base Of Skull - CSF leaks suggest fractures base of skull. CSF rhinorrhoea or otorrhoea is a contraindication to auroscopy for fear of precipitating a meningitis. d. Eyes  Look for hemorrhages inside and outside, foreign bodies under the lids, and signs of penetrating injuries.  Rapidly assess for visual acuity by asking the patient to read a label.  Assess pupils size and reaction to light. e. Face  Palpate symmetrically for deformities and tenderness.  Check for loose or lost teeth.  Grasp the upper incisors and determine whether there is any instability of the maxilla, which would suggest a middle third fracture. If this fracture is compromising the airway, pull the fractured skeleton segment forwards to clear the airway. Penlight. Perils Ambulance Service / Prehospital Care SOP / Azizi. 81 2. Neck:  Look for bruises, lacerations, or deformity.  Palpate each of the cervical spinous processes to detect tenderness and “step off” deformities.  Check spinal cord function by asking to squeeze both hands or wriggle toes or ankles.  Look for jugular vein distension. 3. Chest: a. Subcutaneous emphysema. b. Lacerations. c. Chest movement - look and feel for unequal chest movement, ‘seesaw’ breathing or paradoxical movement with flail chest. d. Local tenderness and gently spring the ribs. e. Tracheal deviation and position of the apex beat. 4. Abdomen: a. Distension. b. tenderness and rigidity. c. Presence of femoral pulse. 5. Pelvis: Gently spring the pelvis. 6. Extremities: a. b. c. d. Lacerations. Tenderness, deformity and swelling. Check distal perfusion and pulses. If no fracture or dislocation, ask patient to move each limb in turn. e. Sensory loss with suspected spinal injuries. 7. Back And Spine: a. Palpate carefully along the spine for tenderness. b. Log roll and look for lacerations, bullets, etc. Use Your Tools 1. Pulse rate. 2. Blood pressure. 3. Respiratory rate. Perils Ambulance Service / Prehospital Care SOP / Azizi. Stethescope. Watch. Vital signs 82 monitor. 4. Chest auscultation  Bilateral air entry both axilla.  Abnormal breath sounds: Decrease breath sounds - pneumothorax, atelectasis. Bronchial breathing - consolidation of the lung. Rhonci - lower airway obstruction such as asthma. Creps - pulmonary edema, sputum retention. Friction rubs - pleurisy.  Heart sounds: Decreased - emphysema, obesity, tamponade. Gallop rhythm - heart failure. 5. ECG monitoring. Obtain History Take history from the patient, relatives or bystanders. 1. Present history and brief description of the incident. Include the:  Chief complaint.  Treatment prior to arrival.  Whether unconscious prior to arrival. 2. Previous illness. 3. Drug therapy. 4. Allergies. Documentation Document all findings. Ambulance Patient Care Form. Ambulance. 2-way radio. Triage Officer At ED. Ambulance Patient Care Form. Cardiac monitor / defibrillator. ECG machine. Transport Patient Perform Triage Refer Case To Doctor . Transport patient to Emergency Department as soon as possible. Inform estimated time of arrival. Reassess patient for priority of care – red zone, yellow zone and green zone. Pass all information orally to attending doctor. Hand over documented findings. Assist doctor in patient care as required. Reference – Advanced Trauma Life Support Course For Physicians; ABC Of Major Trauma; Malaysian Trauma Life Support Manual; CPR 2000 Guidelines For CPR & ECC – International Consensus On Science; ACLS Textbook; Emergency Medicine Companion Handbook; Brady Emergency Care; Protocols for Prehospital Emergency Medical Care; The Paramedic Manual; New South Wales Ambulance Service Paramedic Protocol; Senarai Ubat-Ubatan Kementerian Kesihatan Malaysia. Perils Ambulance Service / Prehospital Care SOP / Azizi. 83 Protocol 8 MANAGING TRAUMATIC SHOCK Perils Ambulance Service / Prehospital Care SOP / Azizi. 84 MANAGING TRAUMATIC SHOCK FLOW CHART Perils Ambulance Service / Prehospital Care SOP / Azizi. 85 WORK PROCESS DESCRIPTION INSTRUCTION / TOOLS Perils Ambulance Service / Prehospital Care SOP / Azizi. 86

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