fr3 student guide - unit 12

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First Responder Program

Student Training ManualLevel III

Prepared by:Paramedic Academy

Justice Institute of British Columbia New Westminster, BC

December 2004



2 FIRST RESPONDER STUDENT MANUAL LEVEL III

Paramedic Academy

Justice Institute of British Columbia

New Westminster, BC

Content Revised December 2004

© 1990, 1991, 1994, 1999, 2001, 2004

Province of British Columbia.

All rights reserved. No part of this guide may be reproduced or

transmitted in any form, or by any means, electronic or mechanical,

including photocopy, recording, or any information storage and

retrieval system, without written permission from the Province of

British Columbia.

Paramedic Academy

Justice Institute of British Columbia

715 McBride Boulevard

New Westminster, BC

V3L 5T4

Tel: (604) 528-5690. Fax: (604)528-5715

email: [email protected]

www.paracademy.com

www.jibc.bc.ca

Published 1990. Format revised August 1995.

Content revised September 1999. Revised Edition March 2001.

Printed in Canada

mailto:[email protected]

http://www.jibc.bc.ca/

http://www.jibc.bc.ca/

mailto:[email protected]



Acknowledgements

PARAMEDIC ACADEMY / MARCH 2001 3

Acknowledgements

The development of the First Responder training program was a collaborative effort of three emergency

services. Representatives of the Police, Fire, and Ambulance Services formed the principal Steering

Committee. In addition, several other departments and units of these services provided the external

validation for the program.

The Steering Committee recognizes the original recommendations made by Chief Coroner Vince Cain

and the impetus his office gave to this project.

Paramedic Academy Project Team (1994)

Director

A.T. Williams, PhD

Program Director

Derek White

Dave Busse

Program Coordinator

Vic Barron

Ron Bowles

Program Planner

Marika Morissette

Medical Coordinator

Dr. Sheldon Glazer

Dr. Jeff Freeman

Content Experts

Geoff Vick

Bill Maser

Jim Bond

Writer

Frank Chow

Layout

Irma Rodriguez

Illustrations

Western Technigraphics

Don Chin

Paramedic Academy Update Team (1999)

A.T. Williams, PhD Director

Urbain Ip, MD Medical Advisor, First Responder Program

Gil Vergilio, MEd Program Director, Basic ProgramsBobbie Walkley, EMA II Program Coordinator

Griff Richards, PhD Program Director, Learning Systems

Tracey Leacock, PhD Project Manager, Editor

Ian Fitzpatrick, First Responder Instructor Subject Matter Expert

F & M Chow Consulting Layout

Training Subcommi ttee (1999)

A.T. Williams, Director, Paramedic Academy

Wayne Markel, Township of Langley Fire Department

Rich Courtney, Workers’ Compensation Board of BC

Urbain Ip, Medical Advisor

Randy Shaw, Port Coquitlam Fire Department

Ian Brethour, EMA Licensing Branch,

Ministry of Health

Wilf Meyer, Superintendent , BC Ambulance Service

Jim Mancell, Police AcademyGil Vergilio, Program Director, Paramedic Academy

Bobbie Walkley, Program Coordinator,

Paramedic Academy




1990 External Validation Committee

Ambulance Service

Fred Bates, Executive Director

Gord Bates, Chief Superintendent

Tom Breiter, Chief Superintendent

Del Collin, Director

Neil Leard, Director

Alan Miller, Superintendent

Gerry Parrott, Superintendent

Fred Platteel, Chief Superintendent

Brian Porritt, Supervisor

Terry Reid, Chief Superintendent

John Schinbein, Director

Dr. Charles Sun, Medical Director

Coroner’s Office

Vince Cain, Chief Coroner

EMA Licensing Branch

Ian Brethour, Registrar of Licensing

Fire Service

Rick Dumala, Fire Commissioner

Fred Eagle, Captain, Prince George

Terry Erskine

Don Gillis, Chief, Fort Nelson

Dave Hill, Chief, Saanich

Brent Hodgins, Chief, Penticton

Ted Lorenz, Chief, RichmondH.A. Maginnis, Chief, Burnaby

Jim Nelson, Trail

Douglas Norman, Chief, Kamloops

Larry Obst, Prince George

Don Pamplin, Chief, Vancouver

Paul Parnell, Chief, New Westminster

Harry Sommerville, Chief, Nelson

Mark Wakefield, Chief, Vernon

Gerry Zimmerman, Chief, Kelowna

Police Service

S.G. Anderson, Chief Constable, Oak Bay

Ron Brock, Chief Constable, Nelson

K.G. Brown, Chief Constable, New Westminster

Barry Daniel, Chief Constable, Matsqui

D. Egan, Sergeant, District of Saanich

H.A. Jenkins, Chief Constable, West Vancouver

Roger Kambel, Inspector, RCMP

G.W. Laughy, Chief Constable, Port Moody

G.T.L. Lawson, Chief, Central Saanich

P. Marriott, Chief Constable, Esquimalt

R. Miller, Chief, Central Saanich

W. Nixon, Chief Constable, Saanich

R.A. Sharp, Superintendent, Director, Ports

Canada Police & Security

W. Snowdon, Chief Constable, VictoriaR.J. Stewart, Chief, Vancouver

P.D. Wilson, Chief Constable, Delta



Intent and Purpose


Intent and Purpose

In 1989 the Chief Coroner of British Columbia reviewed the collaboration between the three emergency

services (Police, Fire, and Ambulance). He submitted a series of recommendations to the Deputy

Minister of Health in the fall of that year.

One of these recommendations described the development of a first responder program specific to the

needs of police officers and firefighters. Chief Coroner Vince Cain recommended that the Justice

Institute design a course that would enhance the cooperation between the services when treating the sick

and injured. He emphasized the need for a continuum of care beginning with the first responder(s)

working cooperatively with British Columbia Ambulance Service paramedics.

Subsequently, the Justice Institute formed a three-service Steering Committee to guide the program’s

development. Next, an External Validation Committee representing all three services validated the

content and delivery method. The concentrated efforts of these two groups led to the training program

presented in this manual. The Steering Committee recognizes that the training program supports

operational procedures but does not set them.

Mr. Cain’s conclusions and this subsequent training program have led to an improvement in the

continuity of care in BC in the past few years. Both Mr. Cain and the First Responder Steering Committee

are encouraged by the early acceptance, growth and success of the First Responder program. We look

forward to continued cooperation between the emergency services that will continue to raise the quality

of pre-hospital emergency care.

A.T. Williams, PhD

Chair, First Responder Training Steering Committee



Content


Table of Contents

Overview: The First Responder Program .......................................................... 11

How to Work Through the Course ...................................................................................... 13

Icons ....................................................................................................................................13Simulations and Skills Checklists ....................................................................................... 13

Schedule .............................................................................................................................14

Unit 1: Role of the First Responder .................................................................... 15

1.1: Describe the Emergency Medical System (EMS) and the role of the

First Responder ........................................................................................................ 17

Self-Test 1.1 ..............................................................................................................18

1.2: Identify the equipment contained in the First Responder kit ................................. 19

Unit 2: Patient Assessment ............................................................................... 23

2.1: Perform a scene assessment.................................................................................... 25

Case Study 2.1 .......................................................................................................... 26

2.2: Perform a primary survey ....................................................................................... 272.2a: Assess level of consciousness (LOC) using the AVPU method ................... 28

2.2b: Manage a delicate spine .............................................................................. 28

2.2c: Open and maintain the airway ................................................................... 28

2.2c(1): Clear obstructions from the patient’s mouth and throat ............ 29

2.2c(2): Open the airway .......................................................................... 30

2.2c(3): Correctly use an oral airway for unconscious patients ................ 31

2.2c(4): Suction the mouth cavity if required .......................................... 34

2.2c(5): Place unconscious patients and patients with compromised

airways in the recovery position and monitor breathing ............ 35

2.2d: Assess and manage the patient’s breathing ................................................ 42

2.2d(1): Determine when a patient is not breathing adequately .............. 43

2.2d(2): Use a pocket mask to ventilate patients with inadequate breathing ..................................................................................... 43

2.2d(3): Ventilate a pediatric patient (infant or child) with inadequate

breathing using a bag-valve-mask-oxygen reservoir unit........... 44

2.2d(4): Use the bag-valve-mask-oxygen reservoir unit to ventilate adult

patients with inadequate breathing ............................................ 49

2.2e: Assess and manage the patient’s circulation ............................................... 51

2.2f: Perform a rapid body survey (RBS) ............................................................ 53

2.2f(1): Perform a rapid body survey ....................................................... 53

2.2f(2): Give oxygen at high flow (10 L/min) with a standard face mask 53

2.2f(3): Describe the pathophysiology of hypoxic drive and the

management of a COPD patient ................................................. 55

Case Study 2.2 ..........................................................................................................572.3: Perform a secondary survey .................................................................................... 59

2.3a: Establish the chief complaint and history of chief complaint .................... 59

2.3b: Record and monitor the patient’s LOC, pulse, respirations, and skin

colour and temperature ...............................................................................61

Case Study 2.3 ......................................................................................................... 62

2.4: Record data and report it accurately to ambulance personnel ............................... 64

2.5: Describe the principles of triage ............................................................................. 65



Content


Self-Test 2.5 ............................................................................................................. 67

Summary 2 ......................................................................................................................... 68

Unit 3: Management of Medical Emergencies ................................................... 73

3.1: Manage an unconscious medical patient .................................................................75

Case Study 3.1 .......................................................................................................... 76

3.2: Assess and manage heart attack patients ................................................................. 773.2a: List the signs and symptoms of a heart attack ............................................. 77

3.2b: Manage a patient experiencing a heart attack ............................................ 78

Case Study 3.2 ......................................................................................................... 79

3.3: Assess and manage patients with respiratory emergencies .................................... 80

3.3a: List the signs and symptoms of a respiratory emergency .......................... 80

3.3b: Manage a patient experiencing a respiratory emergency ............................81

Case Study 3.3 ......................................................................................................... 82

3.4: Assess and manage stroke patients ......................................................................... 83

3.4a: List the signs and symptoms of a stroke ..................................................... 83

3.4b: Manage a patient experiencing a stroke ..................................................... 83

Case Study 3.4 ......................................................................................................... 85

3.5: Assess and manage patients with diabetes ............................................................. 86

3.5a: List the signs and symptoms of a diabetic emergency ............................... 86

3.5b: Manage a diabetic patient ........................................................................... 87

Case Study 3.5 ......................................................................................................... 88

3.6: Assess and manage overdose/poisoning patients ................................................... 89

3.6a: List the signs and symptoms of an overdose/poisoning ............................ 89

3.6b: Manage a patient suffering from an overdose/poisoning .......................... 90

Case Study 3.6 ..........................................................................................................91

3.7: Assess and manage patients with seizures .............................................................. 92

3.7a: List the signs and symptoms of a generalized seizure ................................ 92

3.7b: Manage a patient experiencing a seizure .................................................... 92

Case Study 3.7 ......................................................................................................... 94Summary 3 ......................................................................................................................... 95

Unit 4: Management of Trauma ........................................................................ 99

4.1: Assess and manage patients who are bleeding/in shock ....................................... 101

4.1a: Describe the signs and symptoms of shock ............................................... 101

4.1b: Describe the different types of bleeding .................................................... 101

4.1c: Control external bleeding ......................................................................... 102

4.1d: Apply dressing and bandages properly......................................................105

4.1e: Manage a patient in shock ........................................................................ 106

Case Study 4.1.........................................................................................................107

4.2: Assess and manage patients with head/neck/spine injuries ................................ 108

4.2a: Describe the signs and symptoms of a head injury .................................. 108

4.2b: Manage a patient with a head injury ........................................................ 109

4.2c: Describe the signs and symptoms of a neck/spine injury ......................... 110

4.2d: Manage a patient with a neck/spine injury ................................................111

Case Study 4.2 ........................................................................................................ 112

4.3: Assess and manage patients with chest injuries .................................................... 113

4.3a: Describe the signs and symptoms of a chest injury ................................... 113

4.3b: Manage patients with open or closed chest injuries .................................. 115

Case Study 4.3 ........................................................................................................ 117



Content


4.4: Manage patients with abdominal injuries ............................................................. 118

Case Study 4.4 ....................................................................................................... 120

4.5: Assess and manage patients with fractures/dislocations ...................................... 121

4.5a: Describe the signs and symptoms of fractures and dislocations ............... 121

4.5b: Manage a patient with a fracture or dislocation ........................................ 122

Case Study 4.5 ........................................................................................................1234.6: Assess and manage burn patients ..........................................................................124

4.6a: Describe the different types of burns and their appearance .....................124

4.6b: Manage a burn patient ...............................................................................126

Case Study 4.6 ....................................................................................................... 128

Summary 4 ........................................................................................................................129

Unit 5: Management of Environmental Emergencies ...................................... 133

5.1: Assess and manage patients suffering from smoke inhalation .............................. 135

5.1a: Describe the signs and symptoms of smoke inhalation ............................ 135

5.1b: Manage a patient suffering from smoke inhalation .................................. 136

Case Study 5.1 ......................................................................................................... 137

5.2: Assess and manage carbon monoxide poisoning patients .................................... 138

5.2a: Describe the signs and symptoms of carbon monoxide poisoning .......... 138

5.2b: Manage a patient with carbon monoxide poisoning ................................ 138

Case Study 5.2 ....................................................................................................... 140

5.3: Assess and manage hypothermia patients ............................................................. 141

5.3a: Describe the signs and symptoms of hypothermia ....................................142

5.3b: Manage a hypothermia patient ..................................................................142

Case Study 5.3 ........................................................................................................144

5.4: Assess and manage patients suffering from hyperthermia.................................... 145

5.4a: Describe the signs and symptoms of heat emergencies ............................ 145

5.4b: Manage patients suffering from heat emergencies ...................................146

Case Study 5.4 ........................................................................................................ 147

5.5: Assess and manage drowning/near-drowning patients ....................................... 1485.5a: Describe the signs and symptoms of near-drowning ............................... 148

5.5b: Manage a drowning/near-drowning patient ............................................ 148

Case Study 5.5 ........................................................................................................150

Summary 5 ........................................................................................................................ 151

Unit 6: Legal Aspects ....................................................................................... 153

6.1: Describe legislation that pertains to the First Responder’s duties ........................ 155

6.2: Describe the principles of preservation of evidence .............................................. 156

Case Study 6.2 ........................................................................................................158

6.3: Describe the First Responder Operational Guidelines on

Do Not Resuscitate (DNR) Orders ......................................................................... 159

Summary 6 ........................................................................................................................ 161

Unit 7: Communicable Diseases ......................................................................163

7.1: Describe the ways by which diseases are transmitted ........................................... 165

Self-Test 7.1 ............................................................................................................ 167

7.2: Describe common communicable diseases........................................................... 168

Self-Test 7.2 ............................................................................................................170

7.3: Describe and demonstrate the precautions for managing patients with

communicable disease ........................................................................................... 171

Case Study 7.3 ........................................................................................................ 173



Content


7.4: Describe the procedure for decontaminating equipment ...................................... 174

7.5: Describe the benefits of immunization .................................................................. 175

Self-Test 7.5 ............................................................................................................ 176

Unit 8: Ambulance Orientation ....................................................................... 177

8.1: Identify commonly used ambulance equipment and describe their function ....... 179

8.2: Demonstrate commonly used lifting/transferring techniques ............................. 182Case Study 8.2 ........................................................................................................185

Summary 8 ....................................................................................................................... 186

Appendix A: References and Glossary ............................................................ 189

References ......................................................................................................................... 191

Glossary .............................................................................................................................192

Appendix B: Answer Key ................................................................................ 199

Self-Test 1.1 ...................................................................................................................... 201

Case Study 2.1 .................................................................................................................. 201

Case Study 2.2 .................................................................................................................. 201

Case Study 2.3 .................................................................................................................. 202

Self-Test 2.5 ...................................................................................................................... 202

Case Study 3.1 .................................................................................................................. 203

Case Study 3.2 .................................................................................................................. 203

Case Study 3.3 .................................................................................................................. 203

Case Study 3.4 .................................................................................................................. 203

Case 3.5 ............................................................................................................................ 204

Case Study 3.6 .................................................................................................................. 204

Case Study 3.7 .................................................................................................................. 204

Case Study 4.1 .................................................................................................................. 205

Case Study 4.2 .................................................................................................................. 205

Case Study 4.3 .................................................................................................................. 205

Case 4.4 ............................................................................................................................ 205Case Study 4.5 .................................................................................................................. 206

Case Study 4.6 .................................................................................................................. 206

Case Study 5.1 ................................................................................................................... 206

Case Study 5.2 .................................................................................................................. 207

Case Study 5.3 .................................................................................................................. 207

Case Study 5.4 .................................................................................................................. 208

Case Study 5.5 .................................................................................................................. 208

Case Study 6.2 .................................................................................................................. 208

Self-Test 7.1 ...................................................................................................................... 209

Self-Test 7.2 ...................................................................................................................... 209

Case Study 7.3 .................................................................................................................. 210

Case Study 7.5 .................................................................................................................. 210Case Study 8.2 .................................................................................................................. 210



Overview:The First Responder Program

Welcome to Level III of the First Responder (FR) Program, a

course designed for independent learning. In it, you will

study and review principles of emergency health care as they

apply to the First Responder.

To get the most out of this program, keep in mind your role as

a First Responder. You will often be the first person to

provide medical attention to the patients at an accident or

medical emergency, and may have to do this until the BC

Ambulance Service arrives. You will have to provide care

immediately – within the first few minutes at the scene and

until more highly trained medical personnel arrive – so that

the injuries do not harm the patient further.

This program focuses on the management of the critical first

moments, when you have to assess the patient and decide if

the injuries are life-threatening and what treatment(s) they

require. This program is designed to sharpen yourassessment skills so that you can size up a patient quickly. It

will also give you the skills you need to respond appropriately

and the self-confidence to act decisively in these situations.



How to Work Through the Course

PARAMEDIC ACADEMY MARCH 2001 OVERVIEW 13

The course has four components:

• this manual

• skills checklists package

• a video (optional)

• 32 hours of practical classroom sessions

The manual will serve as your main source of information. There are

eight units. Each unit has a set of learning objectives, which you can

think of as a road map to guide you through the material. The

objectives cover two things:

• theoretical knowledge that you will need in order to recognize

various types of injuries and medical conditions, and

• skills that you will use to provide emergency care to your patients

Self-tests, case studies, and checklists will help you to assess yourprogress and to practise what you have learned before reporting to

class. Answers to the self-tests and case studies are in the answer key

at the end of the manual.

As you work through the following pages, you will see several icons,

symbols that will help you identify key information and activities.

Key Points – very important concepts or facts

Skills – things you must do to care for apatient properly

Case Studies – case studies where you apply what you have learned to practical situations

Self-Tests – short tests to help you review thecontent of a particular section

How to WorkThrough the Course

Icons

Simulations andSkills Checklists



How to Work Through the Course


Throughout this manual, you will find simulations that will help you

practise the skills you have learned. Do the following:

1. Make sure you have worked through the material pertaining to

each situation.

2. Read the simulation from beginning to end.3. Gather all the necessary equipment to complete the simulation.

4. Practise each step in the Skill Checklists package with a partner,

friend, or family member until you become proficient in it. You

will be expected to demonstrate and master these skills in class.

You should be able to work through the manual and practise the skills

in about two weeks. If you have any questions, contact your

Departmental FR Instructor for clarification. You will then be ready

for the classroom sessions. Use your manual as a reference during

class.

Begin Unit 1 now. Good luck!

Schedule



Unit 1:

Role of the First Responder

As a First Responder, you are an important part of the

Emergency Medical System (EMS) in British Columbia. For

the EMS to work successfully, everyone involved should be

familiar with the system’s other elements and with his or her

role in it.

By the time you complete this unit, you should be able to

accomplish the following objectives:

1.1 Describe the Emergency Medical System (EMS) and the

role of the First Responder.

1.2 Identify the equipment contained in the First Responder

kit.



EMS and the role of the First Responder

PARAMEDIC ACADEMY / MARCH 2001 UNIT 1: ROLE OF THE FIRST RESPONDER 17

The Emergency Medical System (EMS) is a community-wide

coordinated means of responding to sudden illness or injury.

As a First Responder, you may be the first to arrive at the scene of an

accident or emergency. By being the first emergency medical services

worker at the scene, you have the potential to save a life or to reduce

the chances of further harm to the patient.

You have six main patient-related duties at the emergency scene.

These are:

1. to control an accident scene in order to protect yourself and your

patients and to prevent additional accidents

2. to determine the number of patients at an accident scene

3. to gain access to the patient

4. to find out what is wrong with the patient and to provide

emergency care with available equipment

5. to lift or move the patient only when required, and to do so without causing additional injury

6. to transfer care of the patient and provide information about

his/her condition to ambulance personnel when they arrive at the

scene

1.1:Describe the

Emergency MedicalSystem (EMS) and the

role of the FirstResponder



EMS and the role of the First Responder


Answer the following questions and compare your answers with

those provided in Appendix B. Review this section if you make any

mistakes.

1. What does EMS stand for?

____________________________________________

2. Which of the following may be First Responders?

a) Emergency Medical Attendants

b) Air Ambulance personnel

c) in-hospital emergency workers

d) Police officers and Firefighters

e) all of the above

3. List the First Responder’s six main patient-related duties.

____________________________________________

____________________________________________

____________________________________________

____________________________________________

____________________________________________ ____________________________________________

Self-Test 1.1



First Responder kit


Your First Responder kit has five compartments, as shown in the

following diagram.

Take a few moments to inspect each compartment and identify the

following items. Quantities are minimum recommended amounts.

Item Function

COMPARTMENT A

• Bag-valve-mask reservoir unit • To assist respirations. With reservoir and

oxygen flow at a minimum of 15L/min, delivers

oxygen concentration of 90%.

• 1 Set oral airways • Sizes 00, 0 and 1 to 6 (metric sizes 5-12). Used

to maintain an open airway in unconscious

patients.

• 1 Suction unit • For removal of mucus, blood, and vomitus from

the upper airway.

• 2 Standard O2 masks/tubing • Delivers oxygen to patient’s nose and mouth.Exhaust ports expel excess oxygen and permit

entry of outside air on inhalation. Oxygen

concentration of 60% at 8-10 L/min.

• 1 Non-rebreather O2 mask • Delivers high concentrations of oxygen from

reservoir. Oxygen concentration of 90-95% at

10 L/min. Used in treating smoke inhalation,

gas inhalation, or carbon monoxide poisoning.

1.2:Identify the equipment

contained in the FirstResponder kit



First Responder kit


Item Function

• 1 Pocket mask with 1-way valve • May be used for mouth-to-mask or bag-to-mask

ventilation, as an oxygen delivery mask

delivering oxygen concentration of 50-60% at

10 L/min. Used for CPR-on-the-move or whenregular resuscitation mask from BVM does not

create an effective seal.

• 1 Litre saline or sterile water • For cooling thermal burns.

• 1 Burn pack • Used to prepare the stretcher and cover the

burn patient. Helps to maintain a sterile field.

Paper sheets and pillow cases should not be

placed directly onto the burned area.

• Four 12″ × 12″ polygauze

One 18″ × 18″ polygauze

One 24″ × 24″ polygauze

• Used primarily for burn injuries. Size depends

on size of wound.

• 1 Alcare foamed alcohol • An in-field solution to degerm hands and

forearms. For use when FRs do not have

access to soap, water, and wash basins.

• 2 face shields, particulate masks and

goggles

• To protect FR’s eyes, mouth, and nose.

COMPARTMENT B

• 2 Pressure dressings • Gauze with straps that can be wrapped and tied

to create direct pressure on a wound.

• Three 8″ × 10″ abdominal pads

Three 6″ × 8″ abdominal pads

• Large sterile pads used to hold sterile dressings

(e.g., 4″ × 4″ gauze pads) in place, and toabsorb blood and other body fluids.

• One 10″ × 30″ multi-trauma • For use with large wounds.

• Three 3″ cling • To hold dressings in place.

• Three 3″ crepe • To hold dressings in place.

• One 1″ cloth tape • To secure cling or crepe ends, or to hold

dressings in place.

• One 1″ transpor tape • May be used instead of cloth tape if patient is

allergic to tape or you do not want to cause

further damage to a wound.

• 1 Package 4″ × 4″ gauze

10 Sterile 4″ × 4″ gauze

5 Sterile 3″ × 5″ gauze

• Dressing wounds.

• Four 3″ × 5″ telfa pads • Small wound care, burns.

• 1 Esmarch • May be used as a tourniquet as a last resort.

Section may be used to cover open chest

injuries.



First Responder kit


Item Function

COMPARTMENT C

• 1 Ring pad • To protect an embedded object.

• 6 Triangular bandages • To secure large dressings and immobilizelimbs.

• 2 Hot packs • For treatment of hypothermia.

• 2 Cold packs • For treatment of fractures, swelling, and pain if

circulation to the affected area is adequate.

• SAM splints • For splinting of fractures/head immobilization.

• Speed straps • To secure dressings and immobilize limbs.

• 1 Head Immobilization Device • For head immobilization.

COMPARTMENT D

• 4 Pairs non-sterile surgical gloves • To protect the FR from body fluids duringassessment and treatment.

• 2 Pairs sterile surgical gloves • To protect the FR and the patient from

transmission of disease, bacteria.

• 6 Tongue depressors • For examining the oral cavity and applying the

contents of a Glucopak.

• 2 Glucopaks • For applying in the oral cavity (under tongue,

against inside of cheek) in unconscious patients

with history of diabetes.

COMPARTMENT E

• 1 Pair scissors • To cut patient clothing so that injuries can be

assessed; to cut tape, dressings and bandages

as required.

• 1 Pen light • To assess pupil response; to visualize oral

cavity.

• 4 Savlodil • To cleanse small wounds.

• PRESEPT™ tablets • To sterilize FR equipment (masks, etc.).

EXTERNAL EQUIPMENT

• 4 Sandbags • To immobilize a patient’s head and neck; to

immobilize limbs.

• 1 Oxygen tank and regulator • Pressurized oxygen storage with flow regulator.

To increase oxygen concentration to the

patient.

• 1 Blanket • To keep patient warm (prevent shock) and dry;

to support limbs. For patient comfort.



First Responder kit


Item Function

• FR report forms • To record patient assessment and treatment

provided, and any changes to patient’s

condition.



Unit 2:

Patient Assessment

When you arrive at the scene of an accident, disaster, or

other emergency, there may be a multitude of things

competing for your attention. Without a structured and

uniform patient assessment model to follow, you would

probably end up overlooking many steps that are vital to a

patient’s survival.

The patient assessment model you are about to learn will help

you evaluate the patient systematically, starting with the

highest priorities and continuing to the less urgent ones.

Your goal will be to discover and manage hidden injuries and

other potentially life-threatening conditions that may not be

immediately obvious. By following the model consistently,

you can be sure of doing everything you should for your

patient.

First Responders with different levels of training andequipment can all use this model. Because Firefighters may

carry more equipment than other First Responders, they may

be able to treat patients more extensively, but the model does

not change from one level to the next.

Fo l l ow t he pa t i e n t a s ses sm en t m odel w heneve r y ou r espond

t o a n y em er g en c y .




The model has four components:

1. scene assessment

2. primary survey

3. secondary survey

4. reporting of data

Let’s now take a look at each of these in greater detail. By

the time you complete this unit, you should be able to

accomplish the following objectives:

2.1 Perform a scene assessment.

2.2 Perform a primary survey.

2.2a Assess level of consciousness (LOC) using the

AVPU method.

2.2b Manage a delicate spine.

2.2c Open and maintain the airway.2.2d Assess and manage the patient’s breathing.

2.2e Assess and manage the patient’s circulation.

2.2f Perform a rapid body survey (RBS).

2.3 Perform a secondary survey.

2.3a Establish the chief complaint and history of chief

complaint.

2.3b Record and monitor the patient’s LOC, pulse,

respirations, and skin colour and temperature.

2.4 Report data accurately to ambulance personnel.

2.5 Describe the principles of triage.



Scene assessment

PARAMEDIC ACADEMY / MARCH 2001 UNIT 2: PATIENT ASSESSMENT 25

Make a quick assessment of the overall situation at an accident scene.

Concentrate on the “big picture.” Consider three things:

1. environment

2. hazards

3. mechanisms of injury

Watch out for danger from traffic, fire, smoke, gasoline vapours, fallen

power lines, and and other hazards that may be present at the scene.

Consider whether the environment will allow you to treat the patient

safely.

Find out what caused the injury. The mechanism of injury can

alert you to the possibility that certain types of injuries may be

present. For example, fractured bones are usually associated with falls

and motor vehicle accidents; burns with fires and motor vehicle

accidents; and soft tissue injuries with gunshot wounds. Remember,

however, that for every obvious injury, there may be a number of

hidden injuries.

If any of the following factors are present, the patient

should be considered unstable and must be transported to

hospital by ambulance immediately:

• fall from a height greater than 5 metres

• severe deceleration accident

• ejection from a vehicle

• pedestrian struck by a vehicle

• motorcyclist with blunt abdominal trauma or chest injury

• penetrating injuries of the head, neck, chest, and abdomen

• amputation of extremities

• trauma patients older than 65 or younger than five

• evidence of shock

• respiratory distress

• serious head injury

You should be able to describe the patient’s injury. Confirm that theEmergency Medical System (EMS) has been activated, and be

prepared to provide treatment based on the mechanism of injury. In

later units, you will learn how to recognize and treat specific

emergencies.

2.1:Perform a scene

assessment



Scene assessment


Read the following case study and answer the questions about it.

Compare your answers with those provided in Appendix B.

Case A

One January night, you respond to the scene of a motor vehicle

accident on the Upper Levels Highway. Car A has struck Car B,

throwing it against a power pole at the side of the highway. The

impact has knocked down a power line, which lies across the roof of

Car B. Car A has gone off the road too, and smoke is rolling from

under its hood.

1. As you observe the two cars, you do a quick scene assessment. List

10 things you should note during this assessment.

____________________________________________

____________________________________________

____________________________________________

____________________________________________

____________________________________________

____________________________________________

____________________________________________

____________________________________________

____________________________________________

____________________________________________

Case B

You respond to an incident where the victim has suffered a gunshot

wound to the head. The bullet creased the scalp but did not penetrate

the skull.

2. Given the mechanism of injury, what other injury might you

suspect?

____________________________________________

Case Study 2.1



Primary survey


The primary survey is conducted once dangers at the scene have

been neutralized. It is the first step in the physical assessment of the

patient and consists of the following:

• check the level of consciousness (LOC) as you approach the

patient

• check the DABC (Delicate spine, A irway, Breathing, and

Circulation)

• performs a rapid body survey (RBS) to check for external

blood loss and deformities

While conducting the primary survey, you may discover life-

threatening emergencies such as obstructed airways, respiratory

difficulties, external bleeding, and obvious shock. Treat these

problems immediately.

For your safety, always wear personal protective equipment.

To perform a primary survey, you must be able to do the following:

2.2a Assess level of consciousness (LOC) using the AVPU method.

2.2b Manage a delicate spine.

2.2c Open and maintain the airway.

2.2c(1) Clear obstructions from the patient’s mouth, using a

tongue jaw lift or crossed-over finger technique to do

a visual check.

2.2c(2) Open the airway.

2.2c(3) Measure and insert a correctly sized oral airway for

unconscious patients.2.2c(4) Suction the mouth cavity if required.

2.2c(5) Place unconscious patients and patients with

compromised airways in the recovery position and

monitor breathing.

2.2d Assess and manage the patient’s breathing.

2.2d(1) Determine when a patient is not breathing

adequately.

2.2d(2) Use a pocket mask to ventilate patients with

inadequate breathing.

2.2d(3) Ventilate a pediatric patient (infant or child) with

inadequate breathing using a bag-valve-mask-oxygen reservoir unit.

2.2d(4) Use the bag-valve-mask-oxygen reservoir unit to

ventilate adult patients with inadequate breathing.

2.2e Assess and manage the patient’s circulation.

2.2f Perform a rapid body survey (RBS).

2.2f(1) Perform a rapid body survey.

2.2:Perform a primary

survey



Primary survey


2.2f(2) Give oxygen at high flow (10 L/min) with a standard

face mask.

2.2f(3) Describe the pathophysiology of hypoxic drive and

the management of a COPD patient.

Check for level of consciousness as you approach the patient. Thisinformation is important for other emergency personnel when they

take over patient care. A change in the level of consciousness is often

the first sign of a brain injury or other serious medical condition.

THE AVPU METHOD IS A SHORT AND SIMPLE WAY TO ASSESS THE LOC:

A – patient is Alert

V – patient responds to Verbal stimuli

P – patient responds to Pain

U – patient is Unresponsive to your approach and to verbal and painful stimuli

The best way to administer a painful stimulus is to squeeze the

patient’s trapezius muscle, which lies over the shoulder blades

(trapezoidal squeeze).

Always assume that the patient has a neck or spine injury ( de l i ca te

s p i n e ). You may rule it out a f t e r considering the mechanism of

injury, but always check for a delicate spine if the patient must be

moved. If you do not do this, you may seriously damage the patient’s

spinal cord and cause permanent paralysis.

If you suspect that the patient has a delicate spine, do the following:

1. Approach the patient from the head.

2. Tell the patient, “If you can hear me, don’t move.”

3. Stabilize the head in the position found using manual or

temporary stabilization.

4. Do not move the patient unless absolutely necessary to maintain

an open airway or to remove the patient from an immediate

hazard.

Airway management involves three things:

1. opening the airway

2. maintaining the open airway

3. helping the patient breathe effectively (ventilation)

2.2a: Assess level of

consciousness (LOC)using the AVPU method

2.2b:Manage a delicate spine

2.2c:Open and maintain the

airway



Primary survey


You will learn about opening and maintaining the airway under this

objective, and about ventilating the patient under Objective 2.2d.

Look, listen, and feel for the movement of air at the mouth or nose.

After an injury, a patient’s airway may become closed or blocked by

broken teeth, the tongue, or foreign objects.

Before taking steps to open the airway, make sure you have ruled

out a delicate spine or protected the neck. The technique you use will

depend on whether or not the mechanism of injury indicates a

delicate spine.

To manage the airway, you must be able to do the following:

2.2c(1) Clear obstructions from the patient’s mouth, using a tongue

jaw lift or crossed-over finger technique to do a visual check.

2.2c(2) Open the airway.

2.2c(3) Measure and insert a correctly sized oral airway for

unconscious patients.

2.2c(4) Suction the mouth cavity if required.

2.2c(5) Place unconscious patients and patients with compromised

airways in the recovery position and monitor breathing.

2.2c(1): Clear obstructions from the patient’s mouth, using a tongue

jaw lif t or crossed-over finger technique to do a visual check

Make sure your patient’s airway is clear before trying to open it.Remove foreign materials such as broken teeth, vomitus, loose-fitting

dentures, fluid, and mucus before attempting any further treatment.

Use an appropriate technique to open the patient’s mouth, and do a

visual check.

CROSSED-OVER FINGER TECHNIQUE

Do the following:

1. Place thumb on

upper front teeth andfirst finger on lower

front teeth.

2. Spread the mouth

open using a scissor

movement.



Primary survey


3. Visually check for foreign objects, then do a simple finger sweep to

remove any foreign objects. Be especially careful to protect the

patient’s neck if you suspect

a neck injury. Moving the

neck might seriously damage

the patient’s spinal cord.2.2c(2): Open the airway

Open the airway after clearing foreign materials from the mouth. The

tongue can easily act as a lid, closing down onto the back of the throat

and making breathing impossible. To open your patient’s airway, you

must lift the tongue up and off the back of the throat.

The technique you use will depend on whether or not the mechanism

of injury indicates a delicate spine. Assume that a neck injury is

present if the mechanism of injury suggests that neck trauma may

have occurred.

NO NECK INJURY: HEAD-TILT/CHIN-LIFT METHOD

Wa r n i n g : Do not use this procedure on any patient with neck or

spinal injuries.

Do the following:

1. Place one hand (A) on the patient’s forehead.

2. Place the first three fingers of the other hand (B) under the

patient’s chin and the thumb above the chin.

3. Keep fingertips on the bony part of the chin. Do not compress the

soft tissues that are under the lower jaw.

4. Gently push downward

with hand A. At the same

time, lift the chin and bringit to a point where the lower

teeth are almost touching

the upper teeth.

5. Do not allow the mouth to

close.



Primary survey


NECK INJURY SUSPECTED: MODIFIED JAW THRUST METHOD

If you suspect a neck injury, take care not to move the neck.

Do the following:

1. Kneel on the groundabove the patient’s head

with your elbows on theground, before takingcontrol of the head.

2. Place your hands on

either side of the patient’s

head so that your thumbs

are on the zygomas

(cheek bones) and your

middle and index fingersgrasp the angle of the

jaw.

3. Ensure the patient’s head

remains stable during all

procedures.

4. Use your index and

middle fingers to displace

the patient’s jaw upwards

to open the airway.

2.2c(3): Measure and insert a correctly sized oral airway for

unconscious patients

The techniques for opening the mouth to insert an airway are:

• tongue/jaw lift

• crossed-over finger technique

Once the airway passage is clear and open, you must keep it open,

especially if the patient is unconscious and cannot do it himself or

herself. The oropharyngeal airway , a hard plastic tube, is the ideal

tool for this. Inserted correctly, it prevents the tongue from falling

back and blocking the airway. A number of sizes are available, ranging

from size 00 (smallest) to size 6 (the largest) (metric sizes 5 – 12).



Primary survey


Never reuse an airway. Always use a new one foreach patient.

There are three steps in theuse of an oral airway.

1. SELECTION OF AIRWAY

Always use a correctly sized airway. If the airway is too short, it will

not lift the tongue off the back of the throat. If it is too long, it may

occlude the airway, cause damage to the structures of the upper

airway, or protrude from the mouth, complicating the use of the BVM.

Do the following to select the correct airway size for your patient:1. Look at the patient from one side.

2. Estimate the distance from the corner of the mouth (point A in the

diagram) to the angle of the jaw (point B).

3. Select an airway that looks to be the correct size. Measure it by

placing it against the side of the patient’s face (points A to B).



Primary survey


2. INSERTION OF AIRWAY

1. Open mouth using an

acceptable method (tongue- jaw lift, crossed over finger

technique).

2. Put the airway in the mouth,

and point its tip towards the

roof of the mouth.

3. Glide the tip carefully along

the roof of the mouth until it

reaches the soft palate. Be

careful not to damage the

mouth or force the tongue

back into the airway. 4. Rotate the airway 180°.

5. Insert the rest of the airway until the ridge meets the patient’s lips.

6. To prevent aspiration (a situation in which the patient inhales

vomitus), the patient must be placed in the ¾ prone or recovery

position, if possible. (You will learn about this under Objective

2.2c[5].) Patients left on their back must be monitored

continuously to ensure that they are breathing, have a pulse, anddo not aspirate.



Primary survey


3. REMOVAL OF AIRWAY

If the patient is regaining consciousness, he or she will start to gag,

swallow, or make sounds. The patient may also try to push the airway

out with the tongue. You can help the patient by gently pulling it

outward and slightly downward, following the natural shape of the

mouth.

Remove the airway as soon as the patient starts gagging.

If the patient is still unconscious and you have to change the airway

(such as when it becomes plugged), follow these steps:

1. Open the mouth with an appropriate technique.

2. Lift the oropharyngeal airway slightly.

3. Then remove it from the patient’s mouth, allowing it to follow its

normal curve as it comes out.

This minimizes damage to tissues. Because the patient may vomit

when you remove the airway, make sure suctioning equipment is

available.

2.2c(4): Suction the mouth cavity if required

Suctioning the mouth cavity is another procedure used to keep the

airway clear. Secretions and other debris are removed by applying

negative pressure through a hollow tube. If you do not remove the

debris, you may force it into the patient’s lungs during ventilation.

V-Vac or Yankauer suction tips are routinely advised for suctioning

but any rigid suction tip should suffice.



Primary survey


To operate the suction unit, follow these steps:

• Ensure that the new cartridge is in place.

• Remove the protective cap from the intake valve.

• Adjust the stroke (suction pressure) if required.

• Follow the general guidelines for suctioning.

After use:

• Replace the protective cap.

• Ensure the intake valve cover is closed.

• Keep the intake valve above the level of the cartridge fluids;

otherwise, suctioned material may flow out the intake valve.

• Remove the cartridge for ambulance crews to take to hospital, or

dispose of the cartridge in an approved container.

• Clean the handle as necessary.

• Install a new cartridge.

Prepare to suction the following:

• unconscious patients

• conscious patients who are having trouble with secretions, blood,

or vomitus

While preoxygenation for two to three minutes is desirable, in the

prehospital setting you will rarely have the opportunity to do this.

When you need to suction, suctioning takes priority .However, be aware that the suction is removing air as well as fluid.

Suction only as long as you need to in order to clear the airway, and

reoxygenate the patient as soon as possible after suctioning. If you are

assisting respirations or ventilating the patient, consider

hyperventilating the patient after suctioning is complete.

2.2c(5): Place unconscious patients and patients with compromised

airways in the recovery posit ion and monitor breathing

Patients who are unconscious or whose airways are compromised by

fluid or foreign objects should be placed in the ¾ prone or

recovery position. This will protect the airway in case the patient

vomits while unconscious or semi-conscious.

The technique you use for placing the patient in the recovery position

will depend on whether or not the mechanism of injury indicates a

delicate spine. Assume that a neck injury is present if the mechanism

of injury suggests that neck trauma may have occurred.



Primary survey


Moving patients

A general principle for First Responders is that patients should be

cared for in the position found. This principle is based on the

assumption that certain conditions or injuries (such as a neck fracture

in an unconscious patient) may be hidden and therefore missed

during the initial assessment. Unnecessary movement of the patientmay make the situation worse. In such cases, all repositioning should

be done by the most experienced persons on scene, who will also be

responsible for complete immobilization and transport.

In practice, however, there are three situations in which you, the First

Responder, will have to move the patient:

• repositioning the patient to manage immediate ABCs

• moving patients as quickly as possible out of hazardous areas

• rescuing and transporting patients

REPOSITIONING THE PATIENT TO MANAGE IMMEDIATE ABCs

Many patients are found in unusual or difficult positions. It may be

necessary to move them in order to effectively assess or manage their

ABCs by doing such things as:

• maintaining an open airway

• effectively ventilating the patient

• controlling life-threatening bleeding

• providing CPR

If you must move a patient, follow these principles:

• Moves are best done with the help of two or more people.

• Although managing the ABCs is always a priority, try to minimize

movement during urgent repositioning.

• Movement of the neck and spine is potentially more dangerous

than moving an extremity.

• In a conscious patient, increased pain caused by movement should

limit the amount of repositioning you carry out.



Primary survey


Procedure

If time and personnel allow, the suggested procedure is as follows:

1. Manually immobilize the patient’s head.

2. Direct a helper to place a hand on the patient’s shoulder and the

other hand on the patient’s hip. An additional helper may hold thepatient’s legs. If you are alone, support the patient’s head with one

hand, and place your other hand on the patient’s hip.

3. Roll the patient as a unit far enough to manage any life-

threatening problems.

MOVING THE PATIENT AS QUICKLY AS POSSIBLE OUT OF HAZARDOUS AREAS

Often a patient ends up in a precarious position, in which his or her

immediate health is threatened and simple care cannot be given.Examples include:

• a patient found in a fire or in a place where there is danger of fire

• a patient injured in an area where there are explosives or other

hazardous materials

• a patient who has fallen halfway down a staircase

• a patient who has to be moved from a car so that rescuers can

reach a more seriously injured patient trapped inside

In these situations, your job as First Responder is:

• to move the patient as quickly as necessary to an area where

further treatment can be done, and

• to protect the patient from further injury during the move, in the

best manner possible

Move the patient to the closest secure area for assessment and

treatment. Urgent moves such as these require quick decisions and

action, but the principles outlined earlier still apply. If a spine board

or similar rigid board is available, you may log-roll the patient onto

the board with help from assistants. If no board is available, you may

have to lift or drag the patient to a safe area.

The moves should be done in a way that minimizes spinal movement.

If spinal injury is not suspected, you may use the fore-and-aft lift.

(See section 8.2 for a detailed description of this procedure.)

A patient who does not need to be moved should not be moved, but

should be cared for in the position found.



Primary survey


RESCUING AND TRANSPORTING PATIENTS

First Responders are often called upon to move a patient who has to

be rescued. Examples of such situations include:

• embankment rescues

• hazardous terrain rescues

• rescues from heights

• confined space rescues

In these situations, you are expected to perform full spinal

immobilization (as taught in the Management of Spinal Injuries

Module for First Responders). You should then move the patient to

the nearest secure area for treatment and eventual transfer of care to

ambulance personnel.

The role of the First Responder does not include transporting

patients. If, because of extenuating circumstances, you are called

upon to transport injured patients, you should perform full spinal

immobilization. You should make specific arrangements in advance,

in cooperation with the BC Ambulance Service and the medical

coordinator, for these rare instances.

COMPLEX SITUATIONS

When you treat injured patients, you will face conditions that requirecomplex management. Although you may have to improvise, the

principles stay the same:

• Do no harm.

• Concentrate on ABCs first.

• Avoid unnecessary movement.

Airway Management

In a patient with an altered level of consciousness (LOC) or facial

trauma, your primary concern may be managing the airway and

aiding ventilation. These are difficult skills to perform without spinal

movement, but they obviously take precedence over any otherprocedures. The preferred manoeuvre for opening the airway is the

modified jaw-thrust; review this technique with your instructor. If

possible, have a partner keep the head stable while procedures are

being done.



Primary survey


Vomiting

Vomiting is a common problem in injured patients and may change a

simple situation into a crisis. If suctioning or drainage is not adequate

in the position that the patient is in, placing the patient in the lateral

or ¾ prone (recovery) position may solve the problem. If possible,

keep the cervical spine in a neutral position (either manually or withhelp) during repositioning.

Awkward Positions

There is no limit to the number of inconvenient positions that you will

find patients in, but no situation is totally unmanageable. Again,

concentrate on the principles, and do the best with the problems you

encounter.

Infants and Children

Although rare, 5% of all spinal cord injuries occur in the pediatric age

group. The principles are unchanged; however, children have

relatively larger heads and tend to flex their necks when lying supine.Improvise when necessary.

Difficult Patients

Sometimes because of anxiety, injuries, or intoxication, a patient may

not cooperate with you. Never try to immobilize the patient by force if

the struggle will possibly worsen injuries. Patients suffering from

altered LOC, other painful injuries, or intoxication may not even

notice the pain of a spinal injury. Reassure them, and minimize

movement in the best manner available.

Unstable Patients

A patient with critical injuries requires constant monitoring andinterventions. Stabilize the head and neck in the best manner

possible, and reassess ABCs and injuries frequently. Ambulance

attendants may sometimes make the difficult decision to rapidly

transport these patients before they can be fully immobilized. Manual

stabilization is always a reasonable option.

In summary, patients should be moved only in specific instances

where it is in the best interest of the patient’s care. Focus your

attention on ABCs, reassuring the patient, and making him or her

comfortable.



Primary survey


Positioning the patient

In most cases, positioning of the patient is determined by patient

comfort. If possible, the patient should be left in the position found

until ambulance personnel arrive. However, if moving the patient

results in better patient care, consider the following options:

• semi-sitting shortness of breath; obese

patients; chest pain

• supine suspected neck injuries; patients

with no radial pulse; hip fractures

• ¾ prone or recovery position all unconscious patients with no

suspected neck injury; all patients

with airway problems that cannot

be controlled by suctioning

Placing the patient in the recovery position

NO NECK INJURY

Do the following:

1. Kneel at the patient’s side and bring the far leg towards you so that

the patient’s ankles are crossed.

2. Place the arm and hand nearest you along the patient’s side. Place

the other arm across the chest.

3. Position your knee close to the person. Place one hand under the

head to support it, then grasp the pants or belt at the hip on the

side away from you.

4. Roll the patient towards you in one smooth but firm motion,

bringing the chest and abdomen to rest on your thighs. Protect the

head and neck during the roll.



Primary survey


5. Bend the patient’s upper knee towards you to prevent the body

from rolling forward. To maintain an open airway, position the

head so that the neck is extended.

6. Bend the arm nearest you at the elbow to support the upper body.Position the patient’s other arm along his/her side to prevent the

patient from rolling back.

7. Always check that the patient is still breathing and has a pulse

after being put in the recovery position. Monitor the level of

consciousness until medical help arrives.



Primary survey


NECK INJURY SUSPECTED

If the mechanism of injury indicates a possible spinal injury, the

patient is lying on his or her back, and the airway is compromised by

large volumes of vomitus or other secretions that cannot be managed

by suctioning, you must place the patient in the recovery position.

This is a two-person manoeuvre. The FR at the patient’s lower

body performs the same steps as for an unconscious patient who is not

suspected of having a spinal injury. The FR at the patient’s head must

support the head in the position found, and ensure that the head and

body travel as a unit as the patient is turned.

Do the following to immobilize the head:

1. Grasp the patient’s trapezius muscles (trapezoid squeeze).

2. Wedge the patient’s head between your forearms.3. Do not stop supporting the head until you are relieved.

Placing a patient with a suspected spinal injury in the recovery

position might seem contrary to the principles of patient care. Realize,

however, that you are managing priorities. If the patient is not

breathing, he or she will die. Thus, draining the airway and

maintaining it should be the top priority.

A patient may be breathing on his or her own but not doing so

adequately. Do not wait for respiratory arrest before ventilating the

patient.

To assess and manage the patient’s breathing, you must be able to do

the following:

2.2d(1) Determine when a patient is not breathing adequately.

2.2d(2) Use a pocket mask to ventilate patients with inadequate

breathing.

2.2d(3) Ventilate a pediatric patient (infant or child) with inadequate

breathing using a bag-valve-mask-oxygen reservoir unit.

2.2d(4) Use the bag-valve-oxygen reservoir unit to ventilate adult

patients with inadequate breathing.

2.2d:

Assess and manage thepatient’s breathing



Primary survey


2.2d(1): Determine when a patient is not breathing adequately

A patient is not breathing adequately if he or she has fewer than 10

respirations per minute and/or shows any of the following signs of

hypoxia (low oxygen level in the blood):

• agitation

• irritability

• drowsiness

• headache

• decreased level of consciousness

• rapid pulse

• laboured breathing

• abdominal breathing

• bluish skin colour

• irregular heartbeat

2.2d(2): Use a pocket mask to ventilate patients with inadequate

breathing

The pocket mask is designed to help you give assisted ventilations to

patients who need them. You can give mouth-to-mask ventilations

through a port on the mask. Always use a one-way valve with the

pocket mask.

The pocket mask provides several advantages:

• It reduces the effort required to keep the patient’s airway open.

• It allows you to ventilate the patient without touching his or her

mouth and nose (reducing the chances of contamination).

• You can use both hands to maintain the head in the position found

and still hold the mask firmly in place.

• It is easy to keep a good seal between the mask and the patient’s

face.



Primary survey


To provide mouth-to-mask ventilations, follow these steps:

1. Position yourself at the patient’s head.

2. Open the patient’s airway and clear it if necessary.

3. Position the mask on the patient’s face so that the apex (upper tip

of the triangle) is over the bridge of the nose and the base is between the lower lip and the projection of the chin.

4. Clamp the rest of the mask to the patient’s face, keeping both of

your thumbs along the sides of the mask.

5. With your fingers, grasp the patient’s jaw below the angles. Pull

gently upward to maintain the backward tilt of the head.

6. Breathe into the mask port once every 3-5 seconds. This will force

your breath into the patient’s lungs.

7. Monitor the patient’s breathing by watching the rise and fall of the

chest.

2.2d(3): Ventilate a pediatric patient (infant or child) with inadequate

breathing using a bag-valve-mask-oxygen reservoir unit.

Reference: The First Responder Pediatric BVM multi-media CD-

ROM lesson plan. Contact your Training Officer to view the disc or

contact the Justice Institute’s Callcentre at 604-528-5690.

ntroduct ion

You are called for a 9-month old boy who was left unattended in a

bathtub. Dispatch informs you the infant may by in respiratory arrest.When you arrive you are met by a very distraught mother who is

holding a baby that is obviously cyanotic. The mother frantically

passes you the baby and begs you to do something. You quickly

assess the baby’s respirations and pulse – the infant is in respiratory

arrest.

There is nothing more challenging for a First Responder than dealing

with a pediatric patient in a life-threatening situation. The rescue

scene may be emotionally charged and chaotic with reactions ranging

from quiet withdrawal and depression to shock, anger, and frustration.

And this is just from the caregivers. Pediatric patients are quitedistinctive from their adult counterparts. As such, your approach and

interactions with the patient will need to be modified. Unlike adults

who are usually glad to see the arrival of First Responders, children

may be afraid and withdraw from your presence. Let’s begin by

looking at a few of the unique characteristics of pediatric patients.



Primary survey


Unique Characteristics and Tips for ssessment of the Pediatric

Patient

“Pediatrics” refers to infants and children. For the purposes of this

lesson, infants will be defined as newborns up to one-year of age or

approximately 7 kgs or less. Children will be defined from one-year to

eight-years of age or approximately 30 kgs or less.

Infants

• Infants less than 2 months of age spend most of their time eating

and sleeping.

• Infants between 2 and 6 months are more alert and begin to make

eye contact. They will recognize their caregivers. They normally

will be actively moving their extremities. If upset they will cry

vigorously.

• Infants 6 – 12 months begin to babble, put objects in their mouth,

and sit on their own. Around 1 year they begin to crawl or stand

with support. Infants at this age may be very afraid of strangers or

being separated from their caregivers.

• Infants are nose breathers for the first few months of life.

• Infant’s chest muscles are not fully developed so they will appear

to “belly breath”.

• Approach an infant slowly and at eye level. Avoid sudden

movements and loud noises. Leave the infant with the caregiver if

possible.

• If crying, a toy or pacifier may calm the baby.

Toddlers

• By about 1 ½ years of age children can run, play, and

communicate with others.

• They may be scared of the First Responders.

• They are opinionated and self-centered.

• They still use their abdominal muscles to breath.

• When assessing the toddler allow them to remain with the

caregiver if possible.

• Use toys as a form of distraction.

• Approach the toddler slowly and at eye level.

• Praise tends to get cooperation.

• Ask the caregiver for assistance.

Preschoolers



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• Many preschoolers have misconceptions about injury and bodily

functions.

• Use simple statements to explain what you are going to do.

• Ask the child for his/her help.

• Praise tends to get cooperation.

• Use toys or games as a form of distraction.

• Attention span is short.

• Pre-school age children fear separation from their caregivers.

School age

• They need explanations and privacy.

• They do not like to talk about their feelings.

• Peers are becoming important.

• Try and speak directly to the child.

• Explain to the child what you are going to do.

• Reassurance is important.

Indications for Assisting Ventilations of an Infant or Child

There are two indications for the use of the Pediatric BVM:

1. Ventilating a non-breathing infant or child (as determined in

the Primary Survey)

2. Ventilating an infant or child with inadequate breathing.

Determining if a pediatric patient is ventilating adequately is not a

simple task and requires special consideration. Always follow theLook, Listen, and Feel method for assessing breathing:

o Observation skills are critical in assessing a pediatric

patient. Even as you approach the infant or child, look for

signs of respiratory distress. Does the patient make eye

contact, are they crying, are they moving their extremities,

do they appear to be struggling to breath, and what does

their skin colour look like. A child who is vigorously

crying, pink, and thrashing about probably won’t need

respiratory assistance. However, a child who is listless,

with rapid noisy breathing, and noticeable cyanosis may

require immediate respiratory assistance.

o Normal respiratory rates vary considerably with pediatric

patients with rates of 30 – 60 being normal for infants (0

– 1 year of age) and rates of 20 – 30 being normal for

children (1 – 8 years of age). Respiratory rate alone is not

a good indicator to determine whether or not the pediatric

patient is breathing adequately but a First Responder



Primary survey


must be ready to intervene if the patient’s respiratory rate

is significantly below or above the normal expected rate.

o Closely linked to respiratory rates is the character of

breathing. How hard is the pediatric patient working to

breath and are there any abnormal respiratory noises?Normal respirations should be effortless and quiet in any

position. If you hear snoring, grunting, wheezing, or high-

pitched sounds along with signs that the child or infant is

working hard to breath (nasal flaring, abnormal

positioning or using accessory muscles to breath) the First

Responder must be ready to intervene and assist the

patient’s breathing. Using accessory muscles is defined

when the patient is using muscles other than the

diaphragm and intercostals muscles to assist with

breathing – usually the muscles in the neck.

Contraindications and Cautions for Assisting Ventilationson an Infant or Child

Contraindications

The only contraindication for assisting ventilations of an infant or

child is complete airway obstruction. The airway obstruction

must be removed prior to being able to ventilate the patient. Follow

the Canadian Heart and Stroke CPR guidelines for dealing with an

obstructed airway.

Cautions

Infants:

o Infants have very delicate airway structures so the First

Responder must be cautious to prevent injury while inserting

an oropharyngeal airway and using the BVM.

o Head to body size is proportionately greater in the infant than

the older child and this can make effective positioning more

difficult.

o The infant’s airway is very soft and collapsible –

hyperextension of the head during ventilation can close off the

airway.

o Abdominal muscles are the main muscles of respiration in

infants.

o Infants are more prone to airway obstruction from foreign

material or swelling due to very small airway size.

Children:

o It is very difficult to assist a child with inadequate respirations

as they are scared and unable to understand what you are

trying to do. A calm reassuring approach will assist with this.



Primary survey


Selecting the proper Pediatric BVM

The Pediatric BVM must be sized appropriately for the patient. The

First Responder may use age or weight as a guideline:

o Infants (0-1 year of age) use the Infant BVM.

o Children (1 –8 years of age) use the Child BVM.o Children/Adults (over 8 years of age) use the Adult BVM.

o Infants (under 7 kilograms) use the Infant BVM.

o Children (between 7 and 30 kilograms) use the Child BVM.

o Children/Adults (over 30 kilograms) use the Adult BVM.

Mask size is critical. Measure the mask on the patient and ensure the

mask extends from the bridge of the nose to the cleft of the

chin. Proper mask selection will ensure a good seal to facilitate

effective positive pressure ventilation.

Ensure the Pediatric BVM has an attached oxygen reservoir bag and is

connected to an oxygen tank with the flow meter adjusted to 15 litersper minute.

Procedure for Using the Pediatric BVM

As with all patient assessment the First Responder must follow an

established routine.

• RSE: Conduct a Rescue Scene Evaluation.

• PPE: Wear personal protective equipment.

• LOC: Assess patient’s Level of Consciousness.

• D: Take spinal precautions as required.

• A: Open the patient’s Airway.

o Medical Patient – use a Head-Tilt/Chin-Lift maneuver.

o Trauma Patient – use a Jaw Thrust maneuver.

o Insert oropharyngeal airway as required. Important note –

When inserting an oropharyngeal airway in an infant (0-1 year

of age) complete the following procedure:

a. Measure the oropharyngeal airway the same as for

an adult or child.

b. Open and visualize the infant’s mouth.

c. Using a tongue depressor, gently depress the

tongue to the floor of the mouth so that you can

visualize the back of the oral cavity.

d. Insert the oropharyngeal airway directly into

position. Do not rotate the airway as you

would in a child or adult.



Primary survey


e. If a tongue depressor is not available you can

insert an oropharyngeal airway in an infant in the

traditional manner but extreme care must be

taken, as the upper palate of an infant is delicate

and easily damaged.

• B: Assess patient’s Breathing.

o Intervene as required……

The following steps outline the specific use of the Pediatric BVM:

1. Ensure Neutral positioning of the pediatric patient’s airway:

o For an infant the head is positioned in the neutral position by

placing a roll or pad under the baby’s shoulders. Use caution

to not place an item that is too large, as hyperextension will

result in airway collapse and the inability to ventilate

effectively.

2. Begin Ventilation.

o Apply appropriately sized mask to face and get an airtight seal

using the C-clamp grip.

o Failure to provide a good seal between the mask and face will

result in ineffective ventilations.

o Avoid putting any pressure on the soft tissues under the chin

as this could result in airway collapse.

o Think of pulling the lower jaw up into the mask rather than

pushing the mask onto the face.

o Squeeze the bag and watch for the chest to rise, as soon as

chest rise is visually detected release the bag.

o Assess effectiveness of ventilation. You should see the chest

rise and fall on each ventilation. The patient’s skin colour

should improve. Cyanosis, if it was previously present, should

improve. Watch the abdomen for signs of enlargement during

ventilation. If enlargement is noted reposition the airway and

observe chest rise carefully, squeeze the bag o n l y until chest

rise is detected.

o Ventilate at a rate 30/minute for infants.

o Ventilate at a rate of 20/minute for children.

2.2d(4): Use the bag-valve-mask-oxygen reservoir unit to ventilate

adult patients with inadequate breathing

The bag-valve-mask-oxygen reservoir (BVM) unit allows you to

ventilate an adult patient by moving enriched, oxygenated air into the

lungs and removing carbon dioxide. The unit consists of the following:

• Oxygen reservoir



Primary survey


• A bag

• A non-return valve (to prevent rebreathing)

• An anesthetic-type mask available in various sizes (the pocket

mask may also be used with this unit)

• An inlet for oxygen delivery

When using the BVM with oxygen, ensure the oxygen tubing is

connected to the bag-valve mask and the oxygen flow rate is set at a

minimum of 15L/min.

If the patient will accept an oropharyngeal airway, the FR must

ensure the OPA is in place when using the BVM with an unconscious

patient.

Do the following:

1. Place the narrow end of the mask on the bridge of the patient’s

nose and in the groove between the lower lip and the chin.

2. Make sure you are directly behind the patient’s head, not slanted

to one side or the other.

3. Place the apex of the mask over the bridge of the patient’s nose.

4. Place the base of the mask into the groove between the lower lip

and the chin.

5. Extend the head and neck if no neck injury is present.

6. Place the thumb and first finger of one hand in a C-shape on top of

the mask, and grip the rim of the lower jaw with the remaining

fingers.

7. Grip tightly to complete the seal around the mask. Make sure the

seal is tight. If you cannot get a tight seal, you can either

• switch to a pocket mask, or



Primary survey


• if help is available, have one person apply even pressure

around the mask using both hands

8. Place four fingers of the other hand on top of the bag and the

thumb under it.

9. Squeeze the bag as completely as possible. (If your hands aresmall, try pressing the bag against your thigh.)

10. Ventilate the patient at 12 to 20 ventilations per minute.

11. Check for adequate ventilation by

• watching for an even rise and fall of the chest

• feeling for an even resistance from the bag

For a skilled operator, the BVM unit is a useful tool. However, because

it is easier to maintain the skills required to use a pocket mask, the

pocket mask is the preferred tool for ventilating a patient.

2.2e: Assess and manage the

patient’s circulation



Primary survey


After managing a delicate spine, opening and maintaining the airway,

and assisting patient breathing, you must check for adequate

circulation.

Do the following:1. Check the patient’s pulse.

2. If the carotid pulse is absent, begin CPR.

NOTE: CPR should be started only if no pulse is found and the

patient is unconscious. Check both carotid arteries separately if you are unsure about the presence of a pulse.

3. If the radial pulse is absent but the carotid pulse is present , the

patient may be in shock and is therefore unstable. (You will learn

how to manage shock in Unit 4).

Radial pulse

Carotid pulse



Primary survey


The rapid body survey will help you to locate and expose injury

sties, stabilize fractures, and control bleeding. Firefighters carry

oxygen and should administer it to trauma and medical patients.

You should be able to accomplish the following objectives:

2.2f(1) Perform a rapid body survey.

2.2f(2) Give oxygen at high flow (10 L/min) with a standard face

mask.

2.2f(3) Describe the pathophysiology of hypoxic drive and the

management of a Chronic Obstructive Pulmonary Disease

(COPD) patient.

2.2f(1): Perform a rapid body survey

Do the following:

1. Check for bleeding, deformity, and your patient’s response to pain

by systematically running your hands over and under the

following:

• head and neck

• chest and abdomen

• back

• lower extremities

• upper extremities

2. Ask your partner and/or a bystander to bring appropriate

equipment as needed.

3. Control bleeding using direct or indirect pressure, elevation, or a

tourniquet, as described in Unit 4.

4. Stabilize possible fractures, as described in Unit 4.

You should take no more than 30 seconds to perform a rapid body

survey. It should be interrupted only long enough to provide

intervention for life-threatening injuries.

Ambulance personnel will transport unstable patients to the hospital

after the rapid body survey. They will continue with a secondary

survey en route to the hospital.

2.2f(2): Give oxygen at high flow (10 L/min) with a standard face mask

As a First Responder, you should use a standard face mask to give

oxygen at 10 L/min to:

• all trauma patients

• all patients with a medical or respiratory emergency

REGARDLESS of a history of COPD

2.2f:Perform a rapid body

survey (RBS)



Primary survey


This includes:

– All trauma patients

– Medical emergencies including:

• All unconscious patients

• All suspected heart attacks

• All chest pain• All strokes

• All overdose patients with altered LOC

• All seizure patients

• All patients in shock

– Respiratory emergencies including:

• Patients complaining of SOB

• Laboured or noisy breathing

• Increased respiratory rate

• Cyanosis

Oxygen therapy for the non-traumatic COPD patient is 6 L/min

through a standard adult oxygen mask (see Objective 2.2f[3]).

The standard face mask delivers a high concentration of oxygen to

short of breath patients. There are two sizes, adult and child. Try to fit

the patient as best you can. The mask can sometimes appear very

threatening, so explain to the patient how it will help him or her.

Some patients might resist wearing the mask. In this case, you or the

patient could hold the mask inches from the patient’s face.

Clean used oxygen equipment to avoid spreading infection from

patient to patient or to yourself and others. Follow the procedure

described in Objective 7.4, Decontaminating Equipment, in Unit 7.

Your oxygen supply will be found in a small, portable tank that you

can carry with you to the emergency scene.



Primary survey


Make sure your tank always has enough oxygen. Replace it when

there is less than 500 PSI.

Do the following:

BEFORE AN EMERGENCY

1. Hold the oxygen tank upright securely, and position yourself to

the side.

2. “Crack” the valve open with the wrench: slowly open and quickly

close it. This blows away any loose debris.

3. Make sure the main valve is equipped with a new gasket.

4. Tightly fit the oxygen (= pressure) regulator onto the main valve

stem.

DURING AN EMERGENCY

1. Make sure the litre control valve is off, then open the main

cylinder valve slowly. Bring it one-half turn past the point where

pressure begins to register on the regulator.

2. Open the litre control valve to the desired flow and lay the cylinder

down.

3. Explain the use of oxygen to the patient before fitting the mask

over the patient. Attach the tubing to the mask and the oxygen

tank. Determine whether the patient has a history of chronic

lung disease and set the appropriate flow rate (see

Objective 2.2f[3]).

4. When finished, turn the control valve off until the litre flow is

zero.

5. Turn off the main cylinder valve.

6. Bleed all pressure from the regulator by shutting the cylinder

valve but leaving the litre control valve open until the oxygen has

escaped.

2.2f(3): Describe the pathophysiology of hypoxic drive and the

management of a COPD patient

In normal people, the breathing reflex is triggered by high levels of

carbon dioxide (CO2) in the blood. Patients with emphysema, chronic

bronchitis, and chronic asthma may have a condition known as

Chronic O bstructive Pulmonary Disease (COPD). They retain CO2



Primary survey


and thus have a chronically high level of this gas. Their breathing

reflex is triggered only when the oxygen level in their blood is low.

This mechanism is known as hypoxic drive. COPD patients who rely

on hypoxic drive rarely deteriorate as a result of the administration of

high flow oxygen. First Responders rarely experience this situation,

provided that BCAS arrival is less than 10-15 minutes. Generallyspeaking, it requires several minutes for high flow oxygen to inhibit

hypoxic drive and cause a patient to be drowsy, thus reducing their

ventilation. All First Responders should closely monitor the rate and

depth of breathing in all cases where oxygen is administered and be

prepared to assist ventilations with a BVM.

Give the patient with COPD 6 L/min through a standard adult oxygen

mask, if there are no signs of medical, respiratory or traumatic

emergencies. In reality, patients requiring low flow oxygen should

make up less than 5% of calls.



Primary survey




You are called to a local bar where a 40-year-old man has been

injured. When you arrive, you find him lying motionless on his back, with a small amount of blood trickling from the corner of his mouth.

His skin is bluish.

“What happened here?” you ask the people standing around. “Sam’s

been drinking all day,” they reply. “He was sitting on the bar stool

when he fell backwards and hit his head on the table.”

1. List the six major steps you would take to treat this patient before

the ambulance arrives.

____________________________________________

____________________________________________

____________________________________________

____________________________________________

____________________________________________

____________________________________________

2. You call loudly to the man, “Hello, sir! Can you hear me?” He

doesn’t respond to this or to a trapezoidal squeeze. How would

you rate the man’s level of consciousness?

____________________________________________

3. Should you be concerned about a neck injury? Why?

____________________________________________

____________________________________________

4. The ________________________________ technique isused to open a patient’s mouth before making a visual check.

5. What method would you use to open the patient’s airway? Why?

____________________________________________

____________________________________________

Case Study 2.2



Primary survey


6. What tool would you use to maintain an open airway in this

patient?

____________________________________________

____________________________________________

7. From what you know of the patient so far, what signs indicate that

he may not be breathing adequately?

____________________________________________

____________________________________________

8. You can use the _____________________________to give

the patient mouth-to-mask ventilations through a port on the

mask.

9. Is it important to find out whether this patient has COPD before

giving supplemental oxygen?

____________________________________________

____________________________________________

10. When you check the patient’s circulation, you find that both radial

and carotid pulses are absent. What should you do?

____________________________________________

____________________________________________

11. When should this patient be transported to the hospital? Who

should transport him?

____________________________________________

____________________________________________



Secondary survey


The purpose of a secondary survey is to identify problems that,

while not immediately life-threatening, may threaten the patient’s

survival if left undetected. The secondary survey consists of the:

• medical history

• vital signs• head-to-toe physical examination

The information you gather here will be vital for the patient’s care.

You should be able to report it accurately and concisely to ambulance

personnel when they arrive (see Objective 2.4).

To perform a secondary survey, you must be able to do the following:

2.3a Establish the chief complaint and history of chief complaint.

2.3b Record and monitor the patient’s LOC, pulse, respirations, and

skin colour and temperature.

If time permits, perform a head-to-toe examination, which is really a

more thorough rapid body survey. Constantly monitor the patient’s

level of consciousness and DABCs also.

Begin the secondary survey by establishing what is wrong with the

patient.

Chief complaint

The chief complaint is what the patient says is wrong with him orher. Record and report it using the patient’s own words. This will help

you to avoid interpreting what the patient has said, which may

obscure or change the nature of the problem.

Most chief complaints are characterized by pain or abnormal function.

Find out what is bothering the patient most. For example, patient in a

motor vehicle accident may have an obvious leg fracture but his chief

concern may be, “I can’t breath.” This may help you discover an

unsuspected chest injury.

History of the chief complaint

The history of the chief complaint examines the chief complaint

in greater detail. Get a description of the events that caused the chief

complaint. If pain is the chief complaint, use the PQRST mnemonic

to help you organize your questioning.

2.3:Perform a secondary

survey

2.3a:Establish the chief

complaint and history ofchief complaint



Secondary survey


HISTORY OF CHIEF COMPLAINT: PQRST MNEMONIC

P Position of the pain

Where is it located? Can you point to it?

Q Quality of the painWhat does it feel like? Is it sharp, dull, throbbing, or crushing?

R Radiation of the pain

Does it radiate anywhere?

Does it stay in one place or move around?

Does anything relieve it? What makes it worse?

S Severity

How would you rate the pain on a scale of 1 to 10 (10 being the worst)?

T Timing of the pain

When did it start? What brought it on? Does it have a time pattern? Have you

had it before? How long does it last?

Follow these guidelines when interviewing a patient:

• Allow the patient to answer in his or her own words.

• Avoid suggesting answers. (“What provoked the pain?” not “Does

the pain come after exertion?”)

• Use open-ended questions. Avoid asking questions that can be

answered with a yes or no.

• To pinpoint responses, give the patient alternatives. (“Does the

pain stay in one place or does it move around?”)

• Use an empathetic tone, and reassure the patient frequently.

Avoid a rapid-fire interrogation. It will only increase the patient’s

anxiety.

Other information

If time permits, ask the patient about:

• past medical problems

• medications

• allergies

• patient’s identity (name, age, and address)



Secondary survey


Baseline vital signs are one of the most important aspects of

patient assessment. They are taken after the primary survey and the

medical history. Based on them, ambulance personnel and receiving

hospital staff can tell whether or not the patient’s condition is

deteriorating.

As a First Responder you should record the following:

• LOC (using the AVPU method; see Objective 2.2a)

• Pulse – rate, rhythm, and strength

• Respirations – rate, rhythm, and volume

• Skin – colour and temperature

Monitor the LOC, take the pulse, and count the respirations every

five minutes. Check whether the patient’s skin is:

• cool or warm

• moist or dry

• cyanotic (blue), pale, or normal in colour

When patients are suffering from life-threatening conditions,

treating conditions found in the primary survey is more urgent than

taking vital signs.

2.3b:Record and monitor the

patient’s LOC, pulse,respirations, and skin

colour and temperature



Secondary survey




As you drive by a bus stop, you see a crowd gathered around an elderly

man sitting on the bench. He is clutching at his chest in obviousdistress. You stop the vehicle and quickly walk over. As you approach,

you hear the man gasping, “Can’t breathe…pain’s killing me!”

Working efficiently you complete the primary survey.

1. In what order would you perform the following steps of the

secondary survey?

a) Record pulse, respirations, condition of skin; take a history;

perform more thorough rapid body survey.

b) Take a history; perform more thorough rapid body survey;

record pulse respirations, condition of skin.

c) Take a history; record pulse, respirations, condition of skin;

perform more thorough rapid body survey.

2. This patient’s chief complaint is chest pain. Which of the following

sets of questions should you ask in order to get the history of the

chief complaint?

a)

1. Can you show me where the pain is, sir?

2. What type of pain is it?

3. Does this pain stay in one place or does it go somewhere

else?4. On a scale of 1 to 10, with 10 being the worst, how would

you rate this pain

5. Has this ever happened to you before?

b)

1. Have you ever had a heart attack?

2. What were you doing when this happened?

3. Do you feel nauseated?

4. On a scale of 1 to 10, with 10 being the worst, how would

you rate this pain?

5. Does this pain go into your left arm?

c)

1. Is the pain in the middle of your chest, sir?

2. Does this pain feel sharp?

3. When did you first feel this pain?

4. Did you feel dizzy before this occurred?

5. Has this ever happened to you before?

Case Study 2.3



Secondary survey


3. If a patient was shot in the chest, what additional, possibly hidden,

injury might you detect?

____________________________________________

____________________________________________

____________________________________________

____________________________________________



Recording and reporting data


Recording and reporting data is the final major component of the

patient assessment model. Your report will help guide the ambulance

personnel and hospital staff in treating the patient.

It is critical that the record of your findings be as thorough, complete,

and accurate as possible. Besides being useful to medical staff, yourfindings form a crucial record of the patient’s initial conditions, your

assessment, and your treatment that can be subpoenaed at a later date

during a legal inquiry. If patient condition, assessment, and treatment

are not documented, a court may well conclude that the missing items

were not performed or completed as required by your First Responder

licence.

Report your findings orally to responding ambulance personnel. Your

oral report should include the following:

• mechanism of injury

• chief complaint

• history of chief complaint

• LOC, pulse, respirations, and skin colour and temperature

• treatment given

• all relevant physical findings

Follow up your oral report with a completed copy of the First

Responder Report. If you are unable to complete this form before the

ambulance crew departs, forward your copy to the receiving hospital

within 24 hours of the incident. The First Responder Report forms

part of the patient’s permanent medical record.

2.4:Record data and

report it accurately toambulance personnel



Principles of triage


During a disaster, casualties may stretch available facilities, supplies,

equipment, and personnel. Triage is the sorting of multiple patients

according to their need for emergency treatment and evacuation. The

first aid team does primary triage at the disaster site to determine

the order in which patients are brought to the secondary triage

area. In the secondary triage area, stretcher-borne and more seriouslyinjured patients are assessed, sorted into priorities, and stabilized

before further treatment and eventual evacuation.

The general rules of triage are as follows:

1. Injuries threatening life take priority over injuries threatening

limbs.

2. Injuries threatening function, such as those to the respiratory or

cardiovascular systems, take priority over injuries causing

anatomical defects, such as a fractured leg or a skull fracture in a

conscious patient.

3. Criteria for grouping patients will vary with the situation, the

backlog of patients awaiting medical care, and the capabilities of

the emergency services at the scene. As much as possible,

however, patients should be sorted into the following categories

for medical care:

• Urgent category

Patients whose lives are in immediate and serious jeopardy

and who require urgent treatment and evacuation.

• Delayed category

These are patients whose lives or limbs are not in serious

jeopardy although a limb or organ may have sustained acrippling injury. The physical condition of such patients may

be relatively stable for the moment. They are evacuated as

transportation becomes available.

• Minor injuries/walking wounded category

These patients may be managed at a temporary first aid

facility and do not require hospitalization.

4. Airways in unconscious patients can become obstructed at any

time. Noisy respirations indicate partial obstruction.

5. Patients in shock or with a reduced blood volume tolerate

transportation poorly. Ambulance personnel should start

intravenous fluid replacement before evacuation and continue itduring the process if possible.

6. NEVER DELAY URGENT TREATMENT FOR

DOCUMENTATION.

7. Assess patients periodically. A patient may deteriorate at any time

and may have to placed in a more urgent category.

2.5:Describe the

principles of triage





Answer the following questions and compare your answers with

those provided in Appendix B. Review this section if you make any

mistakes.

1. Define triage.

____________________________________________

____________________________________________

____________________________________________

____________________________________________

2. Patients at a disaster site are sorted into three categories for

medical care. What are these categories?

____________________________________________

____________________________________________

____________________________________________

3. Injuries threatening ____________________________

take priority over injuries causing anatomical defects.

Self-Test 2.5



Summary 2


You have just studied the patient assessment model that you should

follow whenever you respond to an emergency. Take a few moments

now to complete the following narrative. Check your work against

the full version that follows. If you made any mistakes, review the

appropriate sections of this unit.

The patient assessment model will help you evaluate patients

systematically. The model has four components:

__________________, _________________________,

__________________________, and

_________________________.

In performing a __________________, concentrate on the “big

picture.” Consider the environment, hazards, and

______________________.

The _____________________ is the first step in the physical

assessment of the patient. In this step, you should check the ________________________ and DABC, and perform a rapid

body survey. For your protection, always wear

___________________.

The AVPU method is a short and simple way to assess the

______________________. “A” means the patient is alert, “V”

means the patient responds to __________________________

stimuli, “P” means the patient responds to

___________________, and “U” means the patient is

_____________________.

Always assume that the patient has a _____________________spine, especially if the mechanism of injury suggests that neck trauma

may have occurred. Stabilize the neck in the position found.

Airway management involves opening the airway, maintaining the

open airway, and helping the patient breathe effectively. Make sure

the patient’s mouth is clear before trying to open the airway. Use the

_______________________ method to open the airway if there

is no neck injury. If you suspect a neck injury, use only the

__________________ method.

Once the airway is open, you must keep it open, especially if the

patient is ____________________. An ________________

airway is useful for this. _____________________ the mouth

cavity is another way to keep the airway clear by removing secretions

and other debris through a catheter. Patients who are unconscious or

whose airways are compromised by fluid or foreign objects should be

placed in the ____________________ or

____________________. The technique you use for this will

Summary 2



Summary 2


depend on whether or not the mechanism of injury indicates a

__________________________.

A patient is not breathing adequately if he or she has fewer than

________ respirations per minute or shows signs of

_______________. You can use the ________________________ to give mouth-to-mask

ventilations to patients who need them. The _________________

unit consists of a bag, reservoir, non-return valve, mask, and inlet for

oxygen delivery.

Trauma patients and medical patients require oxygen at a flow of

_________________. In patients with __________________,

the breathing reflex is triggered only by a low oxygen level in the

blood. This mechanism is known as

_______________________.

In assessing the patient’s circulation check the ___________________ and _______________________

pulses. If both are absent, begin _____________________ to

force blood and oxygen through the heart and lungs and into the blood

vessels.

You should take no more than 30 seconds to perform a

____________.

The ______________________________ consists of the

medical history, __________________________, and

________________________. The

_________________________ is what the patient says is wrong with him or her. The ______________ mnemonic will help you

question the patient about pain.

The ____________________ vital signs are the first set of vital

signs taken after the primary survey and the medical history. As a

First Responder you should take the pulse and count the respirations

every _______ minutes. You should also check the condition of the

skin.

___________________________________ is the last major

component of the patient assessment model. Remember that your

report will guide the ambulance personnel and hospital staff in their

treatment of the patient.



Summary 2


Summary 2 – Answers

The patient assessment model will help you evaluate patients

systematically. The model has four components: scene assessment,

primary survey, secondary survey, and reporting of data.

In performing a scene assessment, concentrate on the “big picture.”

Consider the environment, hazards, and mechanism of injury .

The primary survey is the first step in the physical assessment of

the patient. In this step, you should check the level of

consciousness and DABC, and perform a rapid body survey. For

your protection, always wear personal protective equipment.

The AVPU method is a short and simple way to assess the level of

consciousness (LOC). “A” means the patient is alert, “V” means the

patient responds to verbal stimuli, “P” means the patient responds to

pain, and “U” means the patient is unresponsive.

Always assume that the patient has a delicate spine, especially if the

mechanism of injury suggests that neck trauma may have occurred.

Stabilize the neck in the position found.

Airway management involves opening the airway, maintaining the

open airway, and helping the patient breathe effectively. Make sure

the patient’s mouth is clear before trying to open the airway. Use the

head-tilt/chin-lift method to open the airway if there is no neck

injury. If you suspect a neck injury, use only the modified jaw

thrust method.

Once the airway is open, you must keep it open, especially if the

patient is unconscious. An oral airway is useful for this.

Suctioning the mouth cavity is another way to keep the airway clear

by removing secretions and other debris through a catheter. Patients

who are unconscious or whose airways are compromised by fluid or

foreign objects should be placed in the ¾ prone or recovery

position. The technique you use for this will depend on whether or

not the mechanism of injury indicates a delicate spine.

A patient is not breathing adequately if he or she has fewer than

10 respirations per minute or shows signs of hypoxia. You can use

the pocket mask to give mouth-to-mask ventilations to patients who

need them. The bag-valve-mask (BVM) reservoir unit consists of

a bag, reservoir, non-return valve, mask, and inlet for oxygen delivery.

Trauma patients and medical patients require oxygen at a flow of

10 L/min. In patients with chronic obstructive pulmonary

disease (COPD), the breathing reflex is triggered only by a low



Summary 2


oxygen level in the blood. This mechanism is known as hypoxic

drive.

In assessing the patient’s circulation check the radial and carotid

pulses. If both are absent, begin CPR to force blood and oxygen

through the heart and lungs and into the blood vessels.

You should take no more than 30 seconds to perform a rapid body

survey .

The secondary survey consists of the medical history, vital signs,

and head-to-toe physical examination. The chief complaint is

what the patient says is wrong with him or her. The PQRST

mnemonic will help you question the patient about pain.

The baseline vital signs are the first set of vital signs taken after the

primary survey and the medical history. As a First Responder you

should take the pulse and count the respirations every five minutes. You should also check the condition of the skin.

Recording and reporting data is the last major component of the

patient assessment model. Remember that your report will guide the

ambulance personnel and hospital staff in their treatment of the

patient.

fr3 student guide - unit 12

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