CSB330 All Content

principles of a paramedic

Integrity and impartiality

Promoting the public good

Commitment to the system of government

Accountability and transparency

professional boundaries

the clear separation that should exist between professional conduct (meeting a patient's health needs) and a practitioner's own personal wants, needs, views and feelings

Office of the Health Ombudsman (OHO)

the first place to contact for health service complaints regarding registered and non-registered practitioners

mandatory notifications

practised the practitioner's profession while intoxicated by alcohol or drugs; or

engaged in sexual misconduct in connection with the practice of the practitioner's profession; or

placed the public at risk of substantial harm in the practitioner's practice of the profession because the practitioner has an impairment*; or

placed the public at risk of harm because the practitioner has practised the profession in a way that constitutes a significant departure from accepted professional standards.

practising within your scope

you have to be trained, competent and authorised

harm

An outcome that negatively affects the patient's health and/or quality of life, impairment of structure or function of the body and/or deleterious effect arising there (WHO).

error

a preventable adverse effect on the patient's healthcare.

coroners

the state coroner,

the deputy coroner,

two Brisbane-based coroners and

three regional coroners.

open disclosure

the open discussion of adverse events that result in harm (real or potential) to a patient while receiving health care.

Open disclosure usually takes place with the patient and their family/carers present for support.

Open disclosure ensures that honest, open, timely and empathetic discussions occur between the healthcare provider and the patient following a clinical incident.

WHS

involves the identification and management of hazards and risks to the health and safety of everyone in your workplace, yourself, your colleagues, bystanders, and patients.

risk

probability of harm being caused by a hazard

diagnostic errors

Incorrect or significantly delayed diagnosis leading to patient harm e.g. Bias errors

treatment errors

Medication and/or procedure errors resulting in harme.g. Wrong dose

failure errors

Failure of equipment or systems to function as designed e.g. radio error, stretcher collapse

preventative errors

When drugs/procedures known to reduce harm, are not implemented

why errors happen

Organisation; Poor clinical governance, poor oversight, poor safety culture

Teamwork; Poor communication, poor tasking, poor safety environment

Individual paramedic; Experience, personal beliefs and attitudes, fatigue, stress

Task and equipment design; Difficult to use equipment or procedures, effort involved

Patient; Individual characteristics, typical disease presentations, poor hygiene, mental health/behavioural issues

Australian Commission on Safety and Quality in Health Care

ACSQHC's purpose is to contribute to better health outcomes and experiences for all patients and consumers and improve value and sustainability in the health system by leading and coordinating national improvements in the safety and quality of healthcare.

National Safety and Quality Health Service (NSQHS) Standards

Clinical Governance

Preventing and Controlling Infections

Comprehensive Care

Blood Management

Partnering with Consumers

Medication Safety

Communicating for Safety

Recognising and Responding to Acute Deterioration

informed consent

a person's decision, given voluntarily, to agree to healthcare treatment, procedure or other intervention.

health care rights

access, safety, respect, communication, participation, privacy, comment

6Rs

Right Paitent

Right Drug (Verbalise and confirm the medication name, indication for use, medication is unused and expiry date.)

Right dose (Check the right dose has been Calculated correctly + Prepared and drawn up correctly)

Right Route (method of administration)

Right Time (Drugs that can be repeated often have set periodic intervals, to avoid accidental overdose/adverse effects)

Right to refuse

clinical reasoning

the process of thinking and decision-making in clinical practice

improved by Engaging in reflective practice and self-assessment

requires Technical proficiency in medical procedures, Patient communication and anatomy/ physiology

snake bite

immoblise paitent

reassure

remove jewlery

cut off clothes

pressure bandage (distal to proximal)

splint

check circulation

report (photo of dead snake etc)

use for haemostatic dressing

If there is severe, life-threatening bleeding from a wound site not suitable for tourniquet, or from a limb when a tourniquet has failed to stop the bleeding

haemostatic dressing application

Haemostatic dressings must be applied as close as possible to the bleeding point, held against the wound using local pressure (manually initially) then held in place with the application of a bandage (if available). Haemostatic dressings should be left on the bleeding point until definitive care is available

direct pressure method for a bleed

Applying firm, direct pressure sufficient to stop the bleeding. Pressure can be applied using a pad over the bleeding point.

If bleeding continues, apply a second pad and a tighter bandage over the wound. If bleeding still continues, check that the pad and bandage are correctly applied, directly over the bleeding.

Applying firmer pressure, only using 1 to 2 pads over a small area, will achieve greater pressure over the bleeding point than continuing to layer up further pads

embeded object

Do not remove the embedded object because it may be plugging the wound and restricting bleeding.

Apply padding around or on each side of the protruding object, with pressure over the padding.

Arterial tourniquets

should only be used for life-threatening bleeding from a limb, where the bleeding cannot be controlled by direct pressure. Ideally, a tourniquet should not be applied over a joint or wound, and must not be covered up by any bandage or clothing.

follow instructions or 5 cm above the bleeding point if no instructions

inital torniquet fails can add another/ try combo of tourniquet and homeostatic dressing

internal bleeding

may be difficult to recognise, but should always be suspected where there are symptoms and signs of shock.

Internal bleeding includes bruising, locally contained bleeding (e.g. an "egg on the head") and the bleeding associated with injury or disease of organs in the abdomen or chest, as well as fractures. Severe bleeding may also occur from complications of pregnancy.

Symptoms and signs may include:

pain, tenderness or swelling over or around the affected area

the appearance of blood from a body opening

nose bleed

Pressure must be applied equally to both sides of the nose, over the soft part below the bony bridge (usually between the thumb and index finger).

The person should lean with the head forward to avoid blood flowing down the throat.

Encourage the person to spit out blood rather than swallow it as swallowed blood irritates the stomach, and causes vomiting which can worsen the bleeding.

The person should remain seated at total rest for at least 10 minutes. On a hot day or after exercise, it might be necessary to maintain pressure for at least 20 minutes.

airway obstruction

Airway obstruction may be partial or complete, and present in the conscious or the unconscious person. Typical causes of airway obstruction may include, but are not limited to:

relaxation of the airway muscles due to unconsciousness

inhaled foreign body

trauma to the airway

anaphylactic reaction

obstruction

5 back blows checking if obstruction has been removed after each

if ineffective identify compression point as for CPR and give up to five chest thrusts

encourgae active coughing

An infant may be placed in a head downwards position prior to delivering back blows

breathing

LOOK for movement of the upper abdomen or lower chest

LISTEN for the escape of air from nose and mouth

FEEL for movement of air at the mouth and nose.

location for chest compressions

the lower half of the sternum

lace the heel of hand in the centre of the chest with the other hand on top

Avoid compression beyond the lower limit of the sternum. Compression applied too high is ineffective and if applied too low may cause regurgitation and/or damage to internal organs.

compressions

2 finger technique for infants

Either a one or two hand technique can be used for performing chest compressions in children

person needs to be on back on firm surface

remember full recoil of chest

lower half of the sternum should be depressed approximately one third of the depth of the chest with each compression. This equates to more than 5cm in adults

perform chest compressions for all ages at a rate of 100 to 120 compressions per minute (almost 2 compressions/second)

swap after 2mins

compressions for pregnant people

place padding such as a towel, cushion or similar object under the right hip to tilt the woman's hips (approximately 15-30 degrees) to the left but leave her shoulders flat to enable good quality chest compressions. The reason for this position in pregnant women is to move the weight of the pregnant uterus off of her major blood vessels in the abdomen

Basic Life Support (BLS)

taught in first aid and CPR classes

Primary Survey

Danger

Response (AVPU)

Haemeorage

Airway

Breathing

Circulation (if unresponsive do DRXCABDE)

AVPU

Alert - patient's eyes are open spontaneously.

Verbal - The patient opens their eyes to verbal stimuli/voice (COWS)

Pain - The patient opens their eyes to a painful stimulus. (eg Trap Squeeze)

Unresponsive - The patient does not respond to any stimuli. (does not necessarily mean they are unconscious)

Airway manoeuvres

Head tilt is used to straighten the airway and is conducted by using two hands to gently place the head in the sniffing position. (dont do if suspeted c-spine injury)

Jaw thrust is used to move the tongue anterior (forward) in the mouth so as not to cause further obstruction and to assist in visualising the airway. It is conducted by the paramedic using the fingers of both hands on either side of the patient's jaw, hooking the fingers under the angle of the jaw and lifting anteriorly.

Chin lift / opening the mouth involves the paramedic using their thumbs to open the jaw while maintaining the jaw thrust. This allows for clear visualisation of the airway.

clearing airway

Liquid obstructions can sometimes be cleared by positioning the patient on their side, opening their mouth, and allowing gravity to clear the airway. This is otherwise known as the 'recovery position'. Alternatively, or in conjunction with positioning, oral suctioning can be done to clear the liquid.

Soft solids and liquids can be removed either through positioning and digital external scraping where the paramedic strokes the downward-facing cheek of the patient to encourage the object to loosen and fall out of the oral cavity, through oral suctioning, or removal utilising Magill's forceps.

Solid obstructions will often be removed utilising Magill's forceps, occasionally assisted with a laryngoscope.

checking equipment

At the beginning of each shift, the suction equipment should be checked for serviceability by the oncoming crew. This should include: checking the level of gas available in the oxygen cylinder, ensuring all connections are tight, tubing and equipment are clean and ready for use, and suction pressures are set to the required adult setting. The suction pressure should be checked to ensure it is working correctly.

breathing interventions

Manual ventilation via a bag-valve-mask (BVM), administering intermittent positive pressure ventilation (IPPV). This is colloquially referred to as 'bagging'.

Supplemental oxygen is delivered through a BVM or another type of mask (e.g. a simple face mask, nasal prongs, non-rebreather mask).

checking pulse

The radial pulse is the least invasive and, therefore, most often used. However, it can be difficult to assess if the patient has very low blood pressure.

the carotid pulse is more easily palpated and quickly identified. This makes the carotid favoured when no radial pulse can be confidently identified or the patient appears unresponsive.

The brachial is typically reserved for assessing blood pressure. the femoral pulse is typically only palpated during indirect haemorrhage control techniques. This is due to the particularly invasive nature of the location.

The pulse check should only take ten seconds to complete. The paramedic is simply checking to see if a pulse is present. If a pulse is present, the paramedic will take note of the regularity, strength, and speed of the pulse. If no pulse is present, this will indicate the need for CPR to commence.

SITREP

confirm your crew number, clinical and/or operational situation, resources required, and at what speed

Oropharyngeal airway devices (OPA)

patient can be sitting in any position for insertion

measured from central incisor to angle of jaw or tragus to corner of mouth

for adults inserted opposite way up for half its length then rotated 180, however dont invert for kids

if gagging, remove

Nasopharyngeal airway devices (NPA)

measure from tragus to nostril on that side

lube before inserting

place bevel inside nose facing septum

inserted until flange rests just outside nostril

Intermittent positive pressure ventilation

size mask correctly (better to have slightly bigger than too small)

ensure seal using C3/ CE grip

compress bag 1/3 slowly, let expriy take x3 to 4 longer

oxygen delivery

nasal prongs (small FiO2 increase 1-4L/min)

simple mask (6-8L/min)

nebuliser mask (6-8L/min)

non-rebreather/ resviour mask (bag attached, 8-10L/min)

Manual ventilation bag (8-15L/min)

oxygen uses

hypoxia associated with physical trauma or respiratory emergencies or critical state patient

has immediate effect but lasts <5mins

AVPU equivalence with GCS

Alert (15-12)

Verbal (14-10)

Pain (10-5)

Unresponsive (5-3)

using magill's forceps

put patient in sniffing position

follow laryngoscope towards object

open blades when within 1-2cm

after removal sweep left + right with lyrgoscope to ensure no further obstructing material

visualise glottis to ensure its clear

suction

direct oropharynx suctioning usually requires Yankauer sucker

test before use with container of water (also use water for cleaning throughout)

insert along laryngoscope blade

cover top hole for suction (uncover to withdraw)

collect suctioned liquid for evaluation

sucker can be disregarded if no sufficient reciprocal or potentially reused

laryngoscope

make sure patient is in sniffing position (sometimes need to elevate)

blade inserted on the right side of mouth to displace tounge to the left

advance down the tongue with blade until glottis is located

if using a curved blad, place tip in vecular grove at junction of the tongue and epiglottis

to move mandible, move the laryngoscope up and away, in line with the handle

straight blade moves epiglottis against the tongue to expose glottis

Respiratory status assessment (RSA)

Conscious state

Appearance

Pulse rate

Effort

Respiratory rate

Rhythm

Sounds

Speech

Skin

Perfusion Status Assessment (PSA)

history taking (SAMPLE)

Signs + symptoms

Allergies + Adverse reactions

Medication

PHMx

Last ins/ outs

Events Leading up

Assessing symptoms (OPQRST)

O NSET (mode of onset and time, rapid or gradual? )

P ROVOCATION/PALLIATION (what makes it worse, what makes it better)

Q UALITY (what does it feel like, descriptive)

R ADIATION /REFERRED (localised, travels, felt elsewhere)

S EVERITY (subjective, 0-10, does it interfere with ADLs/Sleep)

T IMING (when did it first start, has it happened before, how long has it lasted, consistent or intermittent?)

hypertension meds

Diuretics: lasix, frusemide, spironolactone

Beta-blockers/β-blockers: "olol's"

ACE inhibitors: "pril's"

Angiotensin II receptor blockers: "sartan's"

Calcium channel blockers: "ipine's"

Alpha-blockers: "azosin's"

Alpha-2 Receptor Agonists: "idine's"

Combined alpha and beta-blockers

diabetes meds

insulin injections

Oral tablets:

Metformin

Glipizide

Jardiance

Januvia

Epilepsy meds

Anti Epileptic Drugs (AEDs) - used to managage long-term

sodium valproate: epilem, valpro

carbamazepine: tegratol, curatil

lamotrigine: lamictal

levetiracetam: keppra

topiramate: Topamax

cannabinoids

Seizure termination drugs:

First line: Benzodiazapines (midazolam, diazepam, lorazepam)

Second line: AEDs (Keppra, phenytoin, sodium valproate)

Third line: Barbituates (phenobarbital), propofol.

anticoagulants

Warfarin: The reversal agent is Vitamin K, has a very small therapeutic window, and requires regular blood tests to monitor to ensure pt is appropriately dosed.

Rivaroxaban: Xarelto

Dabigatran: Pradexa

Apixaban: Eliquis

Clopidogrel:

antibiotics

Penicillins; flucloxacillin, amoxicillin

Cephalosporins: cefalexin, Keflex, ceflex

Tetracyclines; doxycycline

Aminoglycosides; gentamicin

Macrolides; azithromycin, erythromycin, clarithromycin Metronidazole; Flagyl

Quinolones ciprofloxacin

pulse oximetry

can be attached to fingers (no nail polish), ear lobes, sometimes foreheads and infant foots

chose correct paediatric/ adult size

blood pressure can be assed concurrently (different limb)

allow 5-10secs for readings to stabilise

Assessing blood pressure

place stethoscope bell over brachial artery, inflate until 40mmHg over when Korotkoff sounds heard

deflate the cuff, sounds will be heard again when pressure is approx. equal to systolic blood pressure

when sounds disappear again pressure is equal to approx. diastolic pressure

assessing respiratory rate/ rhythm

try and make sure patient doesnt know what your doing

start timing and count inspirations over a 30sec period (x2 for per minute)

temperature sites

rectal (invasive), oral (varies), temporal (variation), axillary (sweating effects), tympanic (in the ear, most easy/reliable)

tympanic assessment

for adults outer ear usually needs to be pulled upwards and for infants pull posteriorly to align ear canal

change probe tip each time

measuring blood glucose

clean finger with antiseptic wipe and allow to dry

draw a drop of blood using a lancet from the side of a finger near the tip (less painful)

test strip is used to absorb the correct amount of blood

glucometer gives results in mmol/L or mg/dL

blood glucose readings

4-7mmol/L normal

<4 hypoglycaemia

>7 hyperglycaemia

signs of acutely ill patient

delirium

Respiratory Signs

cardiovascular signs

neurgolical signs

delirium

Acute change to cognitive function over hours or a few days.

A recent change in mental status, has it fluctuated? Is it worse at night (a.k.a. Sundowner Syndrome)?

Difficulty concentrating, following instructions, easily distracted?

Incoherent thinking, rambling conversation, flight of ideas?

Alert, drowsy, comatose, or increased alertness (agitation, irritable)?

Respiratory Signs

Stridor and intercostal recession

Accessory muscle use

Unable to speak in sentences

SpO2 <90%

Angiooedema

cardiovascular signs

Absent pulse (peripheral or central)

HR <40bpm or >180bpm

SBP <100 mmHg (where previously within normal range)

Poor peripheral perfusion (tissue hypoxia):

neurological signs

Absent gag reflex (airway threatened)

Not obeying commands

Unresponsive to painful stimuli

Moving only one side (stroke, cerebral haemorrhage)

Reduced respiratory rate

Sudden reduced LOC (AVPU)

Pupils size and reaction to light (pinpoint, unequal, dilated, unresponsive, sluggish)

Seizure activity

GCS <10

sepsis

Temperature >38 or <36

Tachycardia >90bpm

Tachypnoea >20breaths/min

SBP <100mmHg

BGL >10mmol

ALOC

Non-blanching petechial (pinpoint) or purpuric rash/bruising:

head-to-toe examination

Inspect the area for obvious injury or deformity

Palpate for pain and/or crepitus

Where applicable, assess passive and active movement (i.e. can I move it for you without pain, can you move it yourself without pain).

assessment of limb

pulse

pallor

perishing cold

pain

paralysis

Paraesthesia

nexus c-spine rule

C-Spine Injury CANNOT be ruled out if ANY of the following are present:

Midline cervical tenderness

Altered mental status (GCS <15)

Focal neurological deficits

Intoxication

Painful and/or distracting injury

Canadian c-spine rule

C-Spine injury CANNOT be ruled out if ANY of the following are present:

HIGH-RISK FACTORS (cannot rule out injury):

>65 years old

Dangerous mechanism of injurya. Fall from height (2m or >5 stairs)b. Axial load to head (e.g. diving)c. High-speed RTC (>60km/hr, rollover, or ejection)d. Motorised recreational vehicles (e-bikes/e-scooters, quadbikes, etc.)e. Bicycle struck, or collision

Parastheasias in extremities

Neurological Status Assessment (NSA)

level of conciousness (GCS)

Cranial Nerve (CN) Assessment

speech

Peripheral motor and sensory function

GCS Scores

3-8 = Severe impairment/injury, <8 = Loss of gag reflex, airway risk!

9-12 = Moderate impairment/injury

13-15 = Mild impairment/injury, you can have a GCS 15 and still have a brain injury/neurological deficit

GCS Adjustments Paediatrics

use baby sounds to determine conscious state

5- orientated + spontaneous

4- inappropriate but spontaneous

3- only after verbal stimuli

2- only after pain

1- not at all

cranial nerve assessment

assessing the level of functioning of the 12 nerves that are located across the ventral surface of the brain. These nerves represent the functioning of several important motor and sensory functions, particularly those that relate to the eyes.

Dysfunction is highly correlated to underlying central nervous system injury. While the ability to complete a full cranial exam would be impressive, it would also be time-consuming. In paramedic care, it would be sufficient to carry out the assessment outlined in your readings:

PEARL (Pupils Equal And Reactive to Light) CN II-IV

Face and Shoulders CN VII, XI

Swallowing CN IX, XDysphagia (difficulty swallowing)

Smell and Taste CN I

speech conditions

Dysphasia = Difficulty in the generation of speech

Dysarthria = Difficulty articulating speech

Peripheral motor and sensory function

important in the assessment of spinal cord injury.

What can the patient feel?Numbness, decreased sensation, burning, tingling, pins and needles?

How can the patient move, power, and gait?

Is there symmetry?

Is there weakness, or hypersensitive reflexes?

Non-pharmacological interventions for pain

cognitive: music, distraction, hypnosis, guided imagery

behavioural: relaxation techniques, biofeedback exercises, breathing control

physical: heat and cold (cryoanalgesia) application, massage or touch, position and comfort, temperature regulation, transcutaneous electrical nerve stimulation (TENS), acupuncture, chiropractic, immobilisation.

pelvic binding

bring legs together and secure at the knees and ankles

apply over greater trochanters (not illiac crests)

only release after definitive examination

informed consent

Benefits

Risks

Alternatives

Intuition (how the paitent feels)

Nothing (what happens if they refuse/ wait)

things causing altered level of consciousness (AEIOUTIPS)

Alcohol/ Acidosis

epilepsy

infection

overdose/ oxygen deficiency

uraemia

Trauma/ tumer

Insulin

Psychogenic/ poison

stroke/ shock

cardiac arrest

the heart is unable to beat and therefore pump adequate amounts of oxygenated blood throughout the body

chain of survival

Recognition of cardiac arrest and activation of additional resources required on scene.

Early cardiopulmonary resuscitation (CPR) with an emphasis on high-quality chest compressions

Rapid defibrillation

CPR

30 compressions to 2 breaths

swap every 2mins during defibulation

100-120 compressions per min

1/3 depth and full recoil of chest

COACHED

Continue chest compressions

Oxygen away (if required)

All others stand clear (the person performing compressions continues to do CPR)

Charging defibrillator

Hands off (order to person performing CPR) & "I'm Safe" "All hands off" (confirmation of hands-off chest, person to do visual and hand sweep to ensure no one is touching the patient)

Evaluate Rhythm

Deliver shock (shockable rhythm, 200J for adult 4J/per kg for paed) or Dump the charge (non-shockable rhythm)

pad placement

centre of the apex (lateral) pad is positioned over the 5th intercostal space on the mid-axillary line (the position of V6 when a 12-Lead is performed). The sternal pad should be positioned to the right of the sternum, below the clavicle.

shockable rhythms

Ventricular Tachycardia (VT):

- can only defib if they're Unconscious/ Pulseless (possible to be neither for a bit but still VT)

- Looks; Regular (each complex is identical and follows the same pattern) Broad complex (the QRS complex is wide), Tachycardia (>100bpm)

ventricle fibulation

- Irregular/chaotic (the complexes have no pattern of varying amplitude)

- Tachycardia (>100bpm)

- Fibrillations/fibrillatory waves can be coarse (jagged and tall) or fine (wide and small)

non-shockable

Asystole: flat/ish line

pulseless electrical activity (PEA): electrical activity is there, but there's no mechanical output to produce a pulse

bias

Attribution bias - defining/diagnosing a person's presentation due to characteristics

Confirmation bias - tendency to search for, interpret or favour in a way that confirms or supports one's prior beliefs

Implicant bias - implicit bias or stereotype is the attribution of qualities by an individual to a member of a social group.

Hypotheticodeductive Reasoning (HR)

Hypothesis generation: Dependent on information gathered during the systematic assessment

hypothesis testing: Further assessment, or intervention/s

Hypothesis verification: Change in patient status or results of furthertesting

who's considered a paediatric

paediatric assessment generally refers to the assessment of patients aged 1 to approximately 14 years.

In Queensland alone, the public system varies greatly on when they consider the paediatric cut-off age. For example, the QAS drug dosage calculations consider the cut-off for a paediatric patient to be 12. However, Queensland public emergency departments accept patient presentations/admissions until the 16, however public mental health, oncology and complex care presentations will accept patients up to 18.

This subject will focus on paediatrics up until 12 years of age.