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ACP_Skills2

QAS_ACP2_skills

QuestionAnswer
Intravenous access Indications The administration of a drug or fluid
Intravenous access Contraindications Whenever possible avoid sites of burn, infection or localised cellulitis
Intravenous access Complications Air embolus Arterial puncture • Cannula shear or breakage • Drug/fluid extravasion • Haematoma or haemorrhage from the site • Infection or phlebitis Irritation to the vein wall • Nerve damage • Vasovagal syncope
Intravenous access Additional info sites are not to be used: - Distal to a complex limb injury - Limb with a fistula present - An area of phlebitis or cellulitis - When a limb has potential or existing lymphodema
Intravenous access Additional info.2 IV access should only be implemented after all basic cares. • The number of cannulation attempts should reflect the urgency of the case.
Airway suctioning Indications • To remove secretions, blood or vomitus from a patient’s airway • For standby use in preparation for endotracheal intubation
Airway suctioning Contraindications • Nil in this setting
Airway suctioning Complications Airway trauma •Stimulate coughing or gagging •Hypoxia from delays in ventilation with tracheal tube suctioning • Vagal stimulation can result in bradycardia and hypotension
Airway suctioning Additional info When performing tracheal suctioning, ensure the disruption to ventilation is less than 30 seconds. •Consider managing patient in lateral position if secretions are overwhelming
Laryngeal mask airway Indications •Impending or actual loss of airway patency or protection, where advanced airway management is necessary, but the clinician is unable to secure airway through endotracheal intubation • Rescue airway in the failed intubation algorithm
Laryngeal mask airway Contraindications • Nil in this setting
Laryngeal mask airway Precautions • Failure to provide adequate airway or ventilation • Can precipitate vomiting and aspiration in a patient with intact airway reflexes • Airway trauma • Patient intolerance
Laryngeal mask airway Additional info An LMA does not protect the airway from aspirption. • An LMA typically causes less gastric insufflation than BVM ventilation alone. •LMA is easier to insert with 50% air in cuff prior to insertion. Note: ACPs are only authorised to use 3, 4 and
Laryngoscopy Indications Clearing the airway • Insertion of an endotracheal tube • Insertion of a gastric tube
Laryngoscopy Contraindications Epiglottitis
Laryngoscopy Complications • Laryngospasm • Hypoxia due to delays in oxygenation while performing procedure • Trauma to mouth or upper airway, particularly teeth/dentures • Exacerbation of underlying C-spine injuries • Failure to visualise glottis
Laryngoscopy Additional info • Laryngoscopy is not advised in patients with intact airway reflexes. • It is possible to use a blade which is larger than necessary However, using a blade which is inappropriately small will make adequate laryngoscopy impossible.
Nasopharyngeal airway Indications Airway adjunct for use in patients with potential or actual airway obstruction, particularly in circumstances where an oropharyngeal airway is inappropriate (e.g. patient has trismus or an intact gag)
Nasopharyngeal airway Contraindications • Nil in this setting
Nasopharyngeal airway Complications • Airway trauma, particularly epistaxis •Incorrect size or placement will compromise effectiveness • Exacerbate base of skull fracture, with NPA potentially displacing into cranial vault [3] stimulate gag reflex precipitating vomiting or aspiration
Nasopharyngeal airway Additional info An NPA does not protect the patient’s airway from aspiration. • The right nostril is often preferred for NPA insertion given that it is typically larger and straighter than the left.
Oropharyngeal airway Indications Maintain airway patency • Bite block in advanced airways
Oropharyngeal airway Contraindications • Nil in this setting
Oropharyngeal airway Complications • Airway trauma from OPA placement • Intolerance of OPA requiring removal • Can precipitate vomiting/aspiration in patient with intact gag reflex • Incorrect size or placement can potentially exacerbate airway obstruction
Oropharyngeal airway Additional info Do not attempt to place an OPA if the patient has an intact gag reflex, or actively resists OPA placement. • An OPA does not protect the airway from aspiration
APGAR Stands for: • colour (Appearance) • heart rate (Pulse) • reflex irritability (Grimace) • muscle tone ( Activity) • breathing (Respiration)
APGAR Appearance Look at skin colour: 0. Blue/pale. 1. Pink (extremities blue). 2. All pink
APGAR Pulse Count heart rate: 0. Absent. 1. < 100 . 2. > 100
APGAR Grimace Monitor response 0. No response. 1. Grimace. 2. Vigorous cough
APGAR Activity Look at muscle tone: 0. Limp. 1. Some flexion/extension. 2. Active motion.
APGAR Respiration Count and assess: 0. Absent. 1. Slow/irregular. 2. Good cry
APGAR Indications An APGAR score is required for all newborns at one minute and five minutes following delivery.
APGAR Contraindications & Complications • Nil in this setting
Glucometry Indications Seizures • Sick paediatric patients • Impaired consciousness • Post collapse • Abnormal behaviour • Any patient who is suspected of being hypoglycaemic
Glucometry Contraindications • Although no actual contraindication exists to glucometry and the recording of BGL, it must be remembered that this procedure is invasive and so judgement must be used as to the appropriateness of performing the procedure
Glucometry Precautions Alwaysconsider other clinical signs and available history. Numerous variables may distort test results such as: • blood volume on the sensor • oxygen level of the blood • glucose contaminants on the skin.
Glucometry Additional info Note: A patient with impaired consciousness must have BGL checked whenever practical, even if the ALOC is suspected to be of other causes.
Glucometry Additional info.2 Blood may be drawn from a cannula while gaining IV access. Alcohol can affect the BGL result
Mental status assessment, Points to consider Appearance Behaviour Speech Mood Affect Thought form Thought content Perception Insight & judgement
12-Lead ECG acquisition Indications To aid in the identification of: - myocardial ischaemia or infarct - rhythm and conduction disturbance - electrolyte imbalance - hypertrophy of the heart - drug toxicity
12-Lead ECG acquisition Contraindications & Precautions Nil in this setting
12-Lead ECG acquisition Additional information •Should be acquired as part of an early secondary assessment of the patient, especially in the setting of suspected cardiac ischaemia or infarct. • Electrodes should remain in their original placement for comparison of serial 12-Lead ECGs
12-Lead ECG acquisition Additional information.2 ECG frequency is set at 0.05–40 Hz, and • paper speed is set at 25 mm/sec
Cardiac monitoring Indications All unconscious or collapsed patients or recently unconscious Patients CO chest pain or dyspnoea Poisoned pts Pts poorly perfused/shocked or hypoxic, or with abnormal vital signs When M.O requests. Pts in arrest
Cardiac monitoring Contraindications Nil in this setting
Cardiac monitoring Precautions Detached electrodes due to diaphoresis, oily skin, or chest hair • Patient movement, breathing, muscle tremor or lead movement • AC electricity/50 hertz interference • Broken cable tip, wire or machine malfunction • Dry electrode conductive
Cardiac monitoring Additional info Note: If the patient goes into cardiac arrest, any electrodes impeding the proper application of the defibrillator pads must be removed.
Valsalva manoeuvre Indications Haemodynamically stable SVT
Valsalva manoeuvre Contraindications Haemodynamic compromise
Valsalva manoeuvre Complications Syncope Prolonged hypotensive state
Valsalva manoeuvre Additional information This reflex bradycardia is induced in an effort to break the pattern of a re-entrant circuit causing the SVT. A maximum of three attempts at the Valsalva manoeuvre is recommended.
Valsalva manoeuvre Additional information.2 - minimum pressure of 40 mmHg - optimal duration of 15 seconds - supine position as an ideal posture
Bimanual compression Indications •Significant bleeding from the vagina • Enlarged soft uterus upon abdominal palpation • Tachycardia • Restlessness • Profound hypotension
Bimanual compression Contraindications • Nil in this setting
Bimanual compression Complications • Trauma • Pain
Bimanual compression procedure: 1)External aortic compression 2) Bimanual compression scrub hands, sterile gloves, Insert a gloved lubricated, form a fist, Apply pressure against anterior wall of uterus, other hand deeply into abdomen, pressure applied against posterior wall of uterus
Breech birth Types: Frank breech, Complete breech, Footling breech, Kneeling breech
Breech birth Breech birth Indications To assist a labouring woman in the delivery of her child when the child presents in a breech position
Breech birth Contraindications • Nil in this setting
Breech birth Complications Failure to deliver • Pain • Prolapsed cord • Shoulder dystocia (refer CPP) • Head entrapment • Meconium aspiration • Post-partum haemorrhage (refer CPG) • Inversion of the uterus
Breech birth Additional information Complications of breech delivery can lead to fetal distress and hypoxia potentiating a compromised neonate. Preparation for neonate resuscitation with breech presentation. Consider early ICP/obstetric team backup. Ensure aseptic technique
Breech birth Procedure:buttocks and legs When buttocks have entered the vagina, woman can push, let lower back and shoulder blades deliver, If not spontaneous deliver 1 leg at a time, Hold the baby by the hips 2 avoid internal damage
Breech birth Procedure:Delivery of the arms Allow arms to disengage spontaneously assist if necessary. After first arm, lift buttocks to mums abdomen to enable the second arm to deliver. If an arm does not spontaneously deliver, place 1 or 2 fingers in elbow, bend arm, hand down over baby’s face.
Breech birth Procedure:Arms stretched above the head Loveset’s manoeuvre: Hold baby by hips, turn half circle,keep back uppermost, applying downward traction at the same time. Sweep hand over the face. 2nd arm:turn back 1/2 circle, keeping the back uppermost, repeat.
Breech birth Procedure: Baby's body cannot be turned To deliver posterior shoulder, Hold and lift baby up by ankles, move the baby’s chest towards woman’s inner leg. The posterior shoulder should deliver, free the arm and hand. Lay the baby back down by the ankles. The anterior shoulder should now deliver
Breech birth Procedure: Delivery of the head, Mauriceau-Smellie-Veit: bby face down,body over ur arm. 1st n 3rd fngrs on bb’s cheek bones, 2nd fngr in bb’s mouth, pull jaw down n flex head. Other hand hooks bb’s shoulders w index n ring fngrs. middle fngr gently flexs bb's head 2 chest,pull on jaw.Pull gently 2 deliver head
Breech birth Procedure:Post-delivery care •Suction the baby’s mouth and nose, if meconium is present. •Clamp and cut the cord. •See the CPG normal cephalic delivery for care of the newborn
Cephalic delivery Indications To assist a labouring woman in the delivery of her child
Cephalic delivery Contraindications • Breech delivery • Mother not in labour or delivery not imminent • Normal transport to hospital a viable option
Cephalic delivery Complications •Pain • Malpresentation • Cephalopelvic disproportion (CPD) • Shoulder dystocia • Infection • Postpartum haemorrhage • Prolapsed cord • Inversion of the uterus
Cephalic delivery definition: process by which fetus, placenta and membranes are expelled via the birth canal. In normal labour: • The fetus presents by the vertex • The occiput rotates anteriorly • The result is the birth of a living, mature fetus (28–42 weeks)with no complication
Cephalic delivery Procedure.1 cervix fully dilated,push. pant as head delivers. to control birth,fingers against head to keep it flexed. support the perineum Once head delivers,no pushing if meconium present,suction mouth then nose. If cord around neck loosely, slip it over th
Cephalic delivery Procedure.2 cord tight around neck, two clamps, cut between them, before unwinding cord from around neck. Allow the fetus’s head to turn spontaneously place hand on each side of fetus’s head. mother to push gently with next contraction.
Cephalic delivery Procedure.3 Move fetus’s head posteriorly then anteriorly to deliver top then bottom shoulder.Support fetus’s body as it slides out. fundus massaged until uterus is contracted. Repeat uterine massage every 15 minutes for the first two hours.
Cephalic delivery Care of the newborn Place baby mother’s abdomen,skin to skin. dry baby, wipe eyes assess breathing. If baby is breathing (rr:30) leave baby with mother. not breathing < 30 seconds, resuscitate . Complete an Apgar score on the baby at 1 and 5 minutes after birth
Cephalic delivery Care of the newborn.2 Clamp cord 10, 15,20 cm from baby cut between 15 and 20cm Deliver placenta and membranes if reqd. Ensure baby is kept warm en route to the receiving facility. Maintain skin to skin with the mother and cover the baby’s head and back with a warm blanket
Shoulder dystocia Indications The anterior shoulder does not deliver spontaneously with good contractions. The head does not restitute and externally rotate. The chin burrows into the perineum as the anterior shoulder is caught on the symphysis pubis.
Shoulder dystocia Contraindications • Nil
Shoulder dystocia Complications Damage to the upper brachial plexus nerves • Fetal hypoxia • Fetal death • Cerebral palsy • Maternal postpartum haemorrhage
Shoulder dystocia Procedure: McRoberts Rubin I (suprapubic pressure): All-fours (Gaskin) Rubin II(1 hand, push shoulder towards fetal chest. Woods screw (2 hands, fingers both shoulders n screw) Reverse Woods screw Delivery of the posterior arm (sweep posterior arm across che
Defibrillation Indications • Ventricular fibrillation • Pulseless ventricular tachycardia
Defibrillation Contraindications • Ventricular fibrillation • Pulseless ventricular tachycardia
Defibrillation Complications Injury incl burns: - Arcing between electrodes - Foreign bodies (inc leads) between pads n patient - Pads with insufficient lubrication Explosion: -shock could cause explosion if combustibles in vicinity. Transmitted shock to operator or bystande
Defibrillation Joules: Shock 1 200 Shock 2 300 Shock 3 360 Children eight years and below: - All shocks given at 4 J/kg Chrildren 9yrs+ Adult shocks
Defibrillation Additional information (ICD) Do not place defibrillation pads over the top of pacemakers or ICDs If ICD is discharging: - Allow ICD to discharge and continue CPR - Do not externally defibrillate.
Donway traction splinting Indications Mid shaft femoral fractures
Donway traction splinting Contraindications • Pelvic injury • Fracture/dislocation of the knee • Ankle injury • Bilateral femoral fractures • Multiple fractures on the same leg
Donway traction splinting Precautions Gently re-align to decrease the chance of a closed fracture becoming a compound fracture
NEANN immobilisation & extrication jacket Indications To facilitate safe extrication from a confined space
NEANN immobilisation & extrication jacket Contraindications • When the patient is actual time critical and the application of the NIEJ will delay transport to a trauma centre, or appropriate hospital.
NEANN immobilisation & extrication jacket Precautions •Chest straps 2 tight interfere with resp. •Groin straps secured 2 minimise jacket and neck movement •Incorrect head padding lead to C-spine hyperextension or hyperflexion. •Immobilising head without properly securing torso may cause C-spine move
SAM Pelvic Sling™ Indications Suspected pelvic fracture with evidence of haemodynamic comprimise
SAM Pelvic Sling™ Contraindications • Suspected isolated neck of femur fracture • Suspected traumatic hip dislocation
SAM Pelvic Sling™ Precautions Once applied, a binder should not be removed due to the risk of haemodynamic instability. • Other methods (e.g. a vacuum splint) may be used in small children. •Apply carefully in gross compound fractures to minimise pain and further complications
Procedure: notification “My name is X I’m an ACP with QAS. I’m phoning with a notification. I have a X year old male / female patient with X. Treatment to this point has involved X and current vital signs are X. I have administered / performed X Our ETA is X minutes.”
Clinical consultation My name is X,I’m an ACP with QAS. I’m phoning with a clinical consult. I have a Xyo m/f pt with X. Treatment has been X VSS are X. I would like to administer / perform / seek advice regarding X. this is appropriate? anything u suggest? Confirm X
Tension pneumothorax decompression Indications Suspected tension pneumo with resp and/or haemodynamic compromise - Resp: Chest pain, dyspnoea, tachypnoea, surgical emphysema, diminished breath sounds on affected side,tracheal deviation, cyanosis. - Cardio: Tachycardia, decreased LOC, hypotension
Tension pneumothorax decompression Contraindictions • Nil in the setting of acute trauma
Tension pneumothorax decompression Complications •Improper diagnosis and insertion of pleural catheter may creat simple or tension pneumo • Incorrect placement may injure heart, great vessels, or damage lung *Bilateral pleural decompression in spontaneously breathing pt may cause resp compromise.
Tension pneumothorax decompression Procedure Locate 2nd intercostal space midclavicularline Swab Insert 14Gcannula, perpendicular to chest on superior border of 3rd rib until sudden loss of resistance Remove stylet, advance cannula until hub is flush Re-evaluate breath sounds n haemodynamic
Waveform capnography Indications •CPR or IPPV (BVM/LMA/ETT) •Sedation and procedural sedation • Endotracheal intubation (placement confirmation) • Ongoing monitoring of ventilation
Waveform capnography Contraindications • Nil in this setting
Waveform capnography Precautions When performing effective CPR during cardiac arrest, EtCO2 values are not to be used to vary IPPV from the recommended rate When capnography is not in use,close EtCO2 connnection port door or it will break
Created by: 532742259