PCT Equipment Manual Reading for Test 1

CEMCAP

Confirm the call

Environment/Scene Safety Assessment

Mechanism of Injury/Nature of Illness

Casualty Count

Additional/Allied Resources

Personal Protective Equipment

Intervals at which the lead paramedic should reassess scene safety

• upon completion of primary survey

• prior to patient extraction

• upon loading into the ambulance

• while in transit

Staging

Relocating ambulance beyond line of sight, within 500 meters of the scene and activate additional resources

CBRNE

Chemical - Biological - Radiological, Nuclear, Environmental

(types of emergency)

Scene safety reassessment should take

3-5 seconds (heads-up)

High-risk mechanism of injury parameters

• Falls from Height (adult >/= 6m, children >/= 3m or 2-3 * height of child)

• High-Risk Motor Vehicle Collision (Intrusion 0.3m ft on occupant’s side, Intrusion 0.5m on any side incl. roof, partial/complete ejection of the occupant from the vehicle, death of an occupant in same passenger compartment, vehicle telemetry data consistent with high-risk injury)

• Pedestrian or Bicyclist (thrown, run over, or struck by an automobile traveling >/= 30kph)

• Motorcycle Crash (travelling >/= 30kph)

Nature of Illness 2-part Assessment

• Cardiac Arrest (Determine if medical event, fbao, or secondary to hypothermia)

• All other complaints (sources of airway compromise, evidence of chronic illness, drug paraphernalia, alcohol use)

LTH

Lead Trauma Hospitals

PCI

Percutaneous Intervention Centers

Specialized receiving facilities

LTHs, PCIs, Acute Stroke Centers

Most common cause of an unrestrained patient being ejected

Single-vehicle, loss of control, motor-vehicle rollovers

Reasons to Activate Police

• on a roadway/highway that needs traffic control

• behaving in a violent/aggressive manner with or without a weapon

• in a structure with an access issue (door/window needs to be breached)

• known or suspected victim of a crime including elder abuse, child abuse/neglect, homicide, physical or sexual assault

• uncooperative or refusing transport when patient needs medical treatment to prevent serious harm/death

• In need of restraint (exc. transfers)

• experiencing a mental health crisis and must be detained and transported for mental health assessment

• Code 5 or Code 6 (obviously or legally dead)

Reasons to Activate Fire/Rescue Service

• expanded basic life support team

• vehicle extrication or management of downed power lines

• fire suppression or hazardous materials management

• rescue team specializing in patient recovery from water/ice, confined spaces/building collapse, location with poor or difficult access)

• lifting and moving assistance

When to Activate an ACP

When airway, breathing, circulation, or neurological criteria have been met:

1. Airway and Breathing

2. Circulatory Criteria

3. Neurological Criteria

(Special Considerations: ACP may be activated for analgesia if available and for any trapped trauma, ACP rendezvous is permitted if clear benefit for the R/V and ACP is able to intercept the PCP transport along route to hospital)

1. Airway and Breathing Criteria

• inability to open or maintain the airway through conventional means

• inability t o decontaminate the airway through conventional means

• inability to oxygenate or ventilate the patient through conventional means

• suspected tension pneumothorax

2. Circulatory Criteria

• Cardiac Arrest

• Pre-cardiac arrest or post-cardiac arrest

• Hypovolemia requiring fluid resuscitation

• inability to obtain IV access or IV access is lost

3. Neurological Criteria

• unconscious

• active seizure

• combative

• paralysis

Activating an Air Ambulance Helicopter

When operational, anatomical, and physiological criteria have been met

PPE Assessment

1. Universal PPE (ask if febrile pt)

2. Splash Protection PPE

3. Pandemic PPE

4. Industrial Roadway/Vehicle Extrication and Air Ambulance Helicopter PPE

5. Waterway PPE

Normal Adult Range RR

10-20 breaths per minute

Normal Adult Range SPO2

92-96% on room air

Normal Adult Range ETCO2

35-35mm/Hg

Normal Adult Range Pulse Rate

60-100 bpm

Normal Adult Range Skin Condition

Pink, warm, dry

Normal Adult Range Blood Pressure

120/80

Normal Adult Range ECG

60-100/minute with regular rhythm

Normal Adult Range GCS

15

Normal Adult Range Pupils (PERLA)

Pupils Equal, (Round), Reactive to Light and Accommodating

2-5mm

Normal Adult Range Temperature

35.8-38 degrees Celsius

BLS Patient Assessment Standard baseline vital signs

• heart rate

• respiration rate

• blood pressure

• pulse oximetry

• Glasgow Coma Scale

• pupils

• skin colour and condition

Cardiac Monitor BLS Guideline typical warranted cases

• VSA

• Unconscious or altered LOC

• Collapse or syncope

• Suspected cardiac ischemia

• moderate to severe shortness of breath

• Cerebrovascular accident (CVA)

• overdose

• major or multi-system trauma

• electrocution

• submersion injury

• hypothermia, heat exhaustion or heat illness

• abnormal vital signs as per the ALS PCS

• if requested by facility transfer staff

Airway Management Decision Tree for altered LOC

1. Inspect the airway

   • open mouth and look in airway (cross-finger technique)

   • Clear the airway (finger sweep, FBAO clearance maneuvers, V-VAC suctioning)

2. Open the airway

   • Non-trauma patient → head tilt, chin lift

   • trauma patient → modified jaw thrust

3. Maintain the airway

   • trismus absent → OPA with ongoing manual airway maneuvers

   • trismus present → NPA with ongoing manual airway maneuvers

trismus

lockjaw, spasm of muscles of mastication, trouble opening the jaw

Signs of airway compromise

• trauma (hemorrhage, swelling, and/or broken teeth)

• vomit

• displaced denture plate(s)

Sounds of airway compromise

• stertorous breathing (snoring respirations)

• stridor

• gurgling

• guppying

a cause of stertorous breathing (snoring respirations)

tongue is obstructing airway

stridor

narrowing of the airway due to swelling/trauma or partial airway obstruction

cause of gurgling sounds

air passing through liquid such as vomit or blood

guppying

obstructed breathing, no sounds of air movement despite chest wall movement

Techniques to open airway when not patent or self-maintained

• FBAO clearance maneuvers

• Manual airway maneuvers

• OPA/NPA airway insertion

• V-VAC suctioning

Manual Airway Maneuvers

• cross-finger technique

• head tilt, chin lift

• sniffing position (medical patients only)

• modified jaw thrust

PICC for NPA

L: Procedure Check

P: Ready

L: I am going to insert a NPA

P: Conditions?

L: Patient must present with a diminished/absent gag reflex and oropharyngeal airway insertion is not possible

P: Contraindications?

L: Contraindications are trauma above the clavicle and/or a lack of aerosolization PPE

P: Proceed

Clinical Considerations for NPA

1. Once NPA has been inserted, airway management must be supported with ongoing manual airway maneuvers

2. NPA provides a channel for mechanical or V-VAC suctioning

3. NPA does not prevent aspiration

4. Poor/aggressive NPA insertion may result in uncontrolled epistaxis

5. In extreme cases, dual NPA insertion may be required to maintain an open airway

PICC for V-VAC

L: Procedure Check

P: Ready

L: I am going to perform V-VAC suctioning

P: Conditions?

L: The patient must present with an airway that needs decontamination and the patient is not near a portable/vehicle mounted mechanical suction unit

P: Contraindications?

L: Contraindications are aggressive or blind V-VAC suctioning and/or a lack of aerosolization PPE

P: Proceed

Clinical Considerations for V-VAC

When possible, a supine patient must be rolled onto their side to facilitate proper drainage when using the V-VAC suction

Indications for OPA

Open airway when patient presents with absent gag reflex and airway is unmanageable by positioning alone

Contraindications for OPA

• conscious patient with an intact gag reflex

• without aerosolization PPE

Clinical Considerations for OPA

1. Once an OPA has been inserted, airway management should be further supported with a manual airway maneuver

2. The OPA is effective because it is simple to use, can be rapidly inserted, and is very effective in preventing airway obstruction by the tongue

3. disadvantages of OPA include a failure to protect patient from aspiration, it cannot be used with trismus, and continuous patient monitoring is required after OPA insertion

Eupnea

Smooth and even breathing pattern, 10-20 breaths/minute, normal

Tachypnea

superficial breathing with rapid respiratory rate >20 breaths/minute, can be caused by fever, anxiety, exercise, shock states

Bradypnea

deep breathing with slow respiratory rate <10 breaths/minutes, can be caused by head trauma, stroke, drug overdose, metabolic disorders

Apnea

Respiratory arrest, 0 breaths/minute, can be caused by head trauma, stroke drug overdose

Hyperpnea

Increased depth of regular breathing with a normal or faster respiratory rate, can be caused by emotional stress, diabetic ketoacidosis

Cheyne-Stokes

respiratory cycle with gradual increases, then decreases, in respiratory depth followed by periods of apnea, caused by head trauma, increased intracranial pressure

Ataxic

Groups/clusters of rapid respirations of equal depth, followed by regular intervals of apnea, can be caused by head trauma, meningitis, CNS dysfunction

Kussmaul’s

deep and regular sighing respirations with a rapid respiratory rate, can be caused by renal failure, metabolic acidosis, diabetic ketoacidosis

Apneustic

long gasping inspiratory phase followed by a short, inadequate expiratory phase, can be caused by lesions of the brain stem

Visual Inspection of chest and sternum acronym

CLAPS + TICS-D

CLAPS + TICS-D

Contusions (blunt trauma to chest, underlying cardiac and pulmonary structures)

Lacerations (possible source of major hemorrhage)

Abrasions (suggests blunt trauma to chest and underlying structures)

Penetration (penetrating trauma causing an open pneumothorax, tension pneumothorax, or a hemothorax, handled in B part of primary survey along with flail chest)

Symmetrical (Chest Rise/Fall)

Tenderness (suggests soft tissue injury or fracture to chest wall)

Instability (suggestive of flail segment on the chest wall)

Crepitus (indicates rib or sternal fracture)

Subcutaneous Emphysema/swelling (suggests pneumothorax or fracture of the trachea/bronchial tree)

Deformity (suggests fracture to ribs or sternum or presence of flail segment)

Air Entry Assessment Decision Tree

1. Auscultate chest

2. a) Normal Air Entry → Continue primary survey

   b) Absent Air Entry

   • absent on both sides → FBAO

   • absent on one side → tracheal deviation, JVD, hypotension

     • YES → Tension Pneumothorax

     • NO → Investigate Further, open/closed pneumothorax, hemothorax

Look, Listen, Feel

Breathing Survey

Look → CLAPS

Listen → Auscultate

Feel → TICS-D

Subcutaneous emphysema

ominous sign of serious underling pulmonary injury when air is found trapped beneath the skin, looks like bubble wrap

Oxygen Therapy Decision Tree for Non-COPD patient with Dyspnea

Patient Presents with Dyspnea and any of the following:

• breathing too slow (bradypnea <8-10 breaths/minute)

• breathing too fast (tachypnea >28 breaths/min)

• too distressed to speak (1-2 words dyspnea)

• accessory muscle use (sternocleidomastoids - shoulder shrugging)

• distressed positioning (tripod, head-bobbing)

» Mild Hypoxia R/A SPO2 = 88-91% → nasal cannula 2-6 Lpm titrated to effect

» Moderate Hypoxia R/A SPO2 = 80-87% → non-rebreather mask 12-15Lpm

» Severe Hypoxia R/A SPO2 <80% → PPV with BVM 12-15Lpm

Cannot Oxygenate/Cannot Ventilate - Decision Tree

1. Verify Airway is not obstructed

   • FBAO clearance maneuvers if indicated

   • V-VAC suction of airway secretions

2. Change Manual Maneuvers

   • Sniffing/head tilt - chin lift (NON-TRAUMA)

   • Modified jaw thrust (TRAUMA)

3. Add Airway Adjuncts in addition to an OPA

   • NPA in right nare

   • NPA in left nare

4. Enhance delivery of Positive Pressure Ventilation

   • Ensure properly sized BVM mask

   • initiate 2-rescuer PPV

5. Rapid Transport to Airway Specialist

   • initiate ACP rendezvous

   • rapid transport to nearest ED

Oxygen Tank Duration Formula

((gauge pressure - safe residual pressure) * tank constant)/flow rate per minute

answer is in minutes

P. I. S. S.

Pin Index Safety System

Flow rates

Nasal cannula → 2-6 Lpm

Simple Mask → 6-10Lpm

Non-rebreather Mask → 10-15 Lpm

High-concentration oxygen indications

• cardiac arrest

• complete airway obstruction

• afflicted with upper airway burns

• suspected or known to have CO2 poisoning

• suspected or known to have cyanide toxicity or noxious gas exposure

• affected by a scuba diving related disorder

• diagnosed with sickle cell anemia and is suspected of having a vaso-occlusive crisis

(when pulse ox fails, administer to altered LOC, respiratory distress, cyanosis, age-specific hypotension, abnormal pregnancy or labour)

MOANS

determination of difficulty of PPV

Mask seal (anything that impedes good mask seal, beard, facial trauma)

Obstruction (severe angioedema, supraglottic swelling, FBAO, tumor, etc)

Age/elderly (reduction in mouth opening and neck mobility die to age)

No teeth (lack of teeth makes PPV extremely challenging, replace dentures prior to PPV)

Stiff lungs (require increased ventilatory pressures i.e. ARDS, COPD)

PPV equipment steps

1. Mask

2. Tapered flex tube

3. MDI adapter

4. Bacterial/viral filter

5. ETCO2

6. Bag

Set oxygen flow rate to 12-15Lpm

Clinical Considerations for ETCO2

1. ETCO2 values may be very low when a patient has been in cardiac arrest for a prolonged period of time

2. when managing a COPD or asthma patient with an intial ETCO2 > 50mmHg, attempt to maintain ETCO2 values between 50-60mmHg

3. If signs of cerebral herniation include a deteriorating GCS < 9 with any of the following:

   • dilated and unreactive pupils

   • asymmetric pupillary response

   • a motor response that shows either unilateral/bilateral decorticate or decerebrate posturing

NIBP

Non-Invasive Blood Pressure