Transcript
SKILLS MANUAL FOR AMBULANCE CARE IN WESTERN AUSTRALIA
Version 6
ST JOHN AMBULANCE AUSTRALIA (Western Australia) Inc.
THE COLLEGE OF PRE–HOSPITAL CARE SKILLS MANUAL INTRODUCTION The skills reflected in this manual are to be used by officers that have been trained and deemed competent and are authorised to use as per the Skills Matrix. The objective of this manual is to assist all officers in the development of their skills and to standardise the manner in which these skills are performed. All relevant areas of the organisation were consulted to ensure a clinical balance between rationale based treatment and practical on–road application of skills. This Manual is to be used in conjunction with lectures / demonstrations and practice of these skills in the training environment. This manual also supports the revision and self–study needs of trained and authorised personnel. Any person issued, purchasing or otherwise acquiring a copy of this publication does so on the specific understanding that it is that person’s sole responsibility to take action in updating their edition of the Skills Manual. St John Ambulance has no obligation to update or advise of changes except to its own staff. This Manual contains SKILL SHEETS, and PERFORMANCE CRITERIA consisting of CONDITIONS, STANDARDS and KEY POINTS.
SKILL SHEET
Contains the approved method of carrying out a particular task, which is broken down into individual steps for ease of understanding and practice.
PERFORMANCE CRITERIA
These contain the laid down conditions, standards and key points which direct the actual performance of the skill.
The Performance Criteria states: SKILL
The name of the Skill.
CONDITIONS
Explains the conditions under which assessment will be carried out.
STANDARDS
Defines how well the skill is to be performed.
KEY POINTS
Critical elements of the skill, which need particular attention.
© Copyright St John Ambulance Australia (Western Australia) Inc.
Introduction
AUTHORITY:
Tony Ahern Chief Executive Officer
CURRENCEY DATE:
As of November 2010 (revised as required).
Enquiries regarding this manual should be directed to: The College of Pre Hospital Care St John Ambulance Australia (Western Australia) Inc. PO Box 183 BELMONT WA 6984
© Copyright St John Ambulance Australia (Western Australia) Inc.
Introduction
TABLE OF CONTENTS Skills Matrix ...............................................................................................................November 2010 Section One Patient Assessment SKILL 101 Primary and Vital Sign Survey .................................................................... October 2007 SKILL 102 Secondary Survey ...................................................................................November 2005 SKILL 103 Central Nervous System Survey CNS Survey .........................................November 2005 SKILL 104 Measure and Record Pulse, Respirations and Conscious State .............November 2005 SKILL 105 Measure and Record Systolic Blood Pressure by Palpation ...................November 2003 SKILL 106 Measure and Record Systolic and Diastolic Blood Pressure using a Stethoscope ...............................................................................September 2004 SKILL 107 Pulse Oximeter Nonin Onyx 9500............................................................November 2005 SKILL 108 Medisense Optium Blood Glucose Testing................................................. October 2007 SKILL 109 Measure the Peak Expiratory Flow Rate of a Patient ..............................December 2006 SKILL 111 Medisense Optium Exceed Blood Glucose Testing ..................................... October 2007 Section Two Oxygen Equipment SKILL 206 Operation of a Bag Valve Mask Resuscitator ....................................................May 2011 SKILL 208 and 210 Oxygen Therapy by Face Mask and Non-rebreathing Oxygen Mask ..May 2011 Section Three Airway Management SKILL 301 Lateral Position ........................................................................................... October 2007 SKILL 302 Yankauer Suction Tube .....................................................................................May 2011 SKILL 303 Oropharyngeal Aspiration Flexible Catheter ............................................November 2008 SKILL 304 Baby Mucus Extractor..............................................................................November 2008 SKILL 305 Oropharyngeal Airway Insertion ................................................................. October 2007 SKILL 306 Laryngeal Mask Airway Ambu Intubation.................................................... January 2011 SKILL 307 Endotracheal Intubation.............................................................................. January 2011 SKILL 308 Assist in the Intubation of a Patient .........................................................November 2010 SKILL 309 Airway Obstruction...................................................................................... October 2007 SKILL 310 Laryngoscope and Magill Forceps.............................................................. October 2007 SKILL 311 Cricothyrotomy............................................................................................ October 2010 SKILL 312 Nasopharyngeal Airway Insertion (NPA) ...................................................... August 2008 Section Five Defibrillation SKILL 501 General Performance Criteria For Defibrillators ......................................... October 2008 SKILL 502 Zoll 1400 Monitor Defibrillator Checking.................................................... October 2007 SKILL 503 Zoll 1400 Monitoring and Recording.......................................................... October 2007 SKILL 504 Zoll 1400 Defibrillation ................................................................................ October 2007 SKILL 505 Zoll M Series AED Biphasic Manual Defibrillation ...................................November 2008 © Copyright St John Ambulance Australia (Western Australia) Inc.
Table of Contents
SKILL 506 Zoll M Series Biphasic Manual Checking ................................................November 2003 SKILL 507 Zoll M Series Biphasic Manual Monitoring and Recording ......................November 2003 SKILL 508 Zoll M Series Biphasic Manual Defibrillation with Advisory ........................ October 2007 SKILL 509 Heartstart 4000 AED Biphasic Defibrillation .................................................. March 2002 SKILL 510 Heartstart 4000 AED Biphasic Monitoring Haemoglobin O2 Saturation SpO2 ......................................................................................November 2001 SKILL 511 Heartstart FR2 / FR2 Plus Checking Monitoring......................................November 2007 SKILL 512 Heartstart FR2 / FR2 Plus Defibrillation...................................................... October 2008 SKILL 513 ZOLL M Series AED Biphasic Monitor Defibrillator Checking ................November 2003 SKILL 514 Zoll M Series AED Biphasic Monitoring and Recording ............................. October 2007 SKILL 515 Zoll M Series AED Biphasic Defibrillation ................................................. February 2007 SKILL 516 Philips AED HeartStart FRX Defibrillation .................................................... August 2010 Section Six Medication: Preparation and Administration SKILL 601 Glucose Oral Gel ........................................................................................ October 2007 SKILL 602 Administration of Salbutamol by Nebuliser ........................................................ July 2007 SKILL 603 Administration of Methoxyflurane via PenthroxTM Inhaler .............................. March 2009 SKILL 604 Fentanyl Intranasal Analgesia .................................................................... October 2007 SKILL 605 Preparation and Administration of Medication Via Intra Muscular Injection October 2008 SKILL 606 Administration of an Intra–Venous Injection ............................................November 2008 SKILL 607 One Handed Needle Recapping Technique ............................................November 2010 SKILL 608 Cannulation of a Peripheral Vein Using a Protectiv Cannula .......................... June 2011 SKILL 609 Prepare, Connect and Maintain an IV Infusion .......................................December 2003 SKILL 610 EpiPen and EpiPen Jr Auto–Injectors......................................................... October 2008 SKILL 611 Administration of Adrenaline By Nebuliser ..............................................November 2005 SKILL 612 ATOXTM ComboPen Auto–Injectors............................................................ October 2008 SKILL 613 Salbutamol via Space ChamberTM ................................................................. March 2009 Bone Injection Gun (BIG) ....................................................................................................May 2011 EZ - IO……..........................................................................................................................May 2011 Section Seven Obstetrics SKILL 701 Childbirth..................................................................................................November 2008 SKILL 702 Shoulder Dystocia....................................................................................November 2008 SKILL 703 Breech Birth ................................................................................................ October 2008 Section Eight Miscellaneous SKILL 801 Application of Medical Anti–Shock Trousers (MAST) ..............................November 2003 SKILL 802 Application and Maintenance of Rotating Tourniquets ............................November 2002 SKILL 804 Wound Closure Suturing and Use of Steri Strips.....................................November 2005 SKILL 805 Valsalva Manoeuvre ......................................................................................... April 2006 © Copyright St John Ambulance Australia (Western Australia) Inc.
Table of Contents
SKILL 806 Non – Invasive Pacing (Fist Pacing).........................................................November 2011 Combat Application Tourniquest (CAT®) .............................................................................May 2011 Section Nine Fracture Management SKILL 901 General Performance Criteria For Fracture and Dislocation Management.............................................................................................November 2007 SKILL 902 Log Roll....................................................................................................... October 2007 SKILL 903 Removal of a Motor Cycle Helmet .............................................................. October 2004 SKILL 905 C-Spine Collar Application.......................................................................... October 2010 SKILL 906 Body Splinting..........................................................................................November 2006 SKILL 907 Rigid Splinting............................................................................................. October 2002 SKILL 908 Soft Splinting—Pillow.................................................................................. October 2002 SKILL 909 Fernotrac Traction Splint ............................................................................ October 2007 SKILL 910 Application of Sandbags ............................................................................. October 2008 SKILL 911 Application of Sager Splint Model 304............................................................. June 2008 SKILL 912 Provision of Complete Spinal Immobilisation.............................................. January 2011 Trauma Pelvic Orthodic Device (T-POD®)...........................................................................May 2011 KED-Pro (KED)…. ...............................................................................................................May 2011 Spinal Immobilisation (SI)....................................................................................................May 2011 Section Ten Patient Movement SKILL 1001 Ferno Washington Stretcher (Series 50) Stretcher Locking Device ......... October 2002 SKILL 1002 50 Series Ferno Washington Stretcher Undercarriage Operation .........November 2007 SKILL 1003 50 E Series Ferno Washington Stretcher Undercarriage / Operation....... October 2007 SKILL 1004 Litter Ferno Washington Stretcher Series 50 / 50E ..............................November 2007 SKILL 1005 50/50E Series Litter / Chair Ferno Washington Stretcher............................ March 2006 SKILL 1006 Ambulance Stretcher Patient Harness Model 417 / 2 Series 50 Model BRH 417 50E Series 50E.............................................................................................. March 2006 SKILL 1007 Use of Child Safety Blanket ...................................................................... October 2007 SKILL 1008 Patient Transfer Slide Boards................................................................... October 2002 SKILL 1009 Scoop Stretcher 65 BSSF-65 .................................................................November2008 SKILL 1010 Easy Fold Wheelchair............................................................................November 2007 SKILL 1011 Compaq Recliner / Premier Safe-N-Sound Baby/Child Safety Seat................May 2010 SKILL 1012 MK5 / MK6 Ambulance Patient Bed.......................................................... October 2008 SKILL 1013 Vacuum Mattress Ferno Model 192 / Ferno Germa 271 101 000 ................. June 2010
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Table of Contents
SKILLS MATRIX The Skills Matrix indicates the level of qualification authorise to perform a skill, or use a piece of equipment. The Skills Matrix also identifies the skills taught only or taught and assessed. Officers are authorised to perform the skills or use equipment they have been assessed and deemed competent in. Key Volunteer First Aid Services (VFAS) ▪ First Responder ▪ Advanced First Responder
FR AFR
Volunteer Ambulance Officer ▪ Volunteer Ambulance Officer - Primary Ambulance Care ▪ Volunteer Ambulance Officer - Advanced Ambulance Care ▪ Volunteer Ambulance Officer - Advanced Ambulance Care
PAC AAC VALS
Industrial ▪ Industrial Paramedic
IP
Career Staff ▪ Ambulance Transport Officer ▪ Ambulance Officer ▪ Ambulance Officer Grade 1 ▪ Ambulance Officer Grade 2 ▪ Paramedic ▪ Critical Care Paramedics ▪ USAR
ATO AO AOG1 AOG2 PA CCP U
Skills ▪ 0 ▪ X ▪ S
▪
= = =
ALS =
Taught only Taught and assessed Ambulance Officers studying for the paramedic degree who are supervised by a paramedic may carry out skills used by a paramedic. Advanced Life Support Skills for AAC Volunteer Ambulance Officers who assist a Paramedic.
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Skill Matrix
Section One SKILL 101 102 103 104 105 106 107 108 109 111
Patient Assessment
FR AFR
PAC
AAC
ATO
IP
X X
X X X X X X X X X X
X X X X X
X X X X X
X X X X X
X X X X X
X X
X X X
X X X X
X X X X
X X
AO AOG1 X X X X X X X X X X
X X X X X X X X X X
AOG2
PA
CCP
U
X X X X X X X X X X
X X X X X X X X X X
X X X X X X X X X X
X X X X X X X X X X
Section Two
Oxygen Equipment
SKILL
FR
AFR
PAC
AAC
ATO
IP
206 208/210
X X
X X
X X
X X
X X
X X
AO AOG1 AOG2 X X
X X
X X
Section Three
PA
CCP
U
X X
X X
X X
Airway Management
SKILL
FR
AFR
PAC
AAC
ATO
IP
AO
AOG1
AOG2
PA
CCP
U
301 302 303 304 305 306 307 308 309 310 311 312
X X X X X
X X X X X
X X X O X
X X X
X
X
X X X O X ALS ALS ALS X ALS ALS X
X X X X X X X X X X X X
X S S S X O O X X
X X X X X X O X X O O X
X X X X X S S X X S S X
X X X X X X X X X X X X
X X X X X X X X X X X X
X X X X X X X X X X X X
X
X
X
X
X
Section Five SKILL 501 502 503 504 505 506 507 508 509 510 511 512 513
Defibrillation
FR AFR X
X
PAC
AAC
X
X ALS ALS ALS ALS ALS ALS ALS X X X X X
X X X X X
ATO IP X
X X X X X X X X
AO X X X S S X X S
AOG1 AOG2 X X X S S X X S
X X X S S X X S
PA
CCP
U
X X X X X X X X
X X X X X X X X
X X X X X X X X
X X
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Skill Matrix
SKILL 514 515 516
FR AFR
PAC X X X
AAC X X X
ATO IP
Section Six
AO
AOG1 AOG2
PA
FR
AFR
PAC
601 602 603 604 605 606 607 608 609 610 611 612 613 BIG EZ-IO
X
X
X
X
X
X
X X
X X
X
X
AAC ATO
IP
AO
AOG1
X X X ALS ALS ALS ALS ALS ALS X
X X X X X X X X X
X S S S S S S
X X X S S
X X X S S
S
X S X
X
S
X
S
X
X
AOG2 PA
CCP
U
X X X X X
X X X X X
X X X X X
X S X
X X X
X X X
X X X
X
X
X
X
X
X
X X X
X X X
X X X
Section Seven SKILL FR
Obstetrics AFR
701 702 703
PAC
AAC
X O O
X O O
ATO
IP
AO
AOG1
AOG2
PA
CCP
X X X
S S S
S X X
S X X
X X X
X X X
Section Eight SKILL FR
AFR
PAC
AAC ATO X
IP X X X X X X
O
X
AO
X X X
AOG1 AOG2 PA CCP
U
S
X
X
X
X
X
X
X X X
X X X
X X X
X X X
X X X
S
Section Nine
Fracture Management
FR AFR X X X X X X X X
U
Miscellaneous
801 802 804 805 806 CAT
901 902 903 905 906 907 908 909
U
Medication: Preparation and Administration
SKILL
SKILL
CCP
X X X X X X X X
PAC
AAC
ATO
IP
X X X X X X X X
X X X X X X X X
X X X X X X X
X X X X X X X
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AO AOG1 X X X X X X X
X X X X X X X
AOG2
PA
CCP
U
X X X X X X X
X X X X X X X
X X X X X X X
X X X X X X X
Skill Matrix
SKILL 910 911 912 T-POD KED SI
FR AFR X X X X
PAC X X X
AAC X X X
ATO X
IP X X X
AO AOG1 X X X X X X
Section TEN
AOG2 X X X
PA X X X X X X
CCP X X X X X X
U X X X
Patient Movement Equipment
SKILL
FR
AFR
PAC
1001 1002 1003 1004 1005 1006 1007 1008 1009 1010 1011 1012 1013
X X X X X
X X X X X
X X X X X X X X X X X X X
X
X
X
X
AAC ATO X X X X X X X X X X X X X
X X X X X X X X X X X
IP
AO
AOG1
AOG2
PA
CCP
U
X X X X X X
X X X X X X X X X X X X O
X X X X X X X X X X X X O
X X X X X X X X X X X X O
X X X X X X X X X X X X O
X X X X X X X X X X X X O
X X X X X X X X X X X X O
X X X
© Copyright St John Ambulance Australia (Western Australia) Inc.
Skill Matrix
SKILL 101 PRIMARY AND VITAL SIGN SURVEY October 2007 When initiating a primary survey: Do a complete initial assessment and reassess regularly.
Treat life-threatening problems before moving to the next part of the assessment.
Assess the effects of the treatment.
PRIMARY SURVEY D
DRABCDE
Check for danger. If there is danger at the scene do not approach or touch the patient until the danger has been eliminated. Also keep others away.
If only the patient is in immediate danger and they can be removed safely, do so at this stage regardless of the potential for further injury.
R
Establish responsiveness to voice, touch or pain. Alert Verbal Pain Unresponsiveness Firstly, speak to the patient (by name if known). If no response, touch the patient’s shoulder. Finally, if still no response, squeeze the muscle between their shoulder and the side of their neck (trapezius).
A
Check airway. Consider Cervical spine (but not at the expense of airway).
If trauma suspected, chin lift or jaw thrust manoeuvres are recommended. Application of a cervical collar is not required whilst the head / neck is under direct control and can be applied later.
Check airway. Assess as per Skills 302, 303, and 305.
Open mouth with cross finger technique.
Look inside:
Is it clear?
Is it partially or completely blocked?
Are there any potential obstructions (damaged or false teeth, vomitus, blood or other fluids)?
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Skill 101 Primary Vital Sign Survey 1 of 4
If there are obstructions, clear the mouth using finger sweeps, drainage (lateral position) for large quantities, or suction if more appropriate. (Refer to Skills Manual for appropriate skills).
Once the airway is clear you can then open the airway by placing head in neutral head position.
Paediatrics No blind finger sweeps. Infants and small children may require padding under shoulders to achieve the head into a neutral alignment.
NOTE: In most cases only simple methods of airway clearance are required. B
Check breathing (5-10 seconds if unconscious or requires ventilations): Look at the patient’s chest and abdomen:
Is the patient breathing at all?
Is the patient struggling to breathe?
What is the respiratory rate? Expose chest if necessary.
Listen for breath sounds:
Is the patient able to speak or make sentences?
Is the breathing adequate to sustain life?
Use stethoscope to assess depth, lung sounds and equal air inspiration and expiration.
Feel for rise and fall of the chest and chest wall integrity: Use appropriate airway management as problem is detected, position patient, oxygenate and ventilate if necessary.
C
Check circulation (5-10 seconds if unconscious or requires ventilations or CPR): Check that there is a carotid pulse if the patient is unconscious.
Paediatrics Infant Brachial or Apical if the patient is unconscious.
What is the rate and rhythm? Note: strength, is it weak and thready, strong and bounding or unable to palpate? If there is no pulse, CPR will be required.
Assess colour and blanch test.
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Skill 101 Primary Vital Sign Survey 2 of 4
D
E
Check the patient for severe bleeding. Stop any life threatening bleeding immediately. Minor bleeding can wait.
Position patient, use elevation as required, consider the need for fluid infusion.
Disability (neurological assessment): Disability refers to the brief neurological examination performed at the end of the primary survey and is a rapid assessment of the conscious level. This is done by assessing the Glasgow Coma Scale (Skill 104) or more simply the level of responsiveness (AVPU).
Assess pupil size, shape and reaction to light.
Consider BSL.
Exposure: During examination the potential injury sites need to be exposed so that life threatening injuries are identified and treated.
Environment. Consider hypothermia and hyperthermia.
Don’t leave exposed unnecessarily.
VITAL SIGN SURVEY
Count and record pulse.
(Skill 104)
Count and record respirations.
(Skill 104)
Take and record blood pressure.
(Skill 105)
Pulse Oximetry.
(Skill 107)
Measure and record blood sugar (BSL) (if indicated).
(Skill 107- 08/111)
Glasgow Coma Scale (GCS).
(Skill 104)
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Skill 101 Primary Vital Sign Survey 3 of 4
PERFORMANCE CRITERIA SKILL 101 PRIMARY AND VITAL SIGN SURVEY CONDITIONS Provide:
A simulated patient. Necessary equipment.
STANDARD 1.
Able to understand and demonstrate Primary and Vital Sign Survey as per Skill 101.
2.
Effectively communicates with patient.
3.
Checks and rechecks the patient's airway, breathing and circulation.
4.
Completes primary survey within 30 seconds.
5.
Completes vital sign survey within four minutes.
KEY POINTS 1.
When conducting Primary and Vital Signs Survey Officers should always take note of the mechanics of injury and pattern of injury. All elements of these surveys have the potential to influence the decision as to whether or not a patient is time critical. Patient history may also be significant at this time.
2.
The arm chosen for pulse and BP. assessment should be thoroughly checked to exclude injury or disability first.
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Skill 101 Primary Vital Sign Survey 4 of 4
SKILL 102 SECONDARY SURVEY November 2005 A systematic head–to–toe survey to detect problems that are not always obvious, and do not pose an immediate threat to life but could become serious, or life threatening if not detected and corrected. 1.
Neck Check cervical spine for mid–line tenderness, pain or obvious deformity, keeping in mind mechanics of injury in relation to history of incident. If any injury found, stop survey and apply extrication collar and sand bags.
2.
Head Scalp
Run fingers over scalp feeling for deformity, soft spots, depressions or swelling. Check fingers for blood.
Face
Look at face and observes any gross deformity or asymmetry.
Pupils
Check if pupils are equal and reacting using penlight torch. Check size of pupil. Check conjunctiva (inside lid colour), pink, pale or blue.
Nose
Check the nose for CSF or blood. If either found check for source (inside or outside).
Ears
Check ears for CSF fluid or blood. If blood found check for source (inside or outside ear).
Mouth
Check inside mouth for broken teeth or bleeding, if conscious, check bite to indicate broken jaw. Ask patient if they are swallowing blood. Swallowing blood will cause nausea and associated airway problems. Encourage patient not to swallow blood and / or reposition patient to allow for drainage.
Facial structures Check for swelling, symmetry, deformity, tenderness of the facial structures by palpation. 3.
Shoulders
Check shoulders for deformity or tenderness. Checking entire clavicle and as much scapula region as possible without moving the patient.
4.
Chest
Ask patient to take a deep breath watching for symmetrical expansion of chest. Compress rib cage checking for tenderness on compression.
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Skill 102 Secondary Survey 1 of 3
5.
Abdomen
Check for obvious penetration. Ask the patient to cough gently, observing for pain and discomfort. Then checks entire abdomen gently with flat of hand (6 point palpation) checking for rigidity, guarding or tenderness.
6.
Lower back
Check for mid–point tenderness or deformity of the lumbar spine.
7.
Pelvis
Check for pain by gently compressing pelvis inwards (do not repeat). Note incontinence.
8.
Legs and feet
Look at legs and feet; observe for any deformity or asymmetry. If conscious, ask the patient if they have any pain. Officer anchors nearest leg at ankle: Check for deformity / tenderness of foot. Anchor leg at knee: Check for deformity / tenderness of lower leg. Anchor leg at hip: Check for deformity / tenderness of upper leg. Remove footwear: Check circulation—pedal pulse / blanch test Check mobility of joints:—flex toes, ankle, knee and hip. Move to other leg—repeat checks.
9.
Arms and Hands Look at arms and hands and observe for any deformity or asymmetry. If conscious, ask the patient if they have any pain. Anchor nearest arm at wrist: Check for deformity / tenderness of hand Anchor arm at elbow: Check for deformity / tenderness lower arm. Anchor arm at shoulder: Check for deformity / tenderness upper arm. Check circulation—radial pulse / blanch test Check mobility of joints:—make a fist, flex and rotate wrist, flex elbow. Anchor shoulder and gently move arm laterally away from the body. Move to other arm—repeat checks.
10.
Back
If other injuries permit, officers roll patient onto side to visualise back, spine and back of head. If spinal injury suspected, a log roll MUST be used to inspect the back. Check for lacerations, deformity / tenderness.
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Skill 102 Secondary Survey 2 of 3
PERFORMANCE CRITERIA SKILL 102 SECONDARY SURVEY CONDITIONS Provide:
A simulated patient lying / sitting. Necessary equipment.
STANDARD 1.
Able to understand and demonstrate a Secondary Survey as per Skill 102 as carried out on a stimulated patient. Elements of the survey may be used separately as the patient’s condition or position dictates.
2.
Effective communication with patient.
3.
Complete secondary survey within four minutes.
4.
Minor sequence errors may be permitted.
5.
Neck, head and lower back to be palpated using both hands simultaneously from either side.
6.
When assessing joints of limbs, they should be supported whilst patient performs movement.
7.
Unless absolutely unavoidable, do not physically move any limb until it has been checked.
KEY POINTS 1.
Continually monitor the patient’s airway, breathing and circulation.
2.
Secondary survey may be interrupted in order to stabilise any neck or life threatening injuries. (e.g. to apply extrication collar, control bleeding) otherwise any injury found during the survey should not be treated until the survey has been completed, unless the injury is potentially life threatening.
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Skill 102 Secondary Survey 3 of 3
SKILL 103 CENTRAL NERVOUS SYSTEM SURVEY CNS SURVEY November 2005 1.
Head: Eyes
Using a penlight check both pupils are equal and reactive to light (PERL). Establish pupil size against scale. Note difference. Check patient sight by holding three or more fingers up in front of the patient and asks patient to indicate how many can be seen. Check eye movement—asks patient to watch finger movement in 4 directions (officer observes for nystagmus).
Ears Check with the patient for any hearing abnormality or loss e.g. tinnitus. Note any difference. Mouth Instruct patient to swallow. Note whether swallow action present. Instruct patient to protrude tongue. Note whether tongue deviates from central extension. Instructs patient to grimace. Note lack of symmetrical muscle action present. Face Sensitivity of touch to the face. This is done by comparing differences in sensation between the left and right side of the forehead, cheeks and chin. 2.
Shoulders: Place palms of hands on shoulders, applies gentle restraining force; asks patient to shrug both shoulders simultaneously. Note muscle action and strength of movement.
3.
Arms and hands: Instruct patient to move fingers of both hands simultaneously Note muscle action and strength of movement. Clasp patients finger and ask patient to verbally identify which finger you are holding (finger recognition check must be done individually on each hand). Hold both of the patient’s hands and ask patient to simultaneously squeeze both your hands.
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Skill 103 Central Nervous System Survey 1 of 3
4.
Chest and abdomen:
5.
Check sensitivity to touch, full length each side in mid axillary line (Compare sensation of one side against other side separately).
Legs and feet:
6.
Note symmetrical muscle action and strength of grip. Check sensitivity to touch. Full–length, lateral, shoulder to finger on each arm. Full–length, medial, shoulder to finger on each arm. (Compare sensation of one arm against the other arm separately).
Instruct patient to move toes of both feet simultaneously. Note muscle action and strength of movement. Clasp patients toe and ask patient to verbally identify which toe you are holding (toe recognition check must be done individually on each foot). Apply gentle restraining force by placing palms of officer’s hands on top of patient’s feet and instructs patient to pull feet back against hands. Note muscle action and strength of movement. Place palm of officer’s hand against soles of patient’s feet, applies gentle restraining force. Instructs patient to push down against hand. Note muscle action and strength of movement (muscle power assessment must be done on both legs simultaneously). Check sensitivity to touch. Full–length, lateral, hip to toe on each leg. Full–length, medial, hip to toe on each leg (compare reaction of one leg against other leg separately).
Co-ordination: Hold patients forefinger up, level with and a short distance above patient’s nose; instructs patient to use a finger to alternately touch officer’s forefinger then their own nose using rapid movements (this procedure is applied to each arm in turn).
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Skill 103 Central Nervous System Survey 2 of 3
PERFORMANCE CRITERIA SKILL 103 CENTRAL NERVOUS SYSTEM SURVEY CONDITIONS Provide:
A simulated patient is lying down.
STANDARD 1.
Able to understand and demonstrate the Central Nervous System Survey as per Skill 103.
2.
Effective communication with patient.
3.
Completes CNS survey within four minutes.
4.
Minor sequence errors may be permitted.
5.
Where sensation is assessed, the question asked should be.
6.
First side—‘Does this feel normal?’
7.
Opposite side—‘Does this feel the same?’
8.
Record CNS examination result as normal or abnormal, reporting any asymmetric reactions of all body sections examined.
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Skill 103 Central Nervous System Survey 3 of 3
SKILL 104 MEASURE AND RECORD PULSE, RESPIRATIONS AND CONSCIOUS STATE November 2005 Pulse 1.
Inform patient that he / she intends to take their pulse.
2.
Pulse may be easily measured by feeling the:
Radial Artery on palm side of forearm, thumb side, approximately, 2cm. up from crease in wrist joint.
Brachial artery medial to the biceps tendon in the crease of the elbow
Carotid Artery located on the groove formed by the sterno–mastoid muscle and the trachea on either side of the neck.
Paediatrics Use brachial or apical pulse. Apical pulse is located below the left nipple.
3.
Feel the pulse by placing two or three fingers upon the artery exerting light pressure.
4.
The rate is counted for fifteen seconds then multiplied by four to get rate per minute. If the pulse is irregular, count for a full sixty seconds.
5.
The rate is recorded as well as rhythm (regular or irregular) and strength (strong or weak).
Respirations 1.
Do not inform patient that he / she intends to take their respirations. Expose the chest if trauma or ALS skills required.
2.
Monitor and count the rise and fall of the chest.
3.
Often patients may only exhibit diaphragmatic breathing. Monitor upper abdomen note rise and fall.
4.
If the radial artery is used to count the pulse rate, the patient's arm can be flexed across their chest, count the pulse and then, with the fingers still on the pulse, the rise and fall of the patient's chest can be felt.
5.
A cycle consists of inspiration, expiration, and pause. This is counted as one respiration.
6.
The number of cycles should be counted for 15 seconds, then multiplied by 4 to get rate per minute. If respirations are irregular or very slow, count for a full sixty seconds.
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Skill 104 Measure Record Pulse, Respirations and Conscious State 1 of 4
7.
Note rate, rhythm, lung sounds and tidal volume. Is breathing adequate to sustain life? Is the airway clear? What airway management is required immediately?
8.
Where trained use a stethoscope to identify sounds and air flow.
Conscious state 1.
General neurological assessment during primary survey can be achieved with the use of: Alert Verbal Pain Unrepsonsiveness
Paediatrics AVPU is especially indicated when assessing children. See Skill 101 Primary Survey. ‘Glasgow Coma Scale’ (GCS) 1.
The Glasgow Coma Scale was introduced to quantify neurological findings and allows uniformity in description of patients with head injury. It can also be used to describe levels of consciousness from other causes.
2.
This is measured by the testing of three (3) areas of response and awarding a numerical ‘score’ to each response. The total of the scores in each area is the patient's level on the Glasgow Coma Scale.
3.
No single score within the range of 3 to 15 points defines the cut–off point for coma. However, 90% of all patients with score of 8 or less, and none of those with a score of 9 or more, are found to be in coma according to the preceding definition. Therefore a score of 8 or less is considered coma.
4.
Generally a score of 9 to 13 represents a moderate head injury and 14 to 15 mild.
5.
Note: It is important to use the best motor response in calculating the score. However, one must record the response on both sides.
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Skill 104 Measure Record Pulse, Respirations and Conscious State 2 of 4
6.
When assessing pain response we are looking for simple flexion or extension to the painfully stimuli. Not neurological posturing as in decorticate (flexion) or decerebrate (extension) posturing. These are associated with severe cerebral irritation.
Areas to be assessed:
1.
Eye opening STIMULI NONE COMMAND PAIN PAIN
2.
SCORE 4 3 2 1
RESPONSE Oriented Confused Inappropriate words Incomprehensible words None
SCORE 5 4 3 2 1
RESPONSE Obeys commands Purposeful movement Withdraws from pain Flexion to pain Extension to pain None
SCORE 6 5 4 3 2 1
Best verbal response STIMULI COMMAND COMMAND COMMAND COMMAND COMMAND
3.
RESPONSE Spontaneous To voice To pain None
Best motor response STIMULI COMMAND PAIN PAIN PAIN PAIN PAIN
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Skill 104 Measure Record Pulse, Respirations and Conscious State 3 of 4
PERFORMANCE CRITERIA SKILL 104 MEASURE AND RECORD PULSE, RESPIRATIONS AND CONSCIOUS STATE CONDITIONS Provide:
A simulated patient lying / sitting. A patient care record as a prompt for GCS and a record for other findings.
STANDARD 1.
Able to understand and demonstrate how to measure and record pulse, respirations and conscious state as per Skill 104.
2.
Painful stimuli applied by squeezing trapezius muscle firmly between the thumb and forefinger.
KEY POINTS Paediatrics 1.
The preferred sites for measuring an infant’s pulse, in order are brachial, carotid and apical.
2.
When handing over patient details at a medical facility, report response in each area of the Glasgow Coma Scale, not just the score total.
3.
When a ‘response’ cannot be assessed due to injury or medical history, document that finding along with the actual observations.
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Skill 104 Measure Record Pulse, Respirations and Conscious State 4 of 4
SKILL 105 MEASURE AND RECORD SYSTOLIC BLOOD PRESSURE BY PALPATION November 2003 1.
Officer explains to patient what he / she intends to do.
2.
Place patient in a relaxed position either sitting or lying down.
3.
Fully support the patient's arm at the level of their heart.
4.
Remove any thick clothing from arm. (Thin clothing not heavily creased makes little difference).
5.
Place cuff on upper arm ensuring:
Centre of bladder is over the Brachial Artery.
Hose connections are on the lower edge of the cuff, this edge being 3cm (1 in) above the crease of the elbow.
6.
Take the loose end of cuff, wrapping it around the upper arm and securing it over the other end of cuff housing the bladder.
7.
Palpate Radial Artery or Brachial artery.
8.
Inflate cuff by:
Grasping the bulb attached to the hose connectors.
Close valve on bulb by rotating serrated edge between thumb and forefinger in a clockwise direction until tight. Whilst observing gauge, intermittently squeeze rubber bulb inflating cuff until pulse can no longer be felt. Note reading on gauge.
9.
Inflate cuff 20mmHg higher.
10.
Deflate cuff slowly by rotating serrated edge of valve between thumb and forefinger in an anti–clockwise direction, at the same time, continuing to feel for the radial pulse.
11.
At the point where radial pulse is again felt, note the reading on the gauge.
12.
Deflate cuff fully and remove.
13.
Record palpable systolic blood pressure e.g.120/Syst.
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Skill 105 Measure Record Systolic Blood Pressure by Palpitation 1 of 2
PERFORMANCE CRITERIA SKILL 105 MEASURE AND RECORD SYSTOLIC BLOOD PRESSURE BY PALPATION CONDITIONS Provide:
A simulated patient is sitting/lying. Necessary equipment.
STANDARDS 1.
Officer to understand and demonstrate the measuring and recording of a systolic blood pressure by palpation as per Skill 105.
KEY POINTS 1.
2.
If unable to palpate the radial artery, use the brachial artery by:
Straightening the patient's arm.
Locate the Brachial Artery by locating the bicep tendon in the crease of the elbow.
Curl the tips of the first and second fingers over the tendons and feel the pulse medial to the tendon.
In instances where the cuff does not fit the patient, you will have to rely on other observations regarding adequate perfusion or apply cuff to forearm and palpate radial pulse. Paediatrics
3.
Paediatric cuffs supplied will need to be fitted with gauge and bulb as necessary.
4.
Reading should not be taken from the point where the gauge needle begins to jump, but rather when the pulse recommences.
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Skill 105 Measure Record Systolic Blood Pressure by Palpitation 2 of 2
SKILL 106 MEASURE AND RECORD SYSTOLIC AND DIASTOLIC BLOOD PRESSURE USING A STETHOSCOPE September 2004 1.
Officer explains to patient what he / she intends to do.
2.
Place patient in a relaxed position either sitting or lying down.
3.
Support the patient’s arm at the level of their heart.
4.
Remove any thick clothing from the arm (thin clothing makes little difference).
5.
Place cuff on upper arm ensuring:
Centre of bladder is over brachial artery.
The distal edge of the cuff should be 3cm above the elbow crease.
6.
Take the loose end of the cuff, wrapping it around the upper arm and securing it over the other end of the cuff housing the bladder.
7.
Feel for the brachial artery in the antecubital fossa, just medial to the tendon of the biceps. Get patient to start to bend the arm to identify the tendon, and then straighten the arm again to make the palpation of the artery easier.
8.
Assess blood pressure by palpation first to identify the range.
9.
Confirm the stethoscope is ‘switched’ to the diaphragm, where appropriate, then place the flat diaphragm of the stethoscope over the palpated artery, pressing lightly.
10.
Inflate the cuff to the systolic blood pressure plus 20-30 mmHg.
11.
Allow cuff to deflate slowly—if too fast, pressure in the cuff will drop significantly between two beats so that the pressure you read will be too low.
12.
Note the pressure where you first firmly hear the pulse appear—this is the systolic blood pressure.
13.
Continue deflation until the sounds suddenly disappear, or at least suddenly and significantly quieter. This is the diastolic blood pressure.
14.
Repeat at least once, to establish a trend.
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Skill 106 Measure Record Systolic and Diastolic Blood Pressure using a Stethoscope 1 of 2
PERFORMANCE CRITERIA SKILL 106 MEASURE AND RECORD SYSTOLIC AND DIASTOLIC BLOOD PRESSURE USING A STETHOSCOPE CONDITIONS Provide:
A simulated patient sitting / lying. Necessary equipment.
STANDARD 1.
Officer to understand and demonstrate the measuring and recording of a systolic and diastolic blood pressure as per Skill 106.
KEY POINTS 1.
In instances where the cuff does not fit the patient, you will have to rely on other observations regarding adequate perfusion. Paediatrics
2.
Paediatric cuffs supplied will need to be fitted with gauge and bulb as necessary.
3.
Reading should not be taken from the point where the gauge needle begins to jump, but rather when the pulse recommences.
4.
Should the patient’s arm be too large for the cuff to be attached, a sufficient blood pressure may be obtained using the cuff on the forearm of the patient and a systolic reading obtained using the radial pulse.
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Skill 106 Measure Record Systolic and Diastolic Blood Pressure using a Stethoscope 2 of 2
SKILL 107 PULSE OXIMETER (NONIN ONYX 9500) November 2005 Description 1.
Pulse oximeter.
2.
Perfusion LED, digital LED’s for SpO2 and pulse rate.
3.
Oxygen saturation range 0-100%, accuracy between 70-100% is + or - 2 digits.
4.
Pulse rate range 18 to 300 BPM, accuracy + or - 3%, or 1 digit.
5.
Powered by two ‘AAA’ batteries, which give approximately. 1000 spot checks or 12 hours continuous use.
6.
Intended for adult and paediatric patients with a finger thickness between 7.5mm and 25mm. Not for infant or neonatal patients.
Replacing batteries FIGURE 1
1.
Numeric LED’S flash once per second when batteries are low, replace as soon as possible.
2.
Loosen the screw at the end of the unit using a coin or screw driver and remove the battery door (Figure1).
3.
Remove the old batteries.
4.
Insert two new ‘AAA’ batteries following the polarity markings indicated on the battery door or bottom label on the unit.
5.
Carefully position the battery door and firmly, but gently tighten the screw. Damage can occur if screw is over tightened or door is misaligned.
6.
Insert your finger (Figure 2) to test the unit is operating. If the unit does not turn on remove the finger, wait two seconds and retry.
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Skill 107 Pulse Oximeter (Nonin Onyx 9500) 1 of 5
FIGURE 2
7.
If unit still fails try reinstalling the batteries.
8.
If the unit requires storage for more than a month remove the batteries.
9.
Do not use different types of battery, or mix partial with fully charged batteries at the same time as batteries may leak.
Operation 1.
Using a one–handed thumb and finger technique, squeeze the base of the unit to open the finger cavity (Figure 2). Hold the unit with the display facing upward.
2.
Insert the selected finger (Figure 2) with the fingernail also upward into the finger cavity until the fingertip touches the built in stop.
3.
Centre the finger.
4.
Gently release grip on the unit.
5.
The unit will auto start and begin to sense the pulse indicated by the blinking indicator light. A minus sign appears in the left digital display.
6.
The display screen has two readings, % SpO2 and a heart sign for the pulse rate. At the base of the unit is an indicator light which, when blinking gives the operator a perfusion status.
7.
Allow the system to stabilize by observing the continuous green blinking indicator light for at least ten seconds (consistent with the patient’s palpable pulse) before relying on the displayed values.
8.
If the perfusion indicator light blinks yellow or red, make sure the blood flow is not restricted or try another finger. Yellow indicates artefact or marginal signal amplitude. Red means inadequate signal amplitude.
9.
If the pulse signal is inadequate for a period of two minutes the unit will auto power off.
10.
A minus sign appears in the left most digit of the % SpO2 display when the unit senses that the finger has been removed. The last measured SpO2 display and pulse rate values freeze for ten seconds, then the displays go blank.
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Skill 107 Pulse Oximeter (Nonin Onyx 9500) 2 of 5
False readings may be produced by:
Moisture on sensor or finger.
Failure to apply the sensor correctly may reduce the accuracy of the SpO2 measurement.
Flickering light and motion may affect the readings.
Hypotension.
Hypothermia, vasoconstriction.
Patient use of vaso–constrictive drugs.
Hypovolaemia or anaemia.
Nail polish / false nails.
Jaundice.
Excessive ambient light.
Abnormal haemoglobins e.g. Carbon Monoxide poisoning.
Cardiogreen and other intravascular dyes, depending on concentration, might affect the accuracy of the SpO2 measurement.
Constricted blood flow to the finger or a finger that is not within size limits of the sensor. Note: avoid using the thumb where possible; avoid using on same arm as BP cuff if possible.
Maintenance 1.
The solid–state circuitry cannot be altered and requires no maintenance other than battery replacement or unit cleaning.
2.
The unit is in two parts held together by a spring that allows the unit to hinge.
3.
The two parts of the oximeter are attached by flexible circuitry. Caution: do not twist or pull against this circuitry.
4.
To open for cleaning, turn the unit upside down. Caution: Removing the spring tension may allow the spring to detach suddenly from the unit and strike the operator. Protect your eyes or wear eye protection if attempting to remove the spring.
5.
The spring is designed to be partially removed for cleaning, or totally for spring replacement.
6.
To partially remove the spring lift the spring–bar out of the groove and allow the spring to pass in front of the finger cavity.
7.
Lay the unit down carefully and commence cleaning.
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Skill 107 Pulse Oximeter (Nonin Onyx 9500) 3 of 5
8.
To clean, wipe surfaces with isopropyl alcohol solution or mild detergent.
9.
Dry with a soft cloth or air dry.
10.
Surfaces should be fully dry before reassembly.
11.
To replace spring, ensure the spring is still attached to the side by the lugs. Rotate the spring so the two loops are out in front of the finger cavity.
12.
Now lift the spring bar back over the finger cavity and back into the groove.
13.
To totally remove the spring the same procedure is used, however the side lugs need to be detached and the spring removed.
14.
The patient finger cavity has a finger grip that may occasionally need replacing. This translucent film can be peeled off cleaned and a new one stuck in place. The unit will operate with or without this grip.
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Skill 107 Pulse Oximeter (Nonin Onyx 9500) 4 of 5
PERFORMANCE CRITERIA SKILL 107 PULSE OXIMETER (NONIN ONYX 9500) Conditions Provide:
Patient either lying or sitting. Finger Pulse Oximeter Nonin Onyx 9500.
STANDARDS 1.
Officer to understand and demonstrate the SpO2 monitor as per Skill 107.
2.
Not suitable for infants or neonatal use.
KEY POINTS 1.
Pulse readings are not considered as accurate unless measured against the patient’s palpable pulse. Pulse readings can be affected by poor circulation or restriction of blood flow by bending fingers, hands or arms.
2.
Caution: High % SpO2 saturation levels do not indicate sufficient oxygen to deprived cells. Examples: Trauma, CVA and AMI patients. Oxygen delivery must remain at high concentration or 100%.
3.
It is sometimes possible to place the monitor on the side of the finger. However accuracy may be compromised.
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Skill 107 Pulse Oximeter (Nonin Onyx 9500) 5 of 5
SKILL 108 MEDISENSE OPTIUM BLOOD GLUCOSE TESTING October 2007 Operation 1.
Put on examination gloves and safety glasses.
2.
Open monitor wallet.
3.
Swab the selected site on the patient’s fingertip using an antiseptic swab and allow it to dry. The preferred site for obtaining a blood sample is to the side of the fingertip.
4.
Caution: Only Medisense Optium electrodes are to be used with this unit.
5.
Remove one electrode strip from the case. Check the expiry date. Note: the monitor will not activate with an expired electrode.
6.
Midway along one side of the test strip packaging is a ‘V’ shaped cut out (Figure 1) with a short and long side. Whilst holding the test strip with one hand, use the other hand to tear along the in the direction of the dotted line as marked on the diagram below. Gold coloured protective electrode covering. FIGURE 1
Opened protective cover
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Skill 108 Medisense Optium Blood Glucose Testing 1 of 5
7.
Once the electrode is exposed, insert the electrode strip into the slot located in the centre top (test port) of the sensor with the black contact bars uppermost.
8.
Retain the protective aluminium cover (avoid contamination or damage to the electrode). FIGURE 2
9.
The monitor (Figure 2) will turn on automatically and a five–digit ‘lot’ number will appear in the display window followed by ‘Apply Blood’.
10.
Gently ‘milk’ the selected finger of the patient. Avoid excessive squeezing of the fingertip as this causes plasma to be released into the blood thereby altering the glucose reading.
11.
Twist off the protective needle cover from the lancet and place the open end of the lancet firmly against the prepared site on the fingertip.
12.
Depress the lever at the side of the lancet to activate the firing mechanism.
13.
Dispose of the lancet into the Sharps container.
14.
Turn the patient’s hand over and obtain a hanging drop of blood, of reasonable size, or a drop of blood sufficient to be absorbed via direct contact. Use the blood sample immediately.
15.
Remove and save the remaining packaging from the electrode (Figure 1). You will observe a green electrode (Figure 3) with a blood–testing region, at the tip of the strip. FIGURE 3
16.
Carefully place the tip of the electrode into the drop of blood and allow the blood to be absorbed. The unit will not start testing until sufficient blood is absorbed.
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Skill 108 Medisense Optium Blood Glucose Testing 2 of 5
Caution: pressing the tip of the electrode against the skin may cause the electrode to bend. When the electrode is loaded and then removed from the patient the electrode may spring and flick blood. Avoid this by gently moving the electrode away from the patient and not in direct line with you. 17.
The monitor will commence a twenty–second countdown and then display the blood glucose reading in millimoles per litre (mmol/L). If the test fails to start, add a second drop of blood to the target area within 30 seconds of the first. If the test still fails to start or an error sign appears, restart the procedure from the beginning with a new electrode.
18.
Place and hold firmly a cotton wool swab over the puncture site or apply a band–aid to stop the bleeding.
19.
Wait for the blood glucose reading to appear in the display window.
20.
Document the result on the Patient Care Record form.
21.
Replace the saved electrode packaging over the soiled end of the electrode; remove the electrode from the monitor and dispose.
22.
Turn the monitor off by pressing the off button, or wait 30 seconds and the monitor will turn off automatically.
Calibration 1.
To ensure accurate results, the monitor must be calibrated for each new box of electrodes before using them. Each new box of electrodes comes with a white calibrator strip.
2.
Remove the calibrator and the electrode insert from the new box of electrodes.
3.
Remove the calibrator from its plastic container. Find three raised bumps in one of the corners of the plastic container. Grasp the clear cover at this corner and pull back, lifting the clear cover away from the container.
4.
Ensure the five digit lot number matches on each of the following (i.e. LOT 5100):
5.
The white glucose calibrator.
Each glucose electrode foil packet.
The glucose electrode package insert.
Hold the calibrator with the lot numbers facing up. Insert the contact bars into the test port of the sensor. ‘LOT’ and the five–digit lot number will appear in the display window (Figure 4).
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Skill 108 Medisense Optium Blood Glucose Testing 3 of 5
FIGURE 4
6.
Check that the lot number displayed matches the calibrator and the electrode package insert. Calibration is now complete.
7.
If the lot number displayed does not match the lot number on the calibrator, check that the correct calibrator was used and restart.
8.
Press and release the button to turn the monitor off.
9.
Remove the calibrator and store it in the carrying case. Do not discard the calibrator until all of the corresponding electrodes have been used.
10.
To check the calibration at any time, start with the unit off, then press and hold the ‘on’ button. Last Result, Recall, Averages, Setup and View Code appear in the display window.
11.
When View Code appears, release the button. LOT and the current five–digit lot number will appear.
Replacing the batteries 1.
The batteries are housed in the rear of the sensor.
2.
To remove the batteries open the battery door by pushing the tab up and swinging the door open. Set the door aside.
3.
Remove the two old batteries carefully by lifting them out separately.
4.
Follow the diagram in the bottom of the battery compartment to see how the new batteries must be inserted. Insert two new ‘AAA’ alkaline batteries as shown.
5.
Replace the battery door and then turn the monitor on to make sure the batteries were correctly inserted.
6.
Battery power is shown in the display window. When the power level of the batteries is getting low you will see the word ‘Batteries’ displayed alongside a small picture of a battery. It is recommended that you replace the batteries at this time.
7.
Do not remove the old batteries until you have the new batteries ready to be installed.
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Skill 108 Medisense Optium Blood Glucose Testing 4 of 5
PERFORMANCE CRITERIA SKILL 108 MEDISENSE OPTIUM BLOOD GLUCOSE TESTING CONDITIONS Provide:
A simulated patient lying / sitting.
Gloves.
Blood glucose monitor (Medisense Optium) with electrode strip and calibrator.
Approved lancet.
Antiseptic swabs, a packet of cotton wool balls and Band–Aids.
Copy of a Patient Care Record form.
STANDARD 1.
Officer to understand and demonstrate the taking of a blood sample for testing the blood glucose level, using a glucometer and lancet as per Skill 108.
2.
Use only Medisense Optium Electrodes.
3.
Aseptic techniques and safety procedures to be maintained.
4.
Gloves to be worn.
5.
Check expiry date of electrode and protective packaging intact before use.
6.
The monitor must be calibrated for each new packet of electrodes. Calibration strips must only be used with electrodes of the same batch number.
7.
Document results and time taken.
KEY POINTS 1.
A second reading is not normally required after the administration of carbohydrates, Oral Glucose Gel, and / or Glucagon.
2.
A sufficient blood sample is acknowledged with a series of three dashes displayed across the screen within three seconds.
3.
It does not matter if the patient’s finger touches the electrode strip.
4.
The Optium monitor has other functions that are not required in pre hospital care and therefore will not be used.
5.
Avoid excessive squeezing of the fingertip as this causes plasma to be released into the blood thereby altering the glucose reading.
6.
Use the blood sample immediately.
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Skill 108 Medisense Optium Blood Glucose Testing 5 of 5
SKILL 109 MEASURE THE PEAK EXPIRATORY FLOW RATE OF A PATIENT December 2006
1.
Place disposable cardboard mouthpiece into peak flow meter (PEF).
2.
Make sure the marker is at the lower end of the scale, if not, move marker gently.
3.
Have the patient hold the peak flow meter horizontally, making sure their fingers do not obstruct the slot.
4.
Ask patient to take as deep a breath as possible.
5.
Ask patient to open mouth and close lips firmly around the outside of the mouth piece.
6.
Ask patient to blow as hard and as fast as they can into the mouth piece (This action is best described as a ‘hard huff’).
7.
Read the value of PEF from the scale, recording the value on patient record form stating the time the reading was taken.
8.
Gently push back the marker to lower end of scale, ready for next use.
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Skill 109 Measure The Peak Expiratory Flow Rate of a Patient 1 of 2
PERFORMANCE CRITERIA SKILL 109 MEASURE THE PEAK EXPIRATORY FLOW RATE OF A PATIENT CONDITIONS Provide:
A simulated patient sitting down. A Peak Expiratory Flow Meter and disposable cardboard mouthpiece.
STANDARD 1.
Officer to understand and demonstrate how to measure the peak expiry flow of air using a Peak Expiry Flow Meter as per Skill 109.
2.
Where possible two readings should be taken to determine a PEF (highest reading used).
3.
Ten minutes after treatment (oxygen / nebuliser), a further PEF reading should be obtained.
4.
If patient condition is severe, a PEF may not be appropriate.
KEY POINTS 5.
Cardboard mouthpieces are disposable.
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Skill 109 Measure The Peak Expiratory Flow Rate of a Patient 2 of 2
SKILL 111 MEDISENSE OPTIUM EXCEED BLOOD GLUCOSE TESTING October 2007 Features 1.
Operating temperature: 10O to 50O.
2.
System operating temperatures vary depending on the type of electrode used.
3.
Uses the same electrodes as the original Medisense Optium Skill 109.
How does it work? When a blood sample is applied or controlled sample solution is applied to the electrode, the glucose reacts with the chemicals on the electrode. The reaction produces a small electrical current that is measured and displayed on the monitor. FIGURE 1
Calibration 1.
To ensure accurate results, the monitor must be calibrated for each new box of electrodes before using them. Each new box of electrodes comes with a white calibrator strip.
2.
Remove the calibrator and the electrode insert from the new box of electrodes.
3.
Remove the calibrator from its plastic container. Find three raised bumps in one of the corners of the plastic container. Grasp the clear cover at this corner and pull back, lifting the clear cover away from the container.
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Skill 111 Medisense Optium Exceed Blood Glucose Testing 1 of 7
4.
5.
Ensure the five digit lot number matches on each of the following (i.e. LOT=5100):
The white glucose calibrator (Figure 2).
Each glucose electrode foil packet.
The glucose electrode package insert.
Hold the calibrator with the lot numbers facing up (Figure 2). Insert the contact bars into the test port of the sensor. ‘LOT’ and the five–digit lot number will appear in the display window. FIGURE 2
6.
Check that the lot number displayed matches the calibrator and the electrode package insert. Calibration is now complete.
7.
If the lot number displayed does not match the lot number on the calibrator, check that the correct calibrator was used and restart.
8.
Press and release the button to turn the monitor off.
9.
Remove the calibrator and store it in the carrying case. Do not discard the calibrator until all of the corresponding electrodes have been used.
10.
To check the calibration at any time, start with the unit off, then press and hold the ‘on’ button. Last Result, Recall, Averages, Setup and View Code appear in the display window.
11.
When View Code appears, release the button. LOT and the current five–digit lot number will appear.
Operation 1.
Put on examination gloves and safety glasses.
2.
Open monitor wallet.
3.
Swab the selected site on the patient’s fingertip using an antiseptic swab and allow it to dry. The preferred site for obtaining a blood sample is to the side of the fingertip.
4.
Remove one electrode strip from the case. Check the expiry date. Note: the monitor will not activate with an expired electrode.
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Skill 111 Medisense Optium Exceed Blood Glucose Testing 2 of 7
Caution: only Medisense Optium electrodes are to be used with this unit. The Optium Exceed uses the same electrodes as that of the Medisense Optium. 5.
Midway along one side of the test strip packaging is a ‘V’ shaped cut out, with a short and long side. Whilst holding the test strip with one hand, use the other hand to tear along the in the direction of the dotted line as marked on the diagram below. Gold coloured protective electrode covering. FIGURE 3
6.
Once the electrode is exposed, insert the electrode strip with the three black lines at the end of the electrode into the electrode port (Figure 1).
7.
Retain the protective aluminium cover (avoid contamination or damage to the electrode).
8.
The monitor will turn on automatically and a five–digit ‘lot’ number will appear in the display window followed by ‘Apply Blood’.
9.
Gently ‘milk’ the selected finger of the patient. Avoid excessive squeezing of the fingertip as this causes plasma to be released into the blood thereby altering the glucose reading.
10.
Twist off the protective needle cover from the lancet and place the open end of the lancet firmly against the prepared site on the fingertip.
11.
Depress the button at the front of the lancet to activate the firing mechanism.
12.
Dispose of the lancet into the Sharps container.
13.
Obtain a hanging drop of blood, of reasonable size, or a drop of blood sufficient to be absorbed via direct contact. Use the blood sample immediately.
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Skill 111 Medisense Optium Exceed Blood Glucose Testing 3 of 7
14.
Remove and save the remaining packaging from the electrode (Figure 3). You will observe a green electrode with a blood–testing region, at the tip of the strip (Figure 4). FIGURE 4
15.
Carefully place the tip of the electrode into the drop of blood and allow the blood to be absorbed. The unit will not start testing until sufficient blood is absorbed. Caution: pressing the tip of the electrode against the skin may cause the electrode to bend. When the electrode is loaded and then removed from the patient the electrode may spring and flick blood. Avoid this by gently moving the electrode away from the patient and not in direct line with you.
16.
The monitor will commence a 5 second countdown and then display the blood glucose reading in millimoles per litre (mmol/L). If the test fails to start, add a second drop of blood to the target area within 30 seconds of the first. If the test still fails to start or an error sign appears, restart the procedure from the beginning with a new electrode.
17.
Place and hold firmly a cotton wool swab over the puncture site or apply a band–aid to stop the bleeding.
18.
Wait for the blood glucose reading to appear in the display window.
19.
Document the result on the Patient Care Record form.
20.
Replace the saved electrode packaging over the soiled end of the electrode; remove the electrode from the monitor and dispose of the electrode in the Sharps container.
21.
To turn off monitor remove the electrode or press and hold mode button for two seconds.
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Skill 111 Medisense Optium Exceed Blood Glucose Testing 4 of 7
Understanding the result 1.
LO reading indicates the result is lower than1.2 mmol/L or there may be a problem with the electrode.
2.
When the reading is higher than 16.8 mmol/L Ketones flashes on and off.
3.
HI reading indicates the reading is higher than 27.8 mmol/L or there may be a problem with the electrode.
4.
E4 indicates the glucose is too high to read or there is a problem with the electrode.
Replacing the battery 1.
The battery is a coin cell lithium CR 2032.
2.
The battery is housed in the rear of the sensor.
3.
To remove the battery, open the battery door by pushing the tab up and removing the slide cover off.
4.
Remove the old battery carefully by lifting out via the tab.
5.
Replace the battery as it was situated previously. Note the writing and plus sign is facing up.
6.
Replace the battery cover by gently pushing the cover in and down until a click is heard. Then turn the monitor on to make sure the batteries were correctly inserted, time and date are correct.
7.
Battery power is shown in the display window. When the power level of the batteries is getting low you will see the word ‘Batteries’ displayed alongside a small picture of a battery. It is recommended that you replace the batteries at this time.
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Skill 111 Medisense Optium Exceed Blood Glucose Testing 5 of 7
PERFORMANCE CRITERIA SKILL 111 MEDISENSE OPTIUM EXCEED BLOOD GLUCOSE TESTING CONDITIONS Provide:
A simulated patient lying / sitting.
Gloves.
Blood glucose monitor (Medisense Optium) with electrode strip and calibrator.
Approved lancet.
Antiseptic swabs, a packet of cotton wool balls and Band–Aids.
Copy of a Patient Care Record form.
STANDARD 1.
No performance errors permitted.
2.
Officer to understand and demonstrate the taking of a blood sample for testing the blood glucose level, using a glucometer and lancet as per Skill 111.
3.
Use only Medisense Optium Electrodes.
4.
Aseptic techniques and safety procedures to be maintained.
5.
Gloves to be worn.
6.
Check expiry date of electrode and protective packaging intact before use.
7.
Dispose of all blood contaminated items into a Sharps container.
8.
The monitor must be calibrated for each new packet of electrodes. Calibration strips must only be used with electrodes of the same batch number.
9.
A second reading is not normally required after the administration of carbohydrates, Oral Glucose Gel, and / or Glucagon.
10.
Document results and time taken.
KEY POINTS 1.
A sufficient blood sample is acknowledged with a series of three dashes displayed across the screen within three seconds.
2.
It does not matter if the patient’s finger touches the electrode strip.
3.
Allow alcohol used in swabbing the site to completely dry before testing as the alcohol will alter the result.
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Skill 111 Medisense Optium Exceed Blood Glucose Testing 6 of 7
4.
The Optium monitor has other functions that are not required in pre hospital care and therefore will not be used.
5.
Avoid excessive squeezing of the fingertip as this causes plasma to be released into the blood thereby altering the glucose reading.
6.
Use the blood sample immediately.
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Skill 111 Medisense Optium Exceed Blood Glucose Testing 7 of 7
SKILL 206 OPERATION OF A BAG VALVE MASK RESUSCITATOR May 2011 Operation Attach, single patient use, disposable Bacterial / Viral filter, between mask and the Bag Valve Mask for patient’s over 10kg as per figure 1. Paediatrics Patients less than 10kg must not be allowed to spontaneously breathe through a Bag Valve Mask device. They can not generate enough pressure to open the valve and risk suffocation. FIGURE 1
Assisted Ventilation 1.
Mask and ventilation bag with or without reservoir bag = 21% ambient air to patient.
2.
Mask, ventilation bag with reservoir bag and O2 = 100% oxygen to patient.
3.
Apnoeic patients are to be ventilated as per CPR Skill. Note: over ventilation may result in gastric distension and airway compromise. Certain devices may include a pressure relief valve that is aimed at preventing this.
4.
Select appropriate size resuscitation bag and mask (figure 2).
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Skill 206 Operation Laerdal Bag Valve Mask Resuscitator Review date: May 2016 1 of 4
FIGURE 2
5.
Attach oxygen therapy tubing to the unit.
6.
Turn oxygen flow rate to at least 8l/m or more and allow the reservoir bag to fill completely before use. Note: The reservoir bag must inflate fully between ventilations to ensure Oxygen is drawn from the reservoir bag and not from ambient air.
7.
Attach resuscitation mask to ‘Patient Valve’ by pushing the round aperture of mask onto the ‘Patient Valve’ as per Figure 3. FIGURE 3
8.
Slide the neck of the mask between index and idle fingers (figure 4 ‘Anaesthetic Grip’), ensuring that the thumb is free at chin section of mask.
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Skill 206 Operation Laerdal Bag Valve Mask Resuscitator Review date: May 2016 2 of 4
FIGURE 4
9.
Place mask on patients face covering the nose first, mouth second.
10.
Downward pressure should also be applied to maintain mask seal.
11.
Maintain appropriate neutral head and neck alignment.
12.
If operating from the head end hold the mask between the thumb and fingers at the neck of the patient valve and press the mask firmly over the nose and mouth (Figure 5 ‘Anaesthetic Grip’), grip the patient’s jaw with the fingers to secure control of the patient’s head. FIGURE 5
13.
Patient may be allowed to breath on demand or be ventilated.
14.
If ventilating, gently squeeze the ventilation bag with the free hand, until the patient’s chest starts to rise (over 1sec).
15.
If the ventilation bag will not compress, the airway may be obstructed.
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Skill 206 Operation Laerdal Bag Valve Mask Resuscitator Review date: May 2016 3 of 4
PERFORMANCE CRITERIA SKILL 206 OPERATE BAG VALVE MASK RESUSCITATOR CONDITIONS Provide:
A manikin and or simulated patient.
Complete Bag Valve Mask resuscitator not assembled.
Bacterial / Viral filter.
STANDARD 1.
Able to understand and demonstrate the bag / mask resuscitator as per Skill 206.
2.
Ventilation of patient as per CPR and Skills.
4.
Oxygen flow rate to be adjusted according to demand at least 8 litres (increase flow rate to ensure the reservoir bag refills between ventilations).
5.
Ventilate the patient until the patient’s chest starts to rise.
KEY POINTS 1.
Allow the reservoir bag to fill before use.
2.
Do not squeeze the reservoir bag.
3.
Avoid forceful rapid ventilation that may cause gastric distension.
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Skill 206 Operation Laerdal Bag Valve Mask Resuscitator Review date: May 2016 4 of 4
SKILL 208 AND 210 OXYGEN THERAPY BY FACE MASK AND NON-REBREATHING OXYGEN MASK May 2011 High Concentration Mask
Oxygen Therapy Face Mask
1.
Ensure oxygen cylinder is turned ‘ON’.
2.
Ensure appropriate size oxygen therapy facemask is fitted securely to oxygen therapy tubing by pushing the tubing on to the nipple on bottom of mask.
3.
Flow meter is opened and adjusted to appropriate flow rate (at least 6 litres is required to achieve 60% Oxygen, increase flow rate or select a non– rebreather therapy face mask if patient severely SOB).
4.
Adjust the facemask to a comfortable position using the adjustable elastic straps on each side of the mask.
5.
Ensure oxygen therapy facemask fits snugly on patient’s nose by squeezing the soft metal strip on mask over the patient’s nose to form a seal.
6.
When using the high concentration mask the bag must be inflated prior to mask application. To inflate the bag place a finger over the oxygen inlet valve (one way valve) inside the mask, while the oxygen is flowing, until the reservoir bag is inflated.
7.
Patients using the high concentration mask should be monitored closely as the mask has no provision for allowing room air to enter the mask should the oxygen flow be interrupted or ceased.
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Skill 208 Oxygen Therapy by Face Mask Review date: May 2016 1 of 2
PERFORMANCE CRITERIA SKILL 208 AND 210 OXYGEN THERAPY BY FACE MASK AND NON-REBREATHING OXYGEN MASK CONDITIONS Provide:
Disposable therapy mask and oxygen tubing.
Non-rebreathing oxygen mask
A simulated patient is lying / sitting down.
Oxygen source with flow meter.
STANDARDS 1.
Officer to understand and demonstrate the administration of oxygen via a disposable therapy mask and non-rebreathing oxygen mask as per skills 208 and 210.
2.
Officer reassures patient as to the need for oxygen therapy.
3.
No performance errors permitted.
4.
Reading of flow meter is from top of ball or by needle position.
5.
Ball type flow meter must be vertical when read.
6.
Therapy masks are disposable and a new mask should be used for each patient.
KEY POINTS 1.
If patient does not tolerate therapy mask ascertain reason and correct if possible.
2.
The bag of the high concentration mask must be inflated fully prior to application.
3.
Oxygen flow rate must be sufficient to ensure bag of high concentration mask refills during respirations.
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Skill 208 Oxygen Therapy by Face Mask Review date: May 2016 2 of 2
SKILL 301 LATERAL POSITION October 2007 1.
Moving the patient from supine position to lateral position.
2.
Kneel beside patient (either side), one knee in line with patient's pelvis and the other near patients chest (Figure 1).
3.
Place patient's nearest arm at right angles to patient's body with the palm facing up (Figure 1). This allows the correct rotation of the arm as the lateral position is applied. FIGURE 1
4.
Lift and flex the furthest leg up and support with closest hand.
5.
Using your other hand grasp the patients furthest hand, interlocking the thumb and hand of the patient (Figure 2). FIGURE 2
6.
Bring the patients hand over their chest along with your hand and place under the patients head neck (Figure 3).
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Skill 301 Lateral Position 1 of 4
FIGURE 3
7.
Move the hand on the leg down the leg along the thigh with the elbow resting on the knee region.
8.
Whilst supporting patient’s leg and head / neck pull the patient over towards you (Figure 4). FIGURE 4
9.
Bring the leg further around at right angles to support the patient on their side (Figure 5). FIGURE 5
10.
Whilst supporting the head / neck remove your hand from under the patient. Align patient’s head / neck with mouth turned down to maintain airway and allow any secretions to drain (Figure 6). Note: the patients own hand is used to provide some support to hold this position. Pillows or a folded blanket etc. may also be used to support this position. The patients protruding arm can be repositioned along side the patient (Figure 7).
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Skill 301 Lateral Position 2 of 4
FIGURE 6
FIGURE 7
11.
When transporting a patient in the lateral position on a stretcher consideration should be made to have the patient facing you comfortable during transport. Often supporting the patients back or front can reduce body roll whilst in transit maintaining the lateral position.
12.
Good head / neck alignment can also be achieved for spinal protection.
13.
Ensure upper leg is flexed and laid at a right angle to patient's body.
14.
Completed lateral position (Figure 8). FIGURE 8
Note: To position patient on a stretcher the extended arm and leg position will need to be adjusted to suit the width of the stretcher. The patient should be positioned to face the attendant when in an ambulance where possible (Figure 9). FIGURE 9
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Skill 301 Lateral Position 3 of 4
PERFORMANCE CRITERIA SKILL 301 LATERAL POSITION CONDITIONS Provide:
A simulated patient lying down.
STANDARD 1.
Able to understand and demonstrate the placing of a patient into a lateral position as per Skill 301.
KEY POINTS 1.
Ensure alignment of pelvis and spine is maintained where possible.
2.
If suspected head / neck injury use log roll.
3.
If necessary additional support can be provided by blankets and pillows.
4.
If patient is to be loaded onto a stretcher, position patient on their side appropriate for monitoring (taking into regard the patient’s condition).
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Skill 301 Lateral Position 4 of 4
SKILL 302 YANKAUER SUCTION TUBE May 2011 Officer to wear PPE (eye protection, mask, gloves) as per Infection Control Policy.
1.
Officer connects Yankauer Suction Tube to suction tubing.
2.
Turn suction source 'ON' and ensure appropriate suction pressure.
3.
Officer opens patient's mouth with the crossed finger technique.
4.
Officer inserts Yankauer Suction catheter tip into the oropharynx under direct view.
5.
Officer aspirates by occluding the hole in the tube adjacent to the Yankauer suction handle.
6.
Withdraw the Yankauer suction catheter slowly.
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Skill 302 Yankauer Suction Tube Review date: May 2016 1 of 2
PERFORMANCE CRITERIA SKILL 302 YANKAUER SUCTION TUBE CONDITIONS Provide:
Intubation manikin. Suction source, Yankauer suction catheter and a bowl of water.
STANDARD 1.
Officer to understand and demonstrate aspirating a patient’s airway, using a Yankauer Suction device as per Skill 302.
2.
Officer to wear PPE (eye protection, mask, gloves) as per Infection Control Policy.
3.
Aspiration for a maximum of 5 seconds at any one time.
4.
Aspiration bowl must not fill beyond 2/3 full.
KEY POINTS 1.
Do not leave suction on unnecessarily.
2.
Clean water may be used to clear catheter and tubing by suction as necessary.
3.
Ensure a safe suction technique while in transit.
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Skill 302 Yankauer Suction Tube Review date: May 2016 2 of 2
SKILL 303 OROPHARYNGEAL ASPIRATION FLEXIBLE CATHETER November 2008 Officer to wear PPE (eye protection, mask, gloves) as per Infection Control Policy.
1.
Officer connects appropriate size ‘Y’ suction catheter to end of suction tubing.
2.
Officer determines maximum length of catheter to be inserted by measuring distance from corner of patient's nostril to patient's ear lobe with the catheter and holds catheter with the forefinger and thumb at the mark measured.
3.
Turn suction source ‘ON’.
4.
Officer opens patient's mouth with the crossed finger technique.
5.
Aspiration within the patient’s airway. Insert the ‘Y’ suction catheter to a depth that contacts the fluid. Apply suction by holding a finger over the hole on the ‘Y’ piece of the catheter shaft. Keep moving the suction catheter whilst suctioning. Remove holding suction until clear of the airway.
6.
ETT aspiration. Officer measures depth required against the full length of an equivalent ETT tube. Hold or mark off the required tube length. Insert suction catheter down ETT without suction applied. Aspirate by rotating the catheter continuously as the catheter is withdrawn by holding a finger over the hole on the ‘Y’ piece of the catheter shaft. Remove holding suction until clear of the airway.
7.
Officer aspirates a maximum of five seconds at any one time.
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Skill 303 Oropharyngeal Aspiration – (flexible catheter) 1 of 2
PERFORMANCE CRITERIA SKILL 303 OROPHARYNGEAL ASPIRATION—FLEXIBLE CATHETER CONDITIONS Provide:
Intubation manikin. Suction source ‘Y’ suction catheters and a bowl of water.
STANDARD 1.
Officer to understand and demonstrate aspirating a patient’s airway using a flexible ‘Y’ suction catheter as per Skill 303.
2.
Officer to wear PPE (eye protection, mask, gloves) as per Infection Control Policy.
3.
Officer aspirates a maximum of five seconds at any one time.
4.
Aspiration jar must not fill beyond two thirds full.
5.
If an oropharyngeal airway is in situ, aspirate either side of, as well as the inside the oropharyngeal airway, (depending on size of “Y” suction catheter). If the oropharyngeal airway is blocked remove and clear then replace.
6.
Catheters are single use items. Dispose after use.
7.
Suction equipment should be cleaned as per Infection Control Policy.
KEY POINTS 1.
Do not leave suction on that is powered by oxygen unnecessarily.
2.
Whilst suctioning, clean water may be used to clear catheter and tubing by suction.
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Skill 303 Oropharyngeal Aspiration – (flexible catheter) 2 of 2
SKILL 304 BABY MUCUS EXTRACTOR November 2008 FIGURE 1
1.
For Infection Control purposes attach viral bacterial filter to a size 7 ETT connector, then connect to the green open end of the Baby Mucus Extractor as shown in Figure 1.
2.
Determine maximum length of mucus extractor catheter to be inserted into patient by measuring distance from corner of patient’s nostril to patient’s ear lobe (mark catheter).
3.
Hold the mucus extractor trap jar in a vertical position with the fingers of one hand.
4.
With the other hand :
5.
Place the viral bacterial filter into Officer’s mouth.
Hold the catheter at the marked position and insert catheter into the patient’s nose to marked length or less, as appropriate.
Officer aspirates material by:
Sucking on the open end of the Viral bacterial filter, gently at first, increasing the suction if required, and
Simultaneously withdrawing catheter while rotating the catheter continuously during removal.
6.
Mouth suction can also be performed in the same manner under direct vision if necessary.
7.
If necessary, mucus trap jar can be sealed by use of yellow lid attached to the bottom of the mucus extractor.
8.
Dispose of Filter, ETT connector and Baby Mucus Extractor after use.
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Skill 304 Baby Mucus Extractor 1 of 2
PERFORMANCE CRITERIA SKILL 304 BABY MUCUS EXTRACTOR CONDITIONS Provide:
Baby manikin is provided. Mucus extractor and infection control accessories and a bowl of water are provided.
STANDARD 1.
Officer to understand and demonstrate aspirating a baby’s airway using a Baby Mucus Extractor as per Skill 304.
2.
Officer to aspirate water from the bowl.
3.
Mucus trap jar must not fill beyond 2/3 full.
4.
To empty mucus trap jar, unscrew from mucus catheter unit and empty.
5.
Do not allow mucus trap jar with contents to be laid on its side.
6.
Dispose of extractor after use.
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Skill 304 Baby Mucus Extractor 2 of 2
SKILL 305 OROPHARYNGEAL AIRWAY INSERTION October 2007 Officer to wear PPE (eye protection, mask, gloves) as per Infection Control Policy. 1.
Ensure patient's airway is clear.
2.
Obtain correct size by placing an oropharyngeal airway on the patient's face so it measures from the centre of the lips to the angle of the jaw (Figure 1). FIGURE 1
3.
Using one hand with the thumb and index finger crossed, pry the patient's teeth apart and hold the patient's mouth open (called the crossed finger technique, Figure 2). FIGURE 2
4.
With the tip pointing towards the roof of the patient's mouth, insert oropharyngeal airway approximately 1/3rd of its length into the patient's mouth (Figure 2).
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Skill 305 Oropharyngeal Airway Insertion 1 of 3
5.
Rotate the oropharyngeal airway over on the tongue with the tip of the airway now pointing towards the side of patient's mouth (Figure 3). FIGURE 3
6.
Gently push the oropharyngeal airway approximately 2/3rd of its length into the patient's mouth whilst rotating oropharyngeal airway so that the tip is now pointing down.
7.
Gently push oropharyngeal airway further into the patient's mouth until the flange on the oropharyngeal airway is pressing against the lips (Figure 4). FIGURE 4
8.
Extend the patient's head gently and, if necessary, apply jaw thrust to assist in settling the oropharyngeal airway into correct position and maintain an airway.
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Skill 305 Oropharyngeal Airway Insertion 2 of 3
PERFORMANCE CRITERIA SKILL 305 OROPHARYNGEAL AIRWAY INSERTION CONDITIONS Provide:
Intubation manikin. Four standard sized oropharyngeal airways.
STANDARD 1.
Officer to understand and demonstrate the selection, sizing and insertion of an oropharyngeal airway as per Skill 305.
2.
Officer to wear PPE (eye protection, mask, gloves) as per Infection Control Policy.
3.
If patient shows any signs of rejecting the oropharyngeal airway at any time, remove it immediately.
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Skill 305 Oropharyngeal Airway Insertion 3 of 3
SKILL 306 LARYNGEAL MASK AIRWAY AMBU INTUBATION January 2011 Officer to wear PPE (eye protection, mask, gloves) as per Infection Control Policy. FIGURE 1
AMBU LMA
Preparation 1.
If CPR in progress do not stop compressions.
2.
Immobilize the patient’s head in the neutral position.
3.
Prepare LMA securing equipment (linen strip or adhesive dressing).
4.
Choose correct size LMA. Sizes 1–5 are available. LMA’s are sized to patients weight:
5.
Paediatrics Size 1 (neonate – infant)
up to 5kg.
Size 1.5 (infant)
5-10kg.
Size 2 (small child)
10-25kg.
Size 3 (child)
25-50kg.
Size 4 (adult)
50-70kg.
Size 5 (Large adult)
>70kg.
Test cuff (Figure1): Using a 20ml syringe attach to the mask inflation portal (Figure 2) inflate the mask with minimum amounts of air:
Size 1
up to 4 ml.
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Skill 306 Laryngeal Mask Airway Intubation (Ambu) 1 of 4
Size 1.5
up to 7ml (maximum).
Size 2
up to 10ml (maximum).
Size 3
up to 20ml (maximum).
Size 4 up to 30ml (maximum).
Size 5 up to 40ml (maximum). FIGURE 2
6.
Reattach syringe and deflate the mask.
7.
The mask should be fully deflated before use.
8.
Lubricate the posterior surface of the LMA with a water–soluble jelly.
9.
Remove oropharyngeal or nasopharyngeal airway.
LMA Insertion 1.
Align the centre line marked on the LMA tube with the centre of the patient’s lips, and open the mouth.
2.
Insert the mask into the oral cavity with the tip of the mask against the hard palate. Maintain pressure in this direction as you advance the mask into the airway.
3.
Ensure the mask is not rolling up. If this occurs, withdraw the LMA and start again.
4.
Attach the 20ml syringe (or 10mls in infants) and inflate using the minimum amount of air until an adequate seal is obtained. Do not excees the maximum pressure indicated. Ensure the indicator balloon remains inflated. Remove syringe.
5.
Should the indicator balloon leak after the LMA in situ, artery forceps may be applied onto the cuff inflation tube to stop the leak.
6.
Attach the flexible tube connector to the end of the LMA tube.
7.
Whilst stabilising the LMA, gently inflate the lungs to test for air entry and seal.
8.
Secure the LMA.
9.
Confirm LMA placement every time the patient is moved.
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Skill 306 Laryngeal Mask Airway Intubation (Ambu) 2 of 4
1.
Prior to the insertion of a Size 1 LMA in neonates/infants, due to the proportionally larger tongue in the infant, consider the use of the laryngoscope blade as a tongue depressor to assist with LMA insertion. The blade is only to be inserted to the anterior 1/3 of the tongue to prevent parasympathetic stimulation of the pharynx that can cause Bradycardia.
Extubation 1.
Extubate when:
A mask seal cannot be obtained.
LMA faulty.
Patient’s GCS increases and has an in tact gag reflex.
Patient regains conscious and attempts to remove LMA.
Passive regurgitation.
Procedure for extubation of the LMA 1.
Remove bite block.
2.
Remove securing tape.
3.
Deflate cuff.
4.
Should the patient be conscious the patient may be asked to take a deep breath and cough as the mask is removed or if unconscious remove the LMA gently and slowly at the beginning of exhalation.
Patient transfer: 1.
Whenever an intubated patient is moved, there is a serious risk of displacing the LMA.
2.
Before a patient is transferred the BVM should be disconnected from the LMA.
3.
The officer ventilating MUST ENSURE that the head and neck are supported as one unit, avoiding flexion or rotation, and avoiding traction on the LMA. Use of a cervical collar is NOT sufficient to prevent this. The ventilating paramedic should CONTROL the patient move; reattach the BVM and RE– CHECK air entry immediately after the move.
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Skill 306 Laryngeal Mask Airway Intubation (Ambu) 3 of 4
PERFORMANCE CRITERIA SKILL 306 LARYNGEAL MASK AIRWAY INTUBATION CONDITIONS Provide:
Suitable manikin and necessary equipment. Assistant.
STANDARDS 1.
To understand and demonstrate how to prepare and intubate using the LMA as per Skill 306.
2.
Aseptic techniques must be used.
3.
Officer to wear PPE (eye protection, mask, gloves) as per Infection Control Policy.
4.
Patient must be areflexic.
5.
An attempt should not take any longer than 10 seconds from the time of ceasing ventilation to restarting ventilation.
6.
Maximum of two attempts.
7.
During CPR:
During cardiac arrest management, LMA attempts should not interrupt chest compressions.
KEY POINTS 1.
Consider LMA if you suspect cervical spine injury to avoid neck extension.
2.
Watch for rolling up of the mask on insertion.
3.
Inflating the cuff to slightly stiffen the mask and / or extra lubricant on LMA prior to insertion may assist.
4.
Patient movement may dislodge the tube even if secured. It is ideal that the patient be on the stretcher before any attempts are made. This also improves accessibility.
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Skill 306 Laryngeal Mask Airway Intubation (Ambu) 4 of 4
SKILL 307 ENDOTRACHEAL INTUBATION January 2011 Officer to wear PPE as per Infection Control Policy. FIGURE 1
Preparation 1.
Assemble laryngoscope and check light is bright, white and steady.
2.
Select the Endotracheal tube (Figure 1).
3.
Attach a 10ml syringe and inflate the cuff to check for leaks (Figure 2). FIGURE 2
4.
Fully deflate the cuff.
5.
Lubricate the cuff of the tube with water–soluble gel if necessary.
6.
If a stylet is required, lubricate with water–soluble gel.
7.
When using a stylet, slide it down the ETT and bend the hook end over so that the stylet does not protrude from the cuffed end.
8.
The ETT can then be shape to enable ease of placement.
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Skill 307 Endotracheal Intubation Review date January 2016 1 of 7
Position patient 1.
Position the patient’s head in the neutral alignment. Warning: Head extension and flexion is not to be used for suspected cervical spine injury.
2.
Pre oxygenate patient.
Intubation 1.
Hold the Laryngoscope with the left hand (Figure 3). FIGURE 3
2.
Insert the laryngoscope into the right of the patient’s mouth, controlling the tongue by pushing the tongue to the left.
3.
Advance the blade placing the tip into the vallecula, identifying the epiglottis if possible before exposing the larynx.
4.
Maintaining the angle, lift the laryngoscope, in the direction of the handle, observing the epiglottis while lifting.
5.
Identify the arytenoid cartilages.
6.
Identify the vocal cords.
7.
If necessary, ask your partner to apply gentle external backward, upward, rightward laryngeal pressure to the external larynx, to assist view of the chords.
8.
Should the patient be aspirating stomach contents, apply cricoid pressure by using the thumb and index fingers externally onto the cricoid cartilage and press downward, compressing the oesophagus and preventing passive regurgitation (Sellicks manoeuvre).
9.
If required, ask your partner to gently pull the right side of the patient’s mouth up and out to create more room and improve vision.
10.
Hold the tube with your right hand and insert the tube from the right side of the patient’s mouth.
© Copyright St John Ambulance Australia (Western Australia) Inc.
Skill 307 Endotracheal Intubation Review date January 2016 2 of 7
11.
Slowly insert the tube between the vocal chords under direct vision. Stop after ensuring the cuff has completely passed the chords. Note and record the distance from the tip of the tube to the teeth.
12.
Remove the laryngoscope.
13.
Attach a 10ml syringe and inflate the cuff. As the cuff is inflated the indicator balloon will inflate. Do not over inflate, as the balloon and cuff will only take approximately 10-15mls of air. Ensure the indicator balloon remains inflated. Should the indicator balloon continue to leak after the tube is placed attempt reinflation. If reinflation is unsuccessful, replace the ETT with a new one, proceeding as per failed intubation drill.
14.
Remove the stylet.
Confirming tube placement 1.
To confirm the ETT is placed correctly, apply a tapered end 60ml syringe to the tube and withdraw the plunger quickly. If resistance is felt, the tube is likely to be in the oesophagus. If the plunger is drawn smoothly with no resistance then the tube is likely to be properly placed (WEE test). Tube placement should always be confirmed via other checks outlined below. Where Oesophageal intubation is confirmed, remove the ETT and proceed as per failed intubation drill.
2.
Connect the flexible tube connector (catheter mount) and BVM to the end of the tube. Simultaneously, whilst applying gentle pressure to the self–filling bag to inflate the lungs, look for equal rise of the chest and auscultate to confirm air entry.
3.
Note: auscultate over the stomach, then right and left axilla. Do not listen on the anterior chest as transmitted sounds from oesophageal intubation may be clearly heard at the front of the chest but will not be heard in the axilla.
3.
If no chest rise or easy rise and fall of the abdomen is observed then extubate the patient, ending the attempt. Ventilate at once with 100% oxygen.
4.
If rise and fall is noted only on the right side of the chest, or air entry is heard only on the right side, right mainstem bronchus intubation should be suspected. Slightly deflate the cuff, withdraw the ETT 1-2cm, reinflate and reassess. Continue until movement is seen and air entry is heard on both sides of the chest.
5.
The correct placement of the tube is the responsibility of the intubating officer. The tube placement is confirmed by at least two tests, usually, through viewing the passage of the tube through the cords and the WEE test, auscultation etc. The second test should be carried out by the assisting officer, making this a two–person check. Where practical each officer should carry out an alternative check at regular intervals, during transport and after transfer or patient movement / intervention.
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Skill 307 Endotracheal Intubation Review date January 2016 3 of 7
6.
Where patient care is handed over, tube placement is to be confirmed by both the intubating and receiving officers.
7.
The checks include:
Initial visual placement of the tube.
Use of the Wee test.
Observation of equal chest rise and fall.
Auscultation.
The use of a CO2 detector (the patient must have cardiac output).
Securing the tube 1.
Using either the linen tape or the adhesive tape, secure the tube in place.
2.
Place a bite block in place using the oropharyngeal airway.
3.
Stabilise the head / neck. Note: the neutral head position must be maintained even after tube placement.
4.
A CO2 detector should be connected between the tube and the self–filling bag with reservoir or ventilator.
Patient transfer: 1.
Whenever an intubated patient is moved, ETT placement must be rechecked.
2.
Before the transfer of the patient is made the self–filling bag with reservoir is to be detached from the ETT.
3.
The officer ventilating should CONTROL the patient move, ensuring that the head and neck are supported as one unit, avoiding flexion or rotation, and avoiding traction on the tube.
Endotracheal extubation 1.
Remove bite block.
2.
Remove securing tape.
3.
Deflate the cuff.
4.
Allow patient to cough the tube out if coughing / gagging.
5.
If patient doesn’t cough tube out, gently ventilate and remove
6.
Monitor patient.
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Skill 307 Endotracheal Intubation Review date January 2016 4 of 7
Failed Intubation Drill (Adult) If intubation is not successful the following ‘failed intubation drill’ must be followed: Unsuccessful ETT atempt
Insert OP Airway and ventilate with 100% Oxygen for at least 1 min.
Reattempt intubation 2nd attempt
Checks confirming tracheal placement WEE, ETCO2, auscultation
Yes
Continue management in accordance with relevant CPG
No Immediately remove ETT, insert OP or NP airway and ventilate with 100% Oxygen
Able to ventilate and oxygenate
Yes
No
Insert LMA
Continue management in accordance with relevant CPG
Cricothyrotomy
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Skill 307 Endotracheal Intubation Review date January 2016 5 of 7
CO2 Detectors 1.
A CO2 detector is required for patient transfer, where the patient is intubated via an ETT.
2.
The detector reads CO2 levels and provides a visual guide to the levels of CO2 being expelled by the patient.
3.
The device has two ends and a screen. The patient end has a 22mm tube fitting and a 15mm tube fitting at the circuit end self filling bag with reservoir or ventilator (Figure 4). FIGURE 4
4.
The device can monitor CO2 for up to 2 hours.
5.
It is recommended that after six full breaths, the detector colour should be evaluated at the end of a full expiration.
6.
The screen reads from purple on inspiration (low CO2), t to yellow for the presence of CO2 on expiration.
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Skill 307 Endotracheal Intubation Review date January 2016 6 of 7
PERFORMANCE CRITERIA SKILL 307 ENDOTRACHEAL INTUBATION CONDITIONS Provide:
Suitable manikin and necessary equipment.
Assistant.
STANDARDS 1.
To understand and demonstrate intubation as per skill 307.
2.
Officer to wear PPE (eye protection, mask, gloves) as per Infection Control Policy.
3.
Must use aseptic techniques.
4.
Ensure ETT is from an undamaged sealed package and check expiry date.
5.
No performance errors permitted.
6.
Must be able to identify landmarks.
7.
Only two attempts should be made.
8.
There must be at least 1 minute of ventilation between attempts of intubation.
9.
Self–filling bag and reservoir with 100% oxygen to be used at all times.
10.
The laryngoscope must not be levered back, as this may damage the patient’s teeth.
11.
The receiving medical officer must confirm ETT placement on patient handover.
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Skill 307 Endotracheal Intubation Review date January 2016 7 of 7
SKILL 308 ASSIST IN THE INTUBATION OF A PATIENT November 2010 1.
Intubation by either laryngeal mask or endotracheal tube is to be carried out by a Paramedic or a Medical Officer.
2.
Assisting Officer to locate and prepare equipment required from the Resuscitation and Intubation Kit as required.
3.
Supplementary equipment required:
Oxygen supply.
Accessory equipment.
Assisting Officer to operate equipment that they are authorised to use as per Clinical Practice Guidelines and Skills and assist when required.
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Skill 308 Assist in the Intubation of a Patient Review date November 2015 1 of 2
PERFORMANCE CRITERIA SKILL 308 ASSIST IN THE INTUBATION OF A PATIENT CONDITIONS Provide:
Intubation manikin.
Paramedic or Medical practitioner to intubate patient.
Resuscitation and Intubation Kit.
STANDARD 1.
Officer understand and demonstrate contents layout, of the Resuscitation and Intubation kit and assist a Paramedic or Doctor to perform procedure as per Skill 308.
2.
Intubation as per Skill 306 and 307.
3.
Ventilation of the patient via the endotracheal tube and Laryngeal mask must be by bag / mask system with supplementary oxygen.
To aspirate the patient 1.
2.
Disconnect the ETT at the patient valve and insert suction catheter down the tube (maintaining aseptic techniques), aspirate secretions, re–connect the patient valve.
Aspiration procedure should take no more than 5 seconds.
Ventilate the patient for a minimum of 2 minutes before further suction.
If the patient rejects the tube, ensure the airway and ventilation remain adequate.
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Skill 308 Assist in the Intubation of a Patient Review date November 2015 2 of 2
SKILL 309 AIRWAY OBSTRUCTION October 2007 Officer to wear PPE (eye protection, mask, gloves) as per Infection Control Policy.
CONSCIOUS Assess severity Is cough effective? Mild Airway Obstruction If effective cough. The patient should be given reassurance and encouraged to keep coughing to expel the foreign material. Severe Airway Obstruction If ineffective cough and conscious. 1.
Position patient so that gravity assists removal of foreign material (bending over or on side).
2.
Give up to 5 sharp back blows to try and dislodge obstruction. These should be given using an open hand aimed at the thoracic region between the shoulder blades, just left or right of the spine, at 90o to the surface of the body. Check to see if each back blow has relieved the airway obstruction.
Paediatrics An infant may be placed in a head downwards position prior to delivering back blows i.e. across lap. If still obstructed 1.
Give up to 5 chest thrusts. Check to see each chest thrust has relieved the airway obstruction. The aim is to relieve the obstruction with each chest thrust rather than give all five chest thrusts.
2.
To perform chest thrusts:
3.
Back support is required using a hard surface to push against ie wall or floor. The compression point is as for CPR. However the compressions are sharper and delivered at a slower rate. It is not likely a patient will still be in an upright position however back support can be given by a hand on the back depending on size of patient.
Infants: lay head down and supine down your arm which is placed down or across your thigh.
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Skill 309 Airway Obstruction 1 of 3
4.
If still obstructed continue alternating five back blows with five chest thrusts.
UNCONSCIOUS 1.
Start CPR :
Open airway.
Clear any visible obstruction, i.e. suction, finger sweeps.
If obstruction is lodged or not visible try ventilations to determine if there is a partial obstruction. If chest inflates treat carefully and continue ventilations. Air may be trickled past obstruction using a BVM.
If still obstructed start chest compressions. Chest compressions may be commenced and continued whilst attempts to clear the airway.
Transport urgently.
For paramedics: 1.
If obstruction is visible attempt to remove obstruction using, laryngoscope and Magill Forceps (Figure 1) as per Skill 310.
2.
Consider Cricothyrotomy urgently (Skill 311).
3.
Transport urgently. FIGURE 1 Magill Forceps
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Skill 309 Airway Obstruction 2 of 3
PERFORMANCE CRITERIA SKILL 309 AIRWAY OBSTRUCTION CONDITIONS Provide:
A suitable manikin. Oxygen source, therapy tube and mask, Adult Bag Valve Mask (BVM), demand head and resuscitator.
STANDARD 1.
To understand and demonstrate the correct procedure for the management of a total airway obstruction as per Skill 309.
2.
Officer to wear PPE (eye protection, mask, gloves) as per Infection Control Policy.
3.
Laryngoscope and Magill Forceps Skill 310 maybe used to remove an obstruction if authorised.
4.
Cricothyrotomy Skill 311 may be used if authorised.
KEY POINTS 1.
To achieve slow inflation of the lungs, use the BVM with high concentration oxygen. Backpressure on the self–filling bag with reservoir can indicate resistance caused by the obstruction. Watch chest for rise and fall.
2.
The demand head resuscitator can be used with intermittent pressure ventilation. Where flow regulator is fitted to a demand head, (Robert Shaw Demand Valve) it must be set at the minimum (CHILD) setting. In this way, 100% oxygen may be able to trickle past the obstruction. Note: higher pressures may worsen the blockage by forcing the obstruction hard up against the walls of the trachea. Caution: finger sweeps may cause a partial obstruction to become a total obstruction.
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Skill 309 Airway Obstruction 3 of 3
SKILL 310 LARYNGOSCOPE AND MAGILL FORCEPS October 2007 Officer to wear PPE (eye protection, mask, gloves) as per Infection Control Policy. Laryngoscope
Magill Forceps
Indications for use: Clearing suspected foreign body from the upper airway. Contraindications: 1.
Patient with adequate airway reflexes or gag reflex.
2.
Adequately breathing patient (SpO2 saturation greater than 90% and remaining conscious).
3.
Suspected epiglottitis.
4.
Obstruction below the vocal chords.
Complications: 1.
Further impaction of the obstruction.
2.
Hypoxia and hypercapnoea due to delay in ventilation and supplemented oxygen.
3.
Damage to lips teeth and dentures.
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Skill 310 Laryngoscope and Magill Forceps 1 of 5
Precaution: 1.
Damage to the upper respiratory tract such as the larynx, uvula, tonsils or soft palate.
2.
Caution is required if spinal damage is suspected.
Procedure for use of laryngoscope and Magill Forceps: 1.
Administer 100% O2 via a self–filling bag with reservoir.
2.
Check equipment is ready:
Laryngoscope.
Magill Forceps.
Self–filling bag and reservoir.
Suitable suction equipment.
Oxygen supply.
3.
Position the patient’s head in the ‘sniff the breeze’ position, aligning the pharynx, oropharynx and the larynx. This is done by lifting the head 8 to 10cm and supporting it with the towel / sheet etc. Then using the head extension, tilt the head backwards.
4.
Open the mouth using the cross finger technique and hold open.
5.
Suction airway if required.
6.
If the obstruction can be easily seen without the help of the laryngoscope, and the obstruction can be removed with the Magill forceps proceed to Step 12.
7.
Control the tongue by inserting the laryngoscope into the right of the patient’s mouth, pushing the tongue to the left as you do so. Ensure the lips are not caught between the instrument and the teeth. Be careful not to contact the obstruction with the laryngoscope or push it further down.
8.
Advance the blade to expose the obstructing material.
9.
Maintaining the angle, lift the laryngoscope, in the direction of the handle.
10.
If required, ask your partner to gently pull the right side of the mouth up and out to create more room and improve vision.
11.
Whilst holding this position pick up the Magill Forceps with the right hand, keeping the forceps in the closed position (to avoid damage to the airway).
12.
Insert the Magill Forceps so that the tips of the forceps are clearly visible at all times. Be careful not to push on the obstruction.
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Skill 310 Laryngoscope and Magill Forceps 2 of 5
13.
Open wide enough to obtain a good purchase on the foreign body, and grip with a scissor like action to secure the material that is obstructing the airway. Remove Magill Forceps with a gentle side to side movement to help dislodge the obstruction.
14.
If successful assist patient with oxygenation and reassurance. Caution—A hypoxic patient may become aggressive.
If you see an obstruction but cannot remove it: 1.
Do not waste time trying to remove the obstruction, remove the laryngoscope and the Magill forceps.
2.
Gently squeeze air into the lungs using 100% O2 with the self–filling bag and reservoir where partial airway obstruction exists.
3.
Continue procedures as per Total Airway Obstruction Skill 309 and if necessary Cricothyrotomy Skill 311.
4.
Transport urgently to hospital.
If the patient develops laryngeal spasm: 1.
Remove the laryngoscope and Magill forceps.
2.
Gently squeeze air into the lungs using 100% O2 using a self–filling bag and reservoir.
3.
Eventually laryngeal spasm will subside and allow ventilation.
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Skill 310 Laryngoscope and Magill Forceps 3 of 5
PERFORMANCE CRITERIA SKILL 310 LARYNGOSCOPE AND MAGILL FORCEPS CONDITIONS Provide:
A suitable manikin with simulated upper airway obstruction.
Laryngoscope and Magill Forceps.
An assistant.
Suction equipment.
Self–filling bag with reservoir.
Oxygen supply.
Pulse Oximeter for SpO2 monitoring.
STANDARDS 1.
To understand and demonstrate the use of the Laryngoscope and the Magill Forceps for airway obstruction as per Skill 310.
2.
Officer to wear PPE (eye protection, mask, gloves) as per Infection Control Policy.
3.
Contraindications:
Patient with adequate airway reflexes or gag reflex.
Adequate breathing patient.
Suspected epiglottitis.
Obstruction below the vocal chords.
4.
Patient must be suspected of having an airway obstruction due to foreign body.
5.
Patient to be either in severe respiratory distress or non–breathing to use the laryngoscope and Magill Forceps.
6.
If obstruction is easily seen it may be removable with the Magill Forceps without the use of the laryngoscope. If a patient is still conscious, the laryngoscope may be placed onto the anterior two thirds of the tongue without stimulating a gag reflex.
7.
Administer 100% oxygen via self–filling bag with reservoir and attach SpO2 monitor if partial obstruction and adequate breathing.
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Skill 310 Laryngoscope and Magill Forceps 4 of 5
8.
If the Laryngoscope and Magill Forceps are contra indicated and the obstruction only causes a partial airway obstruction and it cannot be removed, gently squeeze air into the lungs using 100% O2 via the self–filling bag with reservoir and transport urgently. BEWARE OF WORSENING THE OBSTRUCTION.
9.
This Skill may be used with Skill 309 Total Airway Obstruction Skill 311 Cricothyrotomy, Clinical Practice Guidelines Respiratory 3.1 Dyspnoea and Respiratory Distress and 3.5 Advanced Airway Management. Caution: Laryngeal spasm may occur.
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Skill 310 Laryngoscope and Magill Forceps 5 of 5
SKILL 311 CRICOTHYROTOMY October 2010 Officer to wear PPE (eye protection, mask, gloves) as per Infection Control Policy. Indications − −
Complete airway obstruction in patients older than six years of age that cannot be cleared by suction or manual methods. Failed intubation – As a last resort to secure an airway in a severely compromised patient that can not be ventilated via any other means.
Procedure 1.
Select a disposable scalpel.
2.
Prepare a suitable device to be inserted into the incision e.g. ETT size 5.5 endotracheal tube.
3.
Extend the patient’s head, tightening the neck.
4.
Locate cricothyroid membrane:
Stabilise the larynx between your thumb and middle finger.
Place the forefinger on the median ridge of the thyroid cartilage.
Slide finger firmly down the thyroid cartilage, palpating for the cricothyroid membrane (felt as a depression).
Swab the site with an alcohol swab. Hold this position, while keeping the patient's head extended.
Use the forefinger of the stabilising hand to identify your landmark.
5.
Make an incision in the skin and cricothyroid membrane transversely in the midline until airflow is heard or felt, or to a maximum depth of approximately 1cm and a width of 2cm’s.
6.
Open the orifice by using forceps or by rotating the scalpel hand 900 after the blade is retracted.
7.
Insert the ETT until the cuff is just inside the trachea, inflate the cuff and manage as per skill 307.
8.
Remove forceps taking care not to damage the ETT cuff or tubing. Dispose of used scalpel into a sharps container.
9.
Connect self-filling bag-valve-mask using flexible connector, and assist ventilations. Confirm air entry via auscultation.
10.
Release head extension and larynx. Secure the tube in place.
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Skill 311 Cricothyrotomy Review date October 2015 1 of 3
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Skill 311 Cricothyrotomy Review date October 2015 2 of 3
PERFORMANCE CRITERIA SKILL 311 CRICOTHYROTOMY CONDITIONS Provide:
A simulated patient lying down or suitable manikin.
Resuscitation, Intubation kit and scalpel.
Portable Oxygen equipment.
STANDARDS 1.
To understand and demonstrate how to locate the cricothyroid membrane and state how to perform a Cricothyrotomy as per Skill 311.
2.
Officer to wear PPE (eye protection, mask, gloves) as per Infection Control Policy.
3.
Not to be attempted on children less than six years of age.
4.
No performance errors permitted.
5.
A 5.5 ETT with cuff may be used to secure an airway. Manage the ETT as per Skill 307.
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Skill 311 Cricothyrotomy Review date October 2015 3 of 3
SKILL 312 NASOPHARYNGEAL AIRWAY INSERTION (NPA) August 2008 Officer to wear PPE (eye protection, mask, gloves) as per Infection Control Policy. A soft malleable curved plastic airway that is inserted into the nasopharynx. The airway is bevelled at one end (tip), with a flange at the other end. 1.
Ensure patient’s airway is open and clear. If required use jaw thrust or chin lift.
2.
Pay particular attention to ensure patient’s nostrils are clear of obstruction and that there is no significant trauma to the nose or mid–face.
3.
Select correct size of nasopharyngeal airway (Figure 1) by placing the nasopharyngeal airway along the patient’s face so that it measures from the corner of the nose to the end ear lobe. The following is a guide to nasopharyngeal airway size selection:
Large adult
size 8 or 9.
Medium adult size 7 or 8.
Small adult
size 6 or 7. FIGURE 1
4.
Lubricate the bevel (tip) end of the nasopharyngeal airway using water– soluble gel (Figure 2). Ensure sufficient lubrication is applied to aid insertion and advancement of the nasopharyngeal airway.
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Skill 312 Nasopharyngeal Airway Insertion 1 of 4
FIGURE 2
5.
If required push gently up on the tip of the patient’s nose (Figure 3).
FIGURE 3
6.
Select the nostril with the widest opening (usually right nostril).
7.
Hold the nasopharyngeal airway at the flange end, then with the bevelled opening facing toward the septum, gently insert.
8.
With a slight twisting action slowly advance the nasopharyngeal airway (Figure 4) along the floor of the nostril (i.e. straight back or perpendicular to the face, not upwards) following the natural curvature of the nasal passage until the flange rests on the patient’s nostril.
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Skill 312 Nasopharyngeal Airway Insertion 2 of 4
FIGURE 4
9.
Do not push the nasopharyngeal airway if obstruction is met. Remove and try the other nostril.
10.
If the patient shows rejection of the airway, withdraw it slightly as it maybe stimulating the posterior nasopharynx, if this fails remove the nasopharyngeal airway.
11.
If too long the laryngeal reflexes may be stimulated causing vomiting and / or it may pass into the oesophagus and cause gastric distension when ventilating. If the nasopharyngeal airway is too short it will not extend pass the tongue and will fail to assist with airway patency.
Suction If required, the officer can suction down the nasopharyngeal airway using a suitably sized flexible ‘Y’ suction catheter. Maintenance Monitor the position of the nasopharyngeal airway in patients with large nasal openings as the nasopharyngeal airway may slip further into the airway. In this case the nasopharyngeal airway may need to be secured with tape or removed.
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Skill 312 Nasopharyngeal Airway Insertion 3 of 4
PERFORMANCE CRITERIA SKILL 312 NASOPHARYNGEAL AIRWAY INSERTION CONDITIONS Provide:
Intubation Manikin
Four sized nasopharyngeal airways (6, 7, 8, and 9).
Lubricant, PPE.
STANDARD 1.
Officer to understand and demonstrate nasopharyngeal airway insertion as per Skill 312. Only one nasopharyngeal airway to be inserted (not bilateral).
2.
Officer to wear PPE (eye protection, mask, gloves) as per Infection Control Policy.
3.
May be used to establish an airway for an unconscious patient and patients with an altered conscious state who have an intact gag reflex such as:
4.
5.
Patients who are having a seizure.
Patients with clenched jaw or trismus.
Suspected CVA / stroke patients with difficulty maintaining their own airway due to loss of swallowing capability.
Suspected overdose / alcohol intoxicated patients needing airway management.
Not to be used in the following circumstances:
Patients with suspected fractured base of skull.
Patients with significant nasal or mid–face trauma.
Precaution in the following circumstances:
Pregnant women in their 3rd trimester (highly vascular nasal passages and therefore more prone to epistaxis).
Patients prone to nasal bleeding (epistaxis).
6.
Remove the airway if patient rejects it.
7.
If obstruction is felt during insertion, try other nostril.
8.
A nasopharyngeal airway should be used when an oropharyngeal airway (OPA) is contra–indicated or difficult to insert such as from oral injury.
KEY POINTS Rough handling when inserting the nasopharyngeal airway and the failure to lubricate the nasopharyngeal airway may cause nasal trauma such as epistaxis. © Copyright St John Ambulance Australia (Western Australia) Inc.
Skill 312 Nasopharyngeal Airway Insertion 4 of 4
SKILL 501 GENERAL PERFORMANCE CRITERIA FOR DEFIBRILLATORS October 2008 1.
Follow defibrillation guidelines as Clinical Practice Guidelines and according to each unit in the skill sheets.
2.
When using an automated external defibrillator (AED) follow audio and visual prompts. This unit is capable of analysing rhythms without officer intervention.
3.
See attached diagram (Figure 1) for placement of electrodes and defibrillation pads.
4.
In the absence of Paediatric pads Adult multifunction electrodes may be placed front and back for use on infants and small children. Pads marked sternum to the front central chest and apex to the back opposite each other (the central point of the apex pad should be placed little to the left of the spine).
5.
For patients who have a lot of body hair, ensure good adhesion, pads may be placed under the armpit or adjacent hairless area or clip hair with scissors.
6.
A precordial thump should only be administered if the patient arrests whilst attached to or close to a monitor defibrillator.
7.
Observe patient privacy and dignity at all times, especially on placement of electrodes.
8.
Post event reports should be produced and attached to Patient Care Record forms (Hospital and St John Ambulance copy).
9.
Ensure correct time and date is displayed.
10.
Report faults immediately for service.
11.
Do not disassemble the device.
12.
The manual Medical Control Module (MCM) must only be used by authorised personnel (i.e. Doctors, Ambulance Paramedics).
Precautions 1.
Warning loose pads may cause skin burning or arcing. CPR may cause pads to loosen, reattach as required.
2.
Wherever possible, avoid use in a wet environment.
3.
Beware of direct contact with metal (e.g. jewellery, chairs etc).
4.
Ensure no one is in contact with the patient during defibrillation.
5.
Ensure chest is clean and dry before attaching multifunction electrodes.
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Skill 501 General Performance Criteria For Defibrillators 1 of 2
6.
Do not re–use electrodes or use electrodes from packages that have been opened for an extended period prior to use.
7.
The use of radio transmitters directly next to the Heartstart 911 is not recommended as the device may exhibit sensitivity to radio frequency signals. The reverse may also apply.
Contraindications 1.
Do not discharge in a moving vehicle.
2.
Do not use device in presence of flammable vapours or in environments in which an electrical spark could ignite an explosion.
3.
Do not defibrillate over medication patches (e.g. GTN) or pacemaker site. Remove GTN patches.
4.
Do not start ECG analysis until vehicle is brought to a halt and patient area is cleared.
5.
Do not discharge with the electrodes electrically shorted together or left unattached and open. FIGURE 1 RECOMMENDED SITES FOR ELECTRODE PLACEMENT
Defibrillation on a wet or metal surface It is safe to defibrillate a patient on either a wet or metal surface or in a rainy environment as long as the appropriate safety precautions are taken. Specifically care should be taken to ensure that no one is touching the patient when the shock button is pressed.
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Skill 501 General Performance Criteria For Defibrillators 2 of 2
SKILL 502 ZOLL 1400 MONITOR DEFIBRILLATOR CHECKING October 2007
Checking unit 1.
Ensure the monitor / defibrillator contains the following:
1 monitor / defibrillator unit.
1 monitor cable.
1 Multi–Function cable.
1 packet of multi–function electrodes (in sealed packet - within expiry date).
1 accessory bag for unit.
6 monitoring electrodes (minimum).
1 set of paddles.
1 packet of defibrillator Gel pads.
Roll ECG paper.
2.
Verify unit turns on when rotary switch is turned to ‘MONITOR ON’. The word ‘READY’ should be briefly displayed on the screen followed by ‘MONITOR’. ECG size should be 1 X. ‘PADDLES’ or ‘ELECTRODES’ should also be displayed. A four beep tone indicates the power up self–test is complete.
3.
Verify recorder operates by pressing the ‘RECORDER ON–OFF’ button. A strip will run until this button is pressed again.
4.
Check recorder strip speed is correct by generating a series of calibration pulses by pressing and holding the up and down arrow buttons next to the ‘ALARM SET’ button. The strip should show a new calibration pulse approximately every 13 small divisions (1.3cm) and they should be 10+/-1mm high.
5.
Check the correct date and time is recorded on the strip.
6.
Check the defibrillator energy output by turning the rotary switch to ‘DEFIB ON’. Connect the test port to the electrode connector on the Multi–Function Leads. Set energy level to 100 joules.
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Skill 502 Check the Zoll 1400 Checking 1 of 3
When charged, simultaneously press the two red buttons on the Multi– Function lead plug. Verify ‘TEST OK’ is displayed on the monitor. 7.
This test can also be performed on the paddles when they are plugged into the unit. Ensure the paddles are pushed fully into their storage recess and use the discharge buttons on the paddles.
8.
Check that there is sufficient paper in the recorder.
Changing the battery 1.
The battery is located at the back of the unit on the top.
2.
To remove the battery, press tab (next to ‘Lift Here to Release’) on the battery, lift it up and slide out of battery recess.
3.
To insert a charged battery, slide it into recess with the ‘Lift Here to Release’ tab up and on the left side. Press down on battery until it locks into place.
Changing paper 1.
The printer is located on the top of the unit, at the back, left side.
2.
Open the printer door by pressing the release button on the front left corner and lift the door and carrier.
3.
Remove the paper core.
4.
Place the new paper roll between the tabs of the paper holder with the paper coming off the top of the roll—sensitive side down.
5.
Pull enough paper off the roll so that the paper extends out of the recorder when the door is closed.
6.
Close the door.
Set the time and date 1.
Turn the unit off.
2.
While depressing the ‘ALARM SET’ button, turn the rotary switch to ‘MONITOR ON’.
3.
Use the up and down arrow buttons to adjust the selected field (flashing).
4.
Step to the next field by pressing the ‘ALARM SET’ button and adjust as necessary.
5.
After stepping through all the fields, pressing the ‘ALARM SET’ button will exit the clock / date adjustment mode.
6.
Verify that the time / date is correct by running a strip from the recorder.
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Skill 502 Check the Zoll 1400 Checking 2 of 3
PERFORMANCE CRITERIA SKILL 502 ZOLL 1400 MONITOR / DEFIBRILLATOR CHECKING CONDITIONS Provide:
A complete Zoll 1400 Monitor / Defibrillator.
STANDARD 1.
Officer to understand and demonstrate how to check a Zoll 1400 Monitor defibrillator as per Skill 502.
KEY POINTS 1.
Immediately replace battery with a fully charged battery when the ‘LOW BATTERY’ message is displayed.
2.
Batteries should be changed at the start of each shift.
3.
Instructions for battery maintenance system must be followed to ensure serviceability of batteries.
4.
Ensure Multi–Function electrode pads are stored flat. Rolling or folding destroys electrode and renders pad useless and potentially dangerous.
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Skill 502 Check the Zoll 1400 Checking 3 of 3
SKILL 503 ZOLL 1400 MONITORING AND RECORDING October 2007
Monitoring 1.
Connect monitoring electrodes to cable.
2.
Place the three monitoring electrodes or the Multi–Function Electrode pads on the patient (as per diagram in General Performance Criteria, Skill 501).
3.
Turn the rotary switch to ‘MONITOR ON’.
4.
Select lead II using the lead button.
5.
Observe the rhythm.
Recording 1.
A strip showing the current rhythm on the screen is obtained by pressing the ‘RECORDER ON–OFF’ button. The recording will continue until the button is pressed a second time.
2.
To record an event other than defibrillation the recorder button needs to be pressed so that a summary will be available.
3.
There is a delay of six (6) seconds between what is shown on the screen and what is printed at the print head.
4.
A summary report is obtained by pressing the ‘SUMMARY’ button on the top of the unit.
5.
Where changes to the rhythm occur that need to be recorded on the summary, the recorder need only be activated for a short period of time.
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Skill 503 Zoll 1400 Monitoring and Recording 1 of 3
Volume The volume of the systole beeper can be changed using the ‘VOLUME’ button on the top of the unit (the heart rate alarm and charge ready volumes are not altered). Alarm set 1.
The heart rate alarm is set by pressing the ‘ALARM SET’ button on the top of the unit. The low rate is set first (automatically set to 30 BPM). To adjust, use the up and down arrow buttons until the desired rate is set.
2.
To adjust the high rate, press the ‘ALARM SET’ button again. Adjust the rate with the up and down arrow buttons. Press the ‘ALARM SET’ button to exit the setting mode.
3.
To activate the alarm, press the ‘ALARM ON–OFF’ button on the front panel next to the screen.
4.
If an alarm condition occurs, cancel the alarm by pressing the ‘ALARM ON– OFF’ button.
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Skill 503 Zoll 1400 Monitoring and Recording 2 of 3
PERFORMANCE CRITERIA SKILL 503 ZOLL 1400 MONITORING AND RECORDING CONDITIONS Provide:
Patient, defibrillation manikin and rhythm simulator.
Zoll 1400 complete.
Evaluator may require other functions of the Zoll 1400 (as per this skill) to be demonstrated.
Evaluator to operate rhythm simulator as required.
STANDARD 1.
Officer to understand and demonstrate the monitoring and recording of the Zoll 1400 as per Skill 503.
2.
Use only approved, single use, self–adhesive monitor / multi–function electrodes (within expiry date).
3.
Ensure chest is clean and dry before attaching electrodes to the patient.
KEY POINTS 1.
Ask the patient to remain still while recording an ECG strip to improve its quality and reduce chance of artifact.
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Skill 503 Zoll 1400 Monitoring and Recording 3 of 3
SKILL 504 ZOLL 1400 DEFIBRILLATION October 2007
Joules settings: Newborn
15.
Infant
50.
Small child
100.
Large child
200.
Adult
360.
1.
Determine if patient is unconscious, pulseless.
2.
Commence CPR.
3.
Prepare defibrillator / monitor. Decide to use either paddles or multifunction electrodes.
4.
Expose the chest.
5.
Attach monitor electrodes cable and / or multifunction electrodes if required to patient as per General Performance Criteria, Skill 501.
6.
Switch unit on to DEFIB ON. Press the lead button until the word ELECTRODES appears on the screen. Monitoring is now via the multifunction electrodes.
7.
Select correct joule setting if required. Note: the unit defaults to 200J for the first shock and cannot be re set to suit ARC guidelines. Press the up or down arrow on the energy select buttons either on the unit or on the sternum paddle until the desired joule setting is displayed.
8.
Press the red charge up button. A buzzer sounds when the unit is charged.
9.
Caution:
In order to disarm a charged defibrillator.
turn rotary switch to MONITOR or change the defibrillator energy setting or.
If using paddles, place them in their recessed holders.
Stop CPR / Check rhythm and confirm with partner.
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Skill 504 Zoll 1400 Defibrillation 1 of 4
10.
If Asystole decide as per Cardiac Arrest 4.6. Confirm Asystole in alternative leads 1 and 3. Caution: the unit does not warn of asystole.
11.
Check clear / call ‘STAND CLEAR’ the reply should be after checking clear ‘ALL CLEAR’. Caution: Before discharging the shock button check rhythm has not changed on the screen.
12.
State: DEFIBRILLATING NOW Press the red shock button on the unit to deliver a shock. If using paddles hold them in the same position on the chest, press discharge buttons on paddle.
13.
The unit records decisions if advisory is used.
14.
Immediately after delivering a shock continue CPR for 2 minutes even if there is a change of rhythm. Only stop if the change in rhythm is accompanied with signs of life. Follow Skills Manual, CPR skills.
15.
Charge defibrillator when stopping for status check.
16.
Status check every 2 minutes following 2 minutes of CPR.
17.
Give further shocks if indicated either:
Single shock regime for unwitnessed arrest.
3 stacked shocks for arrest witnessed by a paramedic with a manual defibrillator (continued by single shock regime thereafter).
18.
Do not stop CPR / Compressions for more 10 seconds to analyse a rhythm.
19.
ALS skills to be carried out by Paramedic as required during CPR cycles.
20.
If battery needs to be replaced switch the unit off first.
If Using Paddles for Defibrillation 1.
Use defibrillation gel pads between paddles and chest. Place as per diagram in General Performance Criteria, Skill 501.
2.
The paddles have the following control buttons on them which may be used in place of the buttons on the unit:
3.
The Sternum paddle:
Recorder On–Off.
Energy select (adjust the joules).
Discharge button.
The Apex paddle: Charge button.
Discharge button.
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Skill 504 Zoll 1400 Defibrillation 2 of 4
4.
Press paddles firmly to chest when delivering a shock. The discharge button on each paddle must be pressed simultaneously.
5.
The paddles should be held on the chest in the same place for a stacked shock regimen (i.e. arrest witnessed by paramedic). The control of the unit should be by the buttons on the paddles.
6.
Use monitor electrodes and select Lead II using the LEAD button to monitor the rhythm of the patient.
© Copyright St John Ambulance Australia (Western Australia) Inc.
Skill 504 Zoll 1400 Defibrillation 3 of 4
PERFORMANCE CRITERIA SKILL 504 PARAMEDIC ZOLL 1400 DEFIBRILLATION CONDITIONS Provide:
Defibrillation manikin and rhythm simulator.
ZOLL 1400 (complete).
Assistant.
STANDARDS 1.
Officer to be able to demonstrate and understand the use of the ZOLL 1400 as per Skill 504.
2.
Give shock if indicated as per CPG 4.6 Cardiac Arrest.
3.
Joules settings: Newborn Infant Small child Large child Adult
15. 50. 100. 200. 360.
4.
Use only approved single use, multifunction electrodes within expiry date.
5.
Ensure chest is clean and dry before attaching multifunction electrodes.
6.
Place multifunction electrodes or paddles as per Skill 501.
7.
Defibrillation / CPR as per Clinical Practice Guidelines 4.6 Cardiac Arrest and Skills manual.
8.
Do not stop CPR / Compressions for more 10 seconds to analyse a rhythm. Continue compression during charge up times where possible.
9.
In order to disarm the defibrillator:
10.
Turn rotary switch to MONITOR; or
Change the defibrillator energy setting; or
If using paddles, place them in their recessed holders.
Should there be a change in rhythm after defibrillation continue until CPR phase is complete, then recheck via status check. Only stop CPR if rhythm change is accompanied with signs of life (Return of spontaneous Circulation —ROSC).
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Skill 504 Zoll 1400 Defibrillation 4 of 4
SKILL 505 ZOLL M SERIES AED BIPHASIC MANUAL DEFIBRILLATION November 2008
Officer A
Officer B
Joule settings: New born
15.
Infant
50.
Small Child
100.
Large child
150.
Adult
200.
2.
Prepare defibrillator / monitor. Decide to use either paddles or multifunction electrodes.
3.
Exposes the chest.
4.
Attach monitor electrodes cable and multifunction electrodes if required to patient as per General Performance Criteria, Skill 501.
5.
Switch unit on to ON.
6.
Either leave unit in AED Mode and operate as per Skill 515 or press the soft key far left with the display marked Manual mode.
7.
A display marked Confirm will appear on the far right of the screen. Press the soft key underneath. The unit is now in Manual mode.
8.
Instruct CPR to cease.
10. Confirm the monitor is displaying a shockable rhythm.
1.
Determines if patient is unconscious, pulseless and not breathing and commences CPR.
9.
Cease CPR and stand clear of the patient.
11. Restart CPR after analyzing rhythm.
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Skill 505 Zoll M Series AED Biphasic Manual Defibrillation 1 of 3
12. Select correct joule setting. The unit defaults to 200J. Press the up or down arrow on the energy select buttons until the desired joule setting is displayed. 13. Press the CHARGE button. A light buzzer will sound until the unit is fully charged. The unit will emit a loud buzzer sound, the shock button illuminates and on screen display will prompt DEF 200J READY when fully charged. 14. State: STAND CLEAR
15. Stop CPR confirm all clear state: ALL CLEAR
16. State: DEFIBRILLATING NOW Press the Red shock button on the unit to deliver a shock. 17. ADVISORY : The Analyse button may be activated at anytime if the officer wishes to let the unit run in auto mode.
NOTE : Advisory function messages ECG TOO SMALL, ECG TOO LARGE may appear, the unit will automatically adjust the ECG gain and restart analyzing a 9 sec segment. SELECT DEFIB MODE will appear if the unit is not in the defib mode. The unit records decisions if advisory is used. Caution: The unit does not warn of asystole.
18. Perform CPR for 2 minutes, then continue defibrillation / CPR as per Clinical Practice Guidelines.
© Copyright St John Ambulance Australia (Western Australia) Inc.
The presence of true asystole should be confirmed in two leads (Lead I and II or Lead II and III). This can be achieved by using paddles or monitor leads. The unit will need to be switched into the mode required.
Skill 505 Zoll M Series AED Biphasic Manual Defibrillation 2 of 3
PERFORMANCE CRITERIA SKILL 505 ZOLL M SERIES AED BIPHASIC MANUAL DEFIBRILLATION CONDITIONS Provide:
Defibrillation manikin and rhythm simulator.
ZOLL M Series AED Biphasic with accessories.
Assistant.
STANDARDS 1.
Officer to understand and demonstrate the Zoll M Series Semi–AED Biphasic Defibrillator using Manual Defibrillation as per Skill 505.
2.
Joule settings for defibrillation:
Newborn
15J.
Infant
50J.
Small Child
Large Child
150J.
Adult
200J.
100J.
3.
Use only approved single use, multifunction electrodes within expiry date.
4.
Place multifunction electrodes as per skill 501.
5.
Defibrillations / CPR as per clinical Practice Guidelines.
6.
If any of the defibrillations are successful at converting the rhythm to a non– shockable rhythm, stop defibrillation and support the patient as required to treat the presenting problem (e.g. continue CPR, support ventilation etc).
7.
Recommence the Clinical Practice Guideline ONLY if, after Return of Spontaneous Circulation (ROSC), the patient again reverts to a non–perfusing shockable rhythm.
8.
In order to disarm a charged defibrillator, turn rotary switch to MONITOR or change the defibrillator energy setting. Warning: Do not touch the patient until the charge is either delivered or dumped internally.
9.
If the battery needs to be replaced switch the unit off first.
KEYPOINTS 1.
Ensure chest is clean and dry before attaching multifunction electrodes.
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Skill 505 Zoll M Series AED Biphasic Manual Defibrillation 3 of 3
SKILL 506 ZOLL M SERIES BIPHASIC MANUAL CHECKING November 2003
Checking 1.
Ensure the monitor / defibrillator contains the following:
1 monitor / defibrillator unit.
1 monitor cable.
1 multi–function cable.
1 packet of multi function electrode pads (MFE).
6 monitoring electrodes (minimum).
2 batteries.
1 spare packet of ECG paper.
1 carry case with accessory bag.
Manual defibrillator testing
Power up sequence check. 1.
Start with the selector switch OFF and the MFE tester disconnected from the cable. Turn the selector to the ‘MONITOR’ position and observe the following.
A 4–beep tone indicates the power–up self–test has been successfully completed.
The ECG size should x 1.5 and the word ‘MONITOR’ should be displayed.
‘PADDLES’ or ‘PADS’ should be displayed in the top right of the screen.
The message ‘CHECK PADS’ ‘POOR PAD CONTACT’ will be displayed alternatively with continuous dashed line.
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Skill 506 Zoll M Series Biphasic Manual Checking 1 of 6
2.
Connect the tester to the MFE cable and the display will read ‘DEFIB PAD SHORT’ with a solid line.
Paddle set–up 1.
Check paddles are locked into their holders and MFE cable attached to Apex paddle.
2.
Turn selector to DEFIB.
3.
Press the ENERGY SELECT button and by pressing on the arrows set the defibrillator energy to 30 joules.
4.
Using the CHARGE button on the Apex paddle, press and wait for the charge ready tone and display ‘DEFIB 30J READY’.
5.
Using the ENERGY SELECT buttons on either the unit or the sternum paddle change the joules to 20J. The unit will disarm.
Multi–function cable set–up 1.
The multi–function cable should be plugged into the unit. Make sure the Multi function Cable is not plugged into its test connector.
2.
Switch the unit to DEFIB and set energy level to 30J.
3.
The message ‘CHECK PADS’ ‘POOR PAD CONTACT ‘ will display alternatively.
4.
Plug the MFE cable into the test connector.
5.
‘DEFIB PAD SHORT’ will be displayed.
Energy delivery test (both paddles and MFE pads). 1.
Press the CHARGE button on the front panel or on the apex paddle handle.
2.
Wait for charge ready tone and screen message ‘DEFIB 30J READY’.
3.
The paddles may be connected to the Multifunction lead. If paddles are installed, using your thumbs, simultaneously press and firmly hold the SHOCK buttons on each paddle until discharge occurs.
4.
If MFE test connectors are attached to the MFE cable press and hold the SHOCK button on the unit until discharge occurs.
5.
The strip recorder will print a short strip indicating ‘TEST OK’ and energy delivered (30 Joules). Note: During energy delivery test the unit will only discharge when the level is set at 30 Joules.
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Skill 506 Zoll M Series Biphasic Manual Checking 2 of 6
6.
If ‘TEST FAILED’ appears seek further advice.
Recorder Check 1.
Check adequate supply of paper.
2.
Press the RECORDER button. The strip will run until the recorder button is pressed again.
3.
Press and hold the SIZE button for at least 2 sec, to generate a calibration pulse. The amplitude of the calibration pulse is 1mv independent of the size setting.
4.
Check strip recorder speed by verifying that the calibration pulse is 2.5mm wide (allow ½ mm for error) and 10 mm high (allow 1mm for error).
5.
Inspect for waveform uniformity and darkness and uniformity of annotation characters and completeness of words.
6.
To check and load paper press down on the drawer printed with ‘Release’ and pull out. To close, push in and downward until flush.
Setting time and date 1.
Turn unit off for at least 10 seconds.
2.
While pressing ‘SOFT KEY’ at lower right of screen and holding it down, turn the unit on. Continue to hold down the ‘SOFT KEY’ until the time date screen appears.
3.
Using the ‘SOFT KEYS’ as indicated by the onscreen menu highlight and change values as required.
4.
Press ‘ENTER and RETURN’ to accept changes and return to the monitoring screen. Note: time and date may need to be set if the unit has been without a charged battery for more than 12 hours.
5.
Press the ‘Enter and Return’ soft key to set all values and return to normal monitoring.
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Skill 506 Zoll M Series Biphasic Manual Checking 3 of 6
Changing the battery 1.
A LOW BATTERY message will be displayed on the monitor and a two–beep low battery tone will sound once a minute whenever the unit detects a low battery condition. Replace the battery immediately to ensure continuous operation.
2.
This message and beeping will persist until just before the unit shuts down when a REPLACE BATTERY message appears.
3.
Ensure the unit is turned OFF prior to removing the battery from the unit.
4.
The battery is located in the top of the unit under the carry handle.
5.
To remove the battery, lower the carry handle. Press the release tab on the left hand end of the battery and pull the battery upwards out of the unit.
6.
To replace the battery insert the right hand end of the battery (opposite the LIFT HERE TO REPLACE tab) into the right hand end of the battery well first. Then push the battery downwards until it clicks into place.
7.
Rotate and change the batteries at the beginning of each shift.
Beeper volume 1.
Press button with a speaker picture located on the left front of the unit.
2.
A 5 level bar appears with the word ‘VOLUME’ above two soft keys with controls to Inc (increase) and Dec (decrease) the volume to off. Voice prompts cannot be turned off.
Brightness / contrast adjustment 1.
Press button next to the volume control marked as a moon with top half white, bottom half black.
2.
A 6 level bar appears with the word ‘CONTRAST’ above two soft keys with controls to Inc (increase) and Dec (decrease) the contrast / brightness.
Alarms 1.
Some alarms may be suspended for 90 seconds by pressing the ALARM SUSPEND button for 3 sec.
2.
A bell shape will be seen in the top right of the screen. When the button is pressed an X will be placed over the bell. To reset the alarm press the ALARM SUSPEND button again.
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Skill 506 Zoll M Series Biphasic Manual Checking 4 of 6
3.
If a second alarm sounds during suspension then press the ALARM SUSPEND again and a separate time out is started.
4.
A computer contained within the unit performs self–diagnostic tests whenever the unit is initially turned on and periodically during operation. During operation a function ‘FAULT XX’ message will be displayed if a fault is detected. If this occurs turn off the unit and on again, if fault still exists report fault.
Cleaning 1.
Approved cleaning solutions:
90% Isopropyl alcohol (except adapters and patient cable).
Soap and water.
Chlorine bleach (30ml/l water).
Use only a damp soft cloth with above.
Changing paper 1.
Press down and pull the PAPER COMPARTMENT drawer where the RELEASE label is located. The draw will slide open.
2.
Check for adequate paper supply. Replace supply if low.
3.
Place a new pad of thermal paper in the drawer with the paper coming off the top of the pad and grid facing up.
4.
Pull enough paper off the pad so that the paper extends out of the strip recorder when the compartment is closed.
5.
Close the compartment drawer by pushing the drawer in and pressing lightly where the RELEASE label is located until the drawer is flush with the front of the unit.
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Skill 506 Zoll M Series Biphasic Manual Checking 5 of 6
PERFORMANCE CRITERIA SKILL 506 ZOLL M SERIES BIPHASIC MANUAL CHECKING CONDITIONS Provide:
Zoll M Series AED Manual Biphasic Monitor Defibrillator and accessories.
STANDARDS 1.
No performance errors permitted.
2.
Officer to understand and demonstrate the checking of the Zoll M Series AED Biphasic Manual as per Skill 506.
3.
Perform testing on the unit operation and defibrillation.
4.
Change time and date.
5.
Replace paper and check recorder.
6.
Replace battery.
KEY POINTS Further tests may be performed using a ZOLL simulator and the ZOLL Operators guide. These are unnecessary for daily use.
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Skill 506 Zoll M Series Biphasic Manual Checking 6 of 6
SKILL 507 ZOLL M SERIES BIPHASIC MANUAL MONITORING AND RECORDING November 2003
Monitoring 1.
Connect monitor cable to socket located at the back of the unit.
2.
Connect ECG electrodes to ECG cable.
3.
Place the three monitor electrodes or multi–function electrodes on the patient (as per diagram in General Performance Criteria, Skill 501).
4.
Ask the patient to remain still whilst recording an ECG strip to improve its quality.
5.
Monitor through the MFE pads if patient condition is serious or deteriorating.
6.
Monitoring is also possible through the paddles. Connect the MFE lead into the Apex paddle.
7.
Turn the unit to ‘MONITOR’ position.
8.
Press the LEAD button until lead two is displayed (11) under the lead display.
9.
If ‘ECG LEAD OFF’, ‘CHECK PADS’ or ‘POOR PADS’ message appears on the screen check electrodes MFE pads.
10.
Press the SIZE button until x 1.0 appears under size top right corner.
11.
A heart rate and a flashing heart symbol also appears next to the x1.0.
12.
A ‘MONITOR’ message with the rhythm above is also displayed.
13.
This unit is capable of detecting implanted pacemaker spikes shown on the ECG as A thin solid line. Warning pacemakers may cause heart rate meter to count during incidents of arrhythmias or cardiac arrest. Remember to check the pulse.
14.
The monitor screen displays 4 second segments of ECG rhythm.
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Skill 507 Zoll M Series AED Biphasic Manual Monitoring and Recording 1 of 3
15.
A fully charged battery provides for 2.5 hrs of monitoring and less if defibrillation or the recorder is used.
Recording 1.
A rhythm strip can be obtained by pressing the ‘RECORDER’ button. The strip recorder normally operates in the delay mode of 6 seconds to ensure capture of critical ECG information. To stop the strip recording, press the button again.
2.
A Summary report may be started at any time by pressing ‘SUMMARY’ followed by the soft key under the ‘PRINT CHART’ message.
3.
The Summary report will automatically record events:
VF alarm triggered.
Defibrillator shock.
Heart rate alarm triggered.
Turning strip recorder on (or on and then off in rapid sequence).
Initiating analysis of the ECG.
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Skill 507 Zoll M Series AED Biphasic Manual Monitoring and Recording 2 of 3
PERFORMANCE CRITERIA SKILL 507 ZOLL M SERIES BIPHASIC MANUAL MONITORING AND RECORDING CONDITIONS 1.
Provide:
Patient / Manikin and rhythm simulator provided.
Zoll M Series Manual Biphasic provided.
STANDARDS 1.
Officer to understand and demonstrate the Zoll M Series Manual Monitor Defibrillator as per Skill 507.
2.
Use only approved, disposable, Multifunction Electrodes to the patient that are within expiry date.
3.
Ensure chest is clean and dry before attaching electrodes to patient. (Good contact must be achieved).
4.
Officer to demonstrate effective monitoring and problem solving techniques.
5.
Officer to be able to operate printer and follow audible and displayed messages.
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Skill 507 Zoll M Series AED Biphasic Manual Monitoring and Recording 3 of 3
SKILL 508 ZOLL M SERIES BIPHASIC MANUAL DEFIBRILLATION WITH ADVISORY October 2007
Joule settings: Newborn
15.
Infant up to 1yr
50.
Small child
100.
Large child
150.
Adult
200.
1.
Determine if patient is unconscious and pulseless.
2.
Commences CPR.
3.
Prepare defibrillator / monitor. Decide to use either paddles or multifunction electrodes.
4.
Exposes the chest.
5.
Attach monitor electrodes cable and multifunction electrodes if required to patient as per General Performance Criteria, Skill 501.
6.
Switch unit on to 1 Defib. SELECT DEFIB MODE will appear if the unit is not in the defib mode.
7.
Select correct joule setting. The unit defaults to 200J. If required press the up or down arrow on the energy select buttons until the desired joule setting is displayed.
8.
Press the CHARGE button. A light continuous buzzer will sound when the unit is charging followed by a louder sound, the shock button illumiates and flashes with the display on screen prompting DEB 200J READY. Caution: In order to disarm a charged defibrillator, turn rotary switch to MONITOR or change the defibrillator energy setting or, if using paddles, place them in their recessed holders.
9.
Stop CPR / Check rhythm and confirm rhythm is still shockable with partner.
10.
Call ‘STAND CLEAR’ and check all clear. The other officer should reply after checking clear ‘ALL CLEAR’.
© Copyright St John Ambulance Australia (Western Australia) Inc.
Skill 508 ZOLL M AED Biphasic Manual Defibrillation with Advisory 1 of 4
11.
State: DEFIBRILLATING NOW. Press the shock button (3) on the unit to deliver a shock. If using paddles hold them in the same position on the chest, press discharge buttons on paddle. Caution: Before discharging the shock button check rhythm has not changed on the screen.
12.
Immediately after delivering a shock continue CPR for 2 minutes even if there is a change of rhythm. Only stop if the change in rhythm is accompanied with signs of life. Follow Skills Manual CPR skills.
Advisory Mode 1.
The Analyse button may be activated at any time if the Officer is in doubt. The unit will then convert into AED mode with the normal functions as per Skill 508. Note: Advisory function messages ECG TOO SMALL, ECG TOO LARGE may appear, the unit will automatically adjust the ECG gain and restart analysing a 9 sec segment.
2.
The unit records decisions if advisory is used.
If Using Paddles for Defibrillation 1.
Use defibrillation gel pads between paddles and chest. Place as per diagram in General Performance Criteria, Skill 501.
2.
The paddles have the following control buttons on them which may be used in place of the buttons on the unit: The Sternum paddle: Recorder On–Off.
Energy select (adjust the joules).
Discharge button.
The Apex paddle.
Charge button.
Discharge button.
3.
Press paddles firmly to chest when delivering a shock. The discharge button on each paddle must be pressed simultaneously.
4.
The paddles should be held on the chest in the same place for a stacked shock regimen (i.e. arrest witnessed by paramedic). The control of the unit should be by the buttons on the paddles.
5.
Use monitor electrodes and select Lead II using the LEAD button to monitor the rhythm of the patient.
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Skill 508 ZOLL M AED Biphasic Manual Defibrillation with Advisory 2 of 4
PERFORMANCE CRITERIA SKILL 508 ZOLL M SERIES BIPHASIC MANUAL DEFIBRILLATION WITH ADVISORY CONDITIONS Provide:
Defibrillation manikin and rhythm simulator.
ZOLL M Series Manual Biphasic Defibrillator with accessories.
Assistant.
STANDARDS 1.
Officer to understand and demonstrate the Zoll M Series Manual Biphasic Defibrillator as per Skill 508.
2.
Joule settings: Newborn Infant up to 1 yr Small child Large child Adult
15. 50. 100. 150. 200.
3.
Use only approved single use, multifunction electrodes within expiry date.
4.
Place multifunction electrodes as per Skill 501.
5.
Defibrillation / CPR as per Clinical Practice Guidelines Cardiac Arrest 4.6 and Skills manual.
6.
Do not stop CPR / Compressions for more 10 seconds to analyse a rhythm. Continue compression during charge up times where possible.
7.
Should there be a change in rhythm after defibrillation continue until CPR phase is complete, then recheck via status check. Only stop CPR if rhythm change is accompanied with signs of life (ROSC).
8.
If Asystole decide as per Cardiac Arrest 4.6. Confirm Asystole in alternative leads 1 and 3. Caution: the unit does not warn of asystole.
9.
Give further shocks if indicated either:
Single shock regime for unwitnessed arrest.
3 stacked shocks for arrest witnessed by paramedic with manual defibrillator (continued by single shock regime thereafter).
10.
Status check every 2 minutes following 2 minutes of CPR.
11.
ALS skills may be carried out by Senior Officer as required during CPR cycles.
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Skill 508 ZOLL M AED Biphasic Manual Defibrillation with Advisory 3 of 4
KEYPOINTS 1.
Ensure chest is clean and dry before attaching multifunction electrodes.
2.
If battery needs to be replaced switch the unit off first.
© Copyright St John Ambulance Australia (Western Australia) Inc.
Skill 508 ZOLL M AED Biphasic Manual Defibrillation with Advisory 4 of 4
SKILL 509 HEARTSTART 4000 AED BIPHASIC DEFIBRILLATION March 2002
OFFICER A
OFFICER B
Joule settings: default only, 150 joules.
1.
Determines if patient is unconscious, pulseless and not breathing. Commence CPR.
6.
Cease CPR and stand clear of the patient
2.
Prepare defibrillator / monitor. Connect multifunction electrodes to cable.
3.
Expose the chest.
4.
Attach multifunction electrodes to patient as per General Performance Criteria, Skill 501.
5.
Instruct CPR to cease
7.
Press ON switch until a continuous beep is heard followed by three short beeps. AED is now on.
8.
Auto analysing begins. Screen display and audio prompt begins.
9.
Press analyse ANALYZING – DO NOT TOUCH PATIENT.
10. If a shockable rhythm is detected the screen display and audio prompt begins SHOCK ADVISED The unit will automatically begin charging to 150 joules. 11. An intermittent charge tone is heard. Once charging is complete the charge tone becomes continuous. Voice prompt STAND CLEAR, PRESS SHOCK. 12. State: STAND CLEAR. © Copyright St John Ambulance Australia (Western Australia) Inc.
Skill 509 Heartstart 4000 AED Biphasic Defibrillation 1 of 3
13. Confirm all clear state: ALL CLEAR. 14. State:’ ALL CLEAR DEFIBRILLATING NOW.’ Press the SHOCK button. 15. Visual display and audio message SHOCK DELIVERED is heard. 16. If no signs of life recommence CPR. Press pause (button 1). Pause button will automatically time unit out for 2 minutes (Time counter located bottom centre of screen). 17. After 2 minutes unit will automatically give audio and visual prompts CHECK PATIENT IF NO PULSE PRESS ANALYSE (button 2). (Do not check pulse unless there are signs of life). 18. If signs of life check patient and pulse. Continue defibrillation / CPR as per Clinical Practice Guidelines.
© Copyright St John Ambulance Australia (Western Australia) Inc.
Skill 509 Heartstart 4000 AED Biphasic Defibrillation 2 of 3
PERFORMANCE CRITERIA SKILL 509 HEARTSTART 4000 AED BIPHASIC DEFIBRILLATION CONDITIONS Provide:
Defibrillation manikin and rhythm simulator.
Heartstart 4000 AED Biphasic Defibrillator and accessories.
Assistant.
STANDARDS 1.
Officer to understand and demonstrate the Heartstart 4000 AED Biphasic Defibrillator as per skill 509.
2.
Joule settings default 150 joules.
3.
Use only approved single use, multifunction electrodes within expiry date.
4.
Place multifunction electrodes as per skill 501.
5.
Ensure chest is clean and dry before attaching multifunction electrodes.
6.
Do not use defibrillator on a patient under 8 years 25 kgs.
7.
Defibrillation / CPR as per Clinical Practice Guidelines. Warning: Do not touch patient until charge is either delivered or dumped internally.
8.
Voice prompt and visual display SHOCK CANCELLED, then CHECK PATIENT, IF NO PULSE PRESS ANALYZE. Press, ANALYZE button.
9.
For any attempted Defibrillation; a Summary or Print strip of the events must be attached to the Patient Care Record form and forwarded to the Medical Director for analysis.
10. If any of the defibrillations are successful at converting the rhythm to a non– shockable rhythm, stop defibrillation and support the patient as required to treat the presenting problem (e.g. continue CPR, support ventilation etc). 11. Recommence the Clinical Practice Guideline ONLY if, after Return of Spontaneous Circulation (ROSC), the patient again reverts to a non–perfusing shockable rhythm.
© Copyright St John Ambulance Australia (Western Australia) Inc.
Skill 509 Heartstart 4000 AED Biphasic Defibrillation 3 of 3
SKILL 510 HEARTSTART 4000 AED BIPHASIC MONITORING HAEMOGLOBIN O2 SATURATION SPO2 November 2001
Preparation SpO2 monitoring Connecting and disconnecting the SpO2 cable to the monitor 1.
Hold the connector with the flat side up.
2.
Insert the connector into the receptacle and push until the blue portion of the connector is no longer visible.
3.
To disconnect, gently pull the cable out.
Attaching the transducer to the patient 1.
Select the most appropriate finger size for the transducer.
2.
Model no M1191A is for adults weighing more than 50kg (reusable).
3.
Ensure that the light source is directed from above onto the fingernail.
4.
Push the transducer over the fingertip in such away that the fingertip touches but does not protrude from the end of the transducer.
5.
The cable should lie on the back of the hand. It may be held in place by the accompanying wristband.
Operation of the SpO2 monitor 1.
In the AED mode, SpO2 monitoring is only available if the SpO2 is conFigured to on, check this at the start up menu. The SpO2 function may be used separately, in conjunction with normal ECG monitoring and defibrillation, or pressed off.
2.
Connect the SpO2 lead to Heartstart 4000 and patient.
3.
Press the on button.
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Skill 510 Heartstart 4000 AED Biphasic Monitoring Haemoglobin O2 Saturation (SpO2) 1 of 4
4.
The screen will now display the SpO2 sign in the top right corner. The Heartstart must be on lead two configuration if only monitoring SpO2, as the alarm will sound and a repeated audible advice will be heard reminding to connect the pads. The ECG monitoring lead 11 will only display a warning, ‘leads not connected’ allowing monitoring the SpO2 without disruption.
5.
Press the button immediately above the SpO2 sign. This will engage the monitoring function.
6.
In a few seconds the SpO2 value is displayed in the place of the dashed line. As the Patient’s oxygen saturation changes, the value in percentage is updated continuously.
7.
On the right of the SpO2 value, a pleth bar and SpO2 alarm indicator are displayed. The pleth bar measures a pulse in the finger and is displayed by the pleth bar as it increases and decreases in size.
8.
The pleth bar should be observed for fluctuation. Under the display of the pleth bar is the pulse rate detected by the SpO2 monitor. The pleth bar and pulse rate should not be used as the sole indicator of pulsation because movement and artifact can influence it.
9.
The alarm symbol with a white diagonal indicates that no alarm has been set.
10. The SpO2button controls function, off, low alarm settings 90, 85, and 80% and alarm off. When alarm is set, a total blacked out alarm sign will be displayed. 11. Should a preset low alarm sound, the screen will also show an inverse video, (white writing on black background) press alarm off and reset if necessary. 12. When SpO2 is off nothing appears below the SpO2 soft key. 13. Alarm and Marked events will record SpO2 monitoring.
© Copyright St John Ambulance Australia (Western Australia) Inc.
Skill 510 Heartstart 4000 AED Biphasic Monitoring Haemoglobin O2 Saturation (SpO2) 2 of 4
PERFORMANCE CRITERIA SKILL 510 HEARTSTART 4000 AED BIPHASIC MONITORING HAEMOGLOBIN O2 SATURATION (SPO2) CONDITIONS Provide:
Assistant.
Heartstart 4000 AED Biphasic Monitor Defibrillator and accessories.
Patient sitting or lying.
STANDARDS 1.
Officer to Understand and demonstrate the Heartstart 4000 AED Biphasic SpO2 as per Skill 510.
2.
Operator to respond correctly to voice prompts and alarms.
3.
Operator to be able to problem solve sensor errors.
4.
Officer to identify low Oxygen saturation level and increase if possible.
KEY POINTS 1.
Make sure sensor is dry.
2.
If patient is moving, secure the sensor cable loosely to the patient.
3.
Avoid excessive pressure at the sensor site; ensure that circulation is not obstructed.
4.
Keep power cable away from sensor cable and connection.
5.
Avoid placing the sensor on any extremity with an arterial catheter, blood pressure cuff, or intravascular venous infusion line.
6.
INOP alerts: Triggered by disconnected sensor, noisy signal, light interference or low signal. (non pulsatile) An audible alarm is heard followed by flashing display––stating problem with SpO2.
7.
Failure to apply sensor correctly may reduce accuracy of SpO2 measurement. Check, sensor application regularly, skin quality and correct optical alignment. If skin quality is compromised, change sensor site.
8.
Event summary will include ECG or SpO2 Alarm: 3 seconds prior to the alarm, plus 8 seconds after the alarm (11 seconds).
9.
Active SpO2 and heart alarms are suspended during the ‘pause’ duration.
© Copyright St John Ambulance Australia (Western Australia) Inc.
Skill 510 Heartstart 4000 AED Biphasic Monitoring Haemoglobin O2 Saturation (SpO2) 3 of 4
10. Care and cleaning;
Clean the transducer in a mild detergent solution, salt solution (1%) or as per cleaning agents listed in the Heartstart 4000 manual.
Rinse the transducer in water. Wipe it with a dry cloth and leave to dry.
Do not autoclave the transducer; or use bleaches containing sodium hypochlorite.
Warning: High SpO2 saturation levels do not indicate sufficient oxygen to deprived cells affected by CVA, MI or to any injured tissue. The level is measured in the finger only. Oxygen must remain at high flow and up to 100%.
© Copyright St John Ambulance Australia (Western Australia) Inc.
Skill 510 Heartstart 4000 AED Biphasic Monitoring Haemoglobin O2 Saturation (SpO2) 4 of 4
SKILL 511 HEARTSTART FR2 / FR2 PLUS CHECKING MONITORING November 2007
Contents 1.
2.
Ensure unit is complete:
1 x Carry case with shoulder harness.
1 x Defibrillator.
2 x M3863A disposable batteries with 5 years battery life. Check expiry date inscribed (one to be installed and the other spare).
2 x External defibrillator pads (DP1). Check expiry date.
1 x Data card M3864A (only if supplied)
Optional with FR2 Plus:
Monitor leads.
Monitor electrodes.
Battery charger M3849A. To suit only rechargeable batteries.
Power cord.
Description of the FR2 / FR2 Plus 1.
The FR2 and the FR2 plus are basically the same unit except the FR2 Plus can monitor patients ECG rhythm. Rechargeable batteries with charger are needed with the monitoring function because of the continual use of the battery.
2.
The unit operation is biphasic and delivers 150 joules with each shock.
3.
Top left corner defibrillator pads connector port with indicator light.
4.
Centre top a green button marked 1 is the on / off button.
5.
Next to the number 2 is the screen display which gives visual display of all voice prompts, a clock, timer and the number shocks delivered. The FR2 plus also displays an ECG rhythm during monitoring and analysis.
© Copyright St John Ambulance Australia (Western Australia) Inc.
Skill 511 Heartstart FR 2/FR2 Plus Checking Monitoring 1 of 7
6.
Centre bottom next to the number 3 is the orange shock button marked with a lightning strike. This when illuminated and flashing is fully charged ready for shock delivery.
7.
The two blue buttons on the right of the unit are for changing the volume control and the setting.
8.
On the right side of the unit is a blue tag, which is the external part of the data cardholder.
9.
Next to the data card port is a window with a special lens, or eye used to transfer data directly to or from another device.
10. At the top right corner is the status window. 11. Bottom left is the speaker.
Installing the battery 1.
Before installing the battery, make sure the defibrillation pads are not connected to the FR2 / FR2 Plus.
2.
Check the expiry date shown on the disposable battery or use a rechargeable battery. Rechargeable batteries should be used if the monitor function is used with the FR2 plus.
3.
Hold the battery pack by the latch end and slide it into the battery compartment at the top of the unit.
4.
Slide the battery all the way into the opening, until the latch clicks into place.
5.
When the battery is installed, the unit automatically turns on. The status indicator displays a flashing black hourglass. The shock button light and the indicator light for the defibrillator pads connector port turn on briefly.
6.
Disposable battery (M3863A) standby life is approximately. 5 yrs with capacity of 300 shocks or 12 hours operating time.
7.
Rechargeable batteries have a capacity of 80-100 shocks or 3 to 5hrs of ECG monitoring. Charge time 3 hrs.
Running the battery insertion self–test 1.
The self–test has two parts, first is to test circuitry and memory. The second part is interactive and requires the operator to respond to voice prompts in order to make sure display, buttons, light, speaker and beeper are working.
2.
The self–test displays a screen message self–test and an indicator bar.
3.
When the auto test is complete a message that the unit passed is displayed and the interactive test will begin.
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Skill 511 Heartstart FR 2/FR2 Plus Checking Monitoring 2 of 7
4.
If the pads are connected to the unit and the patient the self–test will stop and the unit will be in standby mode ready for use. To use, turn on the on / off button.
5.
When the self–test is complete the unit auto turns off. To use, turn on the on / off button.
6.
Make sure the unit has not been in use for at least 5 minutes, and that the defibrillation pads are not connected to the unit.
7.
Insert the battery into the battery port. The screen will display RUN SELF–TEST highlighted.
8.
Press the upper blue option button to activate the test, or make no selection for 10 seconds, and the self–test will start automatically.
9.
In addition to the battery insertion self–test the unit automatically performs periodic self–tests. These daily, weekly and extensive monthly self–tests check circuitry and battery capacity.
10. If the battery power is low replace the battery. If a previous self–test has failed, the screen message displays that the unit must pass a self–test before use. 11.
If a flashing red X is displayed or the Low battery prompt is heard or displayed on the screen, the battery can still be used, until it is fully used up. A spare battery should be with each unit.
12. Once a battery has been installed do not remove unless low battery prompts. 13. Report any fault that the unit displays that cannot be rectified.
Status indicator and problem solving 1.
A flashing black hourglass indicates the unit passed the battery insertion self– test or the last automatic periodic self–test and is ready for use. This flashing continues for the life of the inserted battery providing no problems are detected.
2.
If the unit has a flashing Red X. Turn the unit on and follow the voice and visual display on the screen.
3.
If an error is displayed:
Remove pads if connected and remove and install battery.
Run the battery insertion self test. If the unit passes the Red X will change to a flashing hourglass.
If the unit fails, turn off the unit and install a new battery. Follow voice prompts.
4.
If a Solid Red X appears in the indicator window the unit may not be used.
5.
Try correcting the problem as per No. 3. If the unit still does not clear, do not use the unit. Report fault.
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Skill 511 Heartstart FR 2/FR2 Plus Checking Monitoring 3 of 7
6.
Should a flashing Red X appear and an audio chirping sound is heard, faults could include; low battery, the unit has been stored outside recommended temperature range, an error has been detected as part of the self–test or the unit cannot perform daily self–tests.
7.
Try correcting problem as per No. 3.
8.
If the unit has been physically damaged a chirping audio signal is heard.
9.
Try correcting the problem as per No. 3.
10. Also check for visual damage, do not use if the unit appears damaged. 11. When screen and voice prompts are heard follow the prompts.
Monitoring 1.
The patient may only have their ECG rhythm monitored with the FR2 plus.
2.
Turn the unit on (1).
3.
Connect the monitor leads to the unit. The plug can only be fitted one way and fits into the defibrillator port. Follow voice prompts. Attach leads.
4.
Connect the monitor electrodes to the leads.
5.
Remove backing from each electrode and place the electrodes with leads attached as per Defibrillation Performance Guidelines Skill 501.
6.
The monitor screen will now display the ECG, heart rate (bottom right) and time in minutes and seconds from start of monitoring (left bottom).
Warnings 1.
The Defibrillator pads will also monitor the patient’s ECG. This should be commenced immediately to analyse in case defibrillation is required. The vehicle must be stopped. Patient must be unconscious, pulseless and non– breathing. Vehicle or patient movement can cause artefact that may be interpreted during the analysis and may give a false indication for defibrillation.
2.
The FR2 plus can monitor the ECG via monitoring leads. During monitoring the unit will advise if an analysis is required or if artefact is affecting the unit. The FR2 Plus can distinguish the differences from artefact and the patient’s rhythm.
3.
Any analysis of the ECG must be via the defibrillation leads as per Skill. If the patient has a palpable pulse, is breathing and a warning prompt is heard and seen on the screen, then stop the vehicle and reassess the warning being given. Only use the monitor function when rechargeable batteries are used.
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Skill 511 Heartstart FR 2/FR2 Plus Checking Monitoring 4 of 7
Data card 1.
The Data card M3854A can be used to store several hours of incident data including attempted defibrillation and ECG.
2.
The data card must be installed before the unit is turned on.
3.
Make sure the data card is clean and dry.
4.
Load the data card into its plastic tray, with the tray’s ‘tongue’ fitting over the matching yellow area on the data card. The label on the card should face up. The label has an arrow indicating which side to insert into the data card port.
5.
Hold the tray by its handle and gently insert the tray into the data card port on the right side of the Heartstart FR2. Push the tray all the way into the port. Do not force the tray into the port. If it is hard to insert remove and make sure to card is the correct way up.
6.
The data card will now automatically record incident data the next time the unit is turned on. It is recommended that only one incident be collected per data card.
7.
After an incident or attempted defibrillation the card should be sent to the Medical Director for analysis (see Transport Circulars). Caution: to remove the card the unit must be turned off, prior to removing the card to ensure the incident data is not lost.
8.
Remove the tray by pulling on the external tab.
9.
Remove the data card from the tray by lifting the back edge slightly, then pull the card from the tray.
10. Even if no card is available or to replace the one used, the card tray must be replaced into the unit to ensure moisture or dirt cannot enter the port. The unit will function without a card. 11. The FR 2 also has internal memory that will record the incident, however this is replaced by the next new incident.
Maintenance
The unit conducts many self–tests, requires no calibration and has no user serviceable parts.
The outside can be cleaned with a soft cloth dampened in one of several appropriate cleaning agents:
Isopropyl alcohol (70% in water).
Soapy water.
Chlorine bleach (3% in water).
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Skill 511 Heartstart FR 2/FR2 Plus Checking Monitoring 5 of 7
Ammonia based cleaners.
Hydrogen peroxide.
Caution: do not immerse any portion of the FR2 into fluids or allow fluids to spill onto the unit.
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Skill 511 Heartstart FR 2/FR2 Plus Checking Monitoring 6 of 7
PERFORMANCE CRITERIA SKILL 511 HEATRSTSTART FR2 / FR2 PLUS CHECKING CONDITIONS Provide:
Heartstart FR2 / FR2Plus with all road accessories.
STANDARDS 1.
Officer to understand and demonstrate the checking of the Heartstart FR2 / FR2 Plus as per Skill 511.
KEYPOINTS 1.
A battery should always be installed into an operation unit.
2.
All on road accessories to be included with the unit.
3.
Ensure unit is dry before use.
© Copyright St John Ambulance Australia (Western Australia) Inc.
Skill 511 Heartstart FR 2/FR2 Plus Checking Monitoring 7 of 7
SKILL 512 HEARTSTART FR2 / FR2 PLUS DEFIBRILLATION October 2008
1.
CPR must be started immediately as per CPR skills.
2.
If possible continue CPR whilst AED is setup.
3.
Expose the chest.
4.
Remove electrodes from unit. Open electrode packaging by tearing at top of packet using the notches provided.
5.
Attach Electrodes to bare chest as per Skill 501.
6.
Plug the electrodes into unit. Note: If the pads are not connected the unit will prompt APPLY PADS TO PATIENT’S BARE CHEST. PLUG IN PAD CONNECTOR NEXT TO THE FLASHING LIGHT.
7.
Stop CPR
8.
Turn unit on by pressing the marked on / off button No.1 and follow voice prompts.
9.
The unit will immediately advise: ANALYSING HEART RHYTHM, DO NOT TOUCH THE PATIENT
10. The unit will auto analyse. 11. If a shock is advised the unit will prompt:
SHOCK ADVISED
CHARGING
STAY CLEAR OF PATIENT
DELIVER SHOCK NOW. The number 3 shock button illuminates and flashes. A continuous buzzing sound will sound until the shock is delivered or internally dumped (after 30 seconds).
PRESS THE ORANGE BUTTON NOW.
Caution: Do not press the shock button until operator complies with the stay clear commands. 12. Officer operating the defibrillator must state ‘STAND CLEAR’. © Copyright St John Ambulance Australia (Western Australia) Inc.
Skill 512 Heartstart FR2 / FR2 Plus Defibrillation 1 of 4
13. The assisting Officer must reply ‘ALL CLEAR’ after confirming no one is in contact with the patient. 14. Confirm ‘ALL CLEAR’. 15. State ‘ALL CLEAR DEFIBRILLATING NOW’ press SHOCK BUTTON. Note: if the shock button is not pressed the unit will prompt: DELIVER SHOCK NOW, PRESS THE ORANGE BUTTON NOW (repeats this 3 times).
SHOCK BUTTON NOT PRESSED PAUSED, IF NO SIGNS OF CIRCULATION START CPR.
16. CPR should be carried out for two minutes (if no signs of life) between each shock. (The unit is programmed to a ‘silent’ time out for the two minutes). 17. After two minutes the unit will again repeat process from point 7. 18. If the unit after analysing does not recommend a shock it will prompt NO SHOCK ADVISED. If no signs of life continue CPR. 19. Do not stop CPR for any longer than 10 seconds. 20. Do two minutes of CPR between shocks. 21. Transport urgent and advise receiving hospital as soon as possible. If PTV, crew must call for back up paramedic unit to assist or follow advise as per communications centre. Note: PTV’s cannot be driven under priority one conditions. 22. Do not check pulse unless there are signs of life. Continue defibrillation / CPR as per Clinical Practice Guidelines.
Patient collapse during ECG monitoring 1.
If a patient has a shockable rhythm during ECG monitoring the unit will advise CHECK AIRWAY, CHECK BREATHING CHECK PULSE—IF NEEDED ATTACH DEFIBRILLATION PADS.
2.
Operators need to confirm no signs of life and start CPR, attach the Multi function electrodes.
3.
The unit will then analyse and start defibrillation process as before, follow prompts.
© Copyright St John Ambulance Australia (Western Australia) Inc.
Skill 512 Heartstart FR2 / FR2 Plus Defibrillation 2 of 4
Operation information 1.
Danger: There is a possibility of explosion if used near flammable anaesthetics or concentrated oxygen and in the presence of flammable substances / air mixtures.
2.
The Heartstart FR2 / FR2Plus will hold the defibrillation charge for 30 seconds from the ‘Press the orange button now’ prompt prior to dumping the charge internally.
3.
‘Apply pads, Press pads firmly, Plug in connector, Insert connector firmly, Press pads firmly to patients bare chest, ‘Poor pad contact or Replace pads’ are all prompts that require immediate action to rectify before the unit can proceed. Dry or damaged pads should be replaced.
4.
‘Analysing interrupted, Cannot analyse’ (repeated twice then converts to) ‘Stop all motion’ are heard if the unit is having problems with analysing. It is recommended that 15 seconds be allowed for the unit to have time to analyse.
5.
In addition, stopping CPR, ceasing patient movement, restricting operator or bystander movement (to reduce the generation of static electricity particularly in dry environments) and switching off radio and mobile phones may help.
6.
With hirsute patients, try placing the pad on the left upper chest position, just under the armpit onto the chest, where there is normally less hair. For the right chest position try further around onto the side of the chest.
7.
This unit will not detect a pacemaker.
8.
Avoid placing the pads so that they can touch and avoid placing the pads poorly as air pockets can cause skin burns. Avoid pad contact with GTN patches other leads or electrodes.
© Copyright St John Ambulance Australia (Western Australia) Inc.
Skill 512 Heartstart FR2 / FR2 Plus Defibrillation 3 of 4
PERFORMANCE CRITERIA SKILL 512 HEARTSTART FR2 / FR2 PLUS DEFIBRILLATION CONDITIONS Provide:
Suitable manikin and rhythm simulator is provided.
Heartstart FR2 / FR2 plus (complete).
Assistant.
STANDARDS 1.
Officer to understand and demonstrate defibrillation using the Heartstart FR2 / FR2 plus as per Skill 512.
2.
Joule setting: Default only, Adult 150 J, Child 50 J.
3.
Patient to be unconscious, non–breathing, pulseless.
4.
Do not stop CPR for any longer than 10 seconds. Do one minute of CPR between stops.
5.
Use only approved single use multi function electrodes DP1 pads within expiry date.
6.
Place multifunction electrodes as per skill 501.
7.
Ensure chest is clean and dry before attaching multifunction electrodes.
8.
Defibrillation / CPR as per Clinical Practice Guidelines.
9.
Check battery self–test and ensure batteries are not expired. Warning: Do not touch the patient until the charge is either delivered or dumped internally.
10. If any of the defibrillations are successful at converting the rhythm to a non– shockable rhythm, stop defibrillation and support the patient as required to treat the presenting problem (e.g. continue CPR, support ventilation etc). 11. Recommence the Clinical Practice Guideline ONLY if, after Return of Spontaneous Circulation (ROSC), the patient again reverts to a non–perfusing shockable rhythm. 12. For any incident of attempted defibrillation, the Data card if supplied and Patient Care Record form is to be reviewed by the Medical Director. (See Transport Circulars and follow Operational procedures).
© Copyright St John Ambulance Australia (Western Australia) Inc.
Skill 512 Heartstart FR2 / FR2 Plus Defibrillation 4 of 4
SKILL 513 ZOLL M SERIES AED BIPHASIC MONITOR DEFIBRILLATOR CHECKING November 2003
1.
Ensure unit is complete:
1 monitor / defibrillator unit.
1 monitor cable.
1 multifunction cable with defibrillator tester.
1 packet of multi function electrodes.
1 packet of monitoring electrodes.
1 battery in unit.
1 battery spare in vehicle.
1 accessory bag.
1 shoulder harness.
1 pad fan fold paper in unit.
Power–up sequence check 1.
Connect the patient end of the multifunction cable to the defibrillator test connector.
2.
Start with the selector switch ‘OFF’, turn the selector switch to the ‘ON’ position and observe the following:
A 4–beep tone indicates the power up–self–test has been successfully completed.
‘CHECK PADS’ message is displayed and announced.
Defibrillator Test 1.
Press ANALYSE button. Verify the unit charges to 30 J. The message ‘30J READY MESSAGE’ is displayed.
© Copyright St John Ambulance Australia (Western Australia) Inc.
Skill 513 ZOLL M Series AED Biphasic Monitor Defibrillator Checking 1 of 5
2.
Once the unit has charged, verify the ‘SHOCK’ button illuminates.
3.
Press and hold the ‘SHOCK’ button.
4.
‘TEST OK’ should be briefly displayed on the screen and printed on the strip card recorder (if present). These messages indicate that the unit delivered energy within specifications.
5.
If ‘TEST FAILED’ appears, seek further advice.
Recorder check 1.
Check for adequate supply of paper.
2.
Press the recorder button. The strip recorder will run until the recorder button is pressed again.
3.
Inspect the recorder waveform uniformity and darkness.
4.
Inspect uniformity of annotation characters and completeness of words.
Setting time and date 1.
Turn unit off for at least 10 seconds.
2.
While pressing ‘SOFT KEY’ at lower right of screen and holding it down, turn the unit on. Continue to hold down the ‘SOFT KEY’ until the time date screen appears.
3.
Using the ‘SOFT KEYS’ as indicated by the onscreen menu highlight and change values as required.
4.
Press, ‘ENTER and RETURN’ to accept changes and return to the monitoring screen. NOTE: Time and date may need to be set if the unit has been without a charged battery for more than 12 hours.
Clear memory Unit must be turned ‘OFF’ for at least 15 minutes to clear the internal memory. If this is not done the unit will continue to record information until the memory is full. The unit will then record over existing information on a first in first out basis. Changing the Battery 1.
A LOW BATTERY message will be displayed on the monitor and a two–beep low battery tone will sound once a minute whenever the unit detects a low battery condition. Replace the battery immediately to ensure continuous operation.
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Skill 513 ZOLL M Series AED Biphasic Monitor Defibrillator Checking 2 of 5
2.
This message and beeping will persist until just before the unit shuts down when a REPLACE BATTERY message appears.
3.
Ensure the unit is turned OFF prior to removing the battery from the unit.
4.
The battery is located in the top of the unit under the carry handle.
5.
To remove the battery, lower the carry handle. Press the release tab on the left hand end of the battery and pull the battery upwards out of the unit.
6.
To replace the battery insert the right hand end of the battery opposite the LIFT HERE TO REPLACE tab into the right hand end of the battery well first. Then push the battery downwards until it clicks into place.
7.
Rotate and change the batteries at the beginning of each shift.
Change paper 1.
The printer is located at the lower front left of the unit.
2.
To open the printer draw insert index finger into the recess marked RELEASE and press gently downwards.
3.
Gently pull the paper draw forwards until it is fully open.
4.
Remove any remaining paper if required.
5.
Place new bundle of fan fold paper into the tray with one leaf folded out printed side up and arrows facing out from the unit.
6.
Push the draw inwards until it locks into place.
7.
To test the recorder, turn the unit on to the ON position. Press the recorder button to turn the recorder on. Press the SIZE button for at least two seconds to generate a 1mV calibration pulse.
8.
Switch recorder off by pressing RECORDER button again.
9.
Examine printout for uniformity of waveform and darkness of print.
Beeper volume 1.
Press button with a speaker picture located on the left front of the unit.
2.
A 5 level bar appears with the word ‘VOLUME’ above two soft keys with controls to Inc (increase) and Dec (decease) the volume to off. Voice prompts cannot be turned off.
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Skill 513 ZOLL M Series AED Biphasic Monitor Defibrillator Checking 3 of 5
Brightness / contrast adjustment 1.
Press button next to the volume control marked as a moon with top halve white, bottom halve black.
2.
A 6 level bar appears with the word ‘CONTRAST’ above two soft keys with controls to Inc (increase) and Dec (decrease) the contrast / brightness.
Alarms 1.
Some alarms may be suspended for 90 seconds by pressing the ALARM SUSPEND button for 3 seconds.
2.
A bell shape will be seen in the top right of the screen. When the button is pressed an X will be placed over the bell. To reset the alarm press the ALARM SUSPEND button again.
3.
If a second alarm sounds during suspension then press the ALARM SUSPEND again and a separate time out is started.
Diagnostics A computer contained within the unit performs self–diagnostic tests whenever the unit is initially turned on and periodically during operation. During operation a function ‘FAULT XX’ message will be displayed if a fault is detected. If this occurs turn off the unit and on again, if fault still exists report fault. Cleaning Approved cleaning solutions: 90% Isopropyl alcohol (except adapters and patient cable).
Soap and water.
Chlorine bleach (30ml/l water)
Use only a damp soft cloth with above.
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Skill 513 ZOLL M Series AED Biphasic Monitor Defibrillator Checking 4 of 5
PERFORMANCE CRITERIA SKILL 513 ZOLL M SERIES AED BIPHASIC MONITOR DEFIBRILLATOR CHECKING CONDITIONS Provide:
ZOLL M Series AED Monitor Defibrillator with accessories.
Patient / Manikin and rhythm simulator provided.
STANDARDS 1.
Officer to understand and demonstrate the checking of the ZOLL M Series Semi–AED Monitor and Defibrillator as per Skill 513.
2.
Unit should have a clear memory for each patient if possible.
3.
Periodically change the installed battery for a fully charged battery:
At the start of each shift; or
Immediately replace battery with a fully charged battery when the LOW BATTERY message displayed.
4.
Instructions for battery maintenance system must be followed to ensure the serviceability of the batteries.
5.
Use only Multifunction Electrodes within expiry date.
KEY POINTS Further tests may be performed using a ZOLL simulator and the ZOLL Operators guide. These are unnecessary for daily use.
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Skill 513 ZOLL M Series AED Biphasic Monitor Defibrillator Checking 5 of 5
SKILL 514 ZOLL M SERIES AED BIPHASIC MONITORING AND RECORDING October 2007
Monitoring 1.
Connect monitor cable to socket located at the back of the unit.
2.
Connect ECG electrodes to ECG cable.
3.
Ensure chest is clean and dry before attaching electrodes to patient (good contact must be achieved).
4.
Place the three monitor electrodes or mullti–function electrodes on the patient (as per diagram in General Performance Criteria, Skill 501).
5.
Turn the unit to ON 1 position.
6.
Ask the patient to remain still whilst recording an ECG strip to improve its quality.
7.
Monitor through the MFE pads if patient condition is serious or deteriorating.
8.
If no MFE or ECG electrodes have been attached to the patient and connected to the unit an ‘ATTACH PADS’ message will display.
9.
The unit ‘MONITOR’. Also a short reminder message displays ‘INSERT CARD’ and ‘ATTACH PADS’.
10. Should the rhythm change to a shockable rhythm the unit will after 10 seconds display a message ‘CHECK PATIENT’. 11. Whilst monitoring should the ANALYSE button be pressed a message ‘USE PADS’ will be displayed. Pads need to be applied. 12. This unit is capable of detecting implanted pacemaker spikes shown on the ECG as a thin solid line. Warning pacemakers may cause heart rate meter to count during incidents of arrhythmias or cardiac arrest. Remember to check the pulse. 13. The monitor screen displays 4 second segments of an ECG rhythm. 14. A fully charged battery provides 2.5 hrs of monitoring and less if defibrillation or the recorder is used. © Copyright St John Ambulance Australia (Western Australia) Inc.
Skill 514 Zoll M Series AED Biphasic Monitoring and Recording 1 of 3
Recording 1.
A rhythm strip can be obtained by pressing the RECORDER button. The strip recorder normally operates in the delay mode of 6 seconds to ensure capture of critical ECG information. To stop the strip recording, press the button again.
2.
A Summary report may be started at any time by pressing SUMMARY followed by the soft key under the message ‘PRINT CHART’.
3.
The Summary report will automatically record events:
4.
VF alarm triggered.
Defibrillator shock.
Heart rate alarm triggered.
Turning strip recorder on (or on and then off in rapid sequence).
Initiating analysis of the ECG.
With any defibrillation attempted a Summary or Print strip of the events must be attached to the Patient Care Record form and forwarded to the Medical Director for analysis.
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Skill 514 Zoll M Series AED Biphasic Monitoring and Recording 2 of 3
PERFORMANCE CRITERIA SKILL 514 ZOLL M SERIES AED BIPHASIC MONITORING AND RECORDING CONDITIONS Provide:
Patient / Manikin and rhythm simulator. Zoll M Series AED Biphasic Monitor Defibrillator.
STANDARDS 1.
Officer to understand and demonstrate monitoring and recording of the Zoll M Series AED biphasic Monitor Defibrillator as per skill 514.
2.
Use only approved disposable, Multifunction Electrodes within expiry date.
3.
Officer to demonstrate effective monitoring and problem solving techniques.
4.
Any attempted Defibrillation; a Summary or Print strip of the events must be attached to the Patient Care Record form and forwarded to the Medical Director for analysis.
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Skill 514 Zoll M Series AED Biphasic Monitoring and Recording 3 of 3
SKILL 515 ZOLL M SERIES AED BIPHASIC DEFIBRILLATION February 2007
Auto Mode All shocks are at 200J using Adult Multifuction electrodes. Children under 8 years use Paediatric Multifunction Electrodes (50 Joules) if available. If not use Adult MFE’s front and back. 1.
CPR must be started immediately as per CPR skills.
2.
If possible continue CPR whilst AED is setup.
3.
Expose the chest.
4.
Remove Multi Functional Electrodes from unit. Open electrode packaging by tearing at top of packet using the notches provided.
5.
Attach Electrodes to bare chest as per Skill 501.
6.
Turn the marked on / off switch to the number 1 position. Follow the on screen display and voice prompts. The unit automatically begins to analyse the rhythm. If a shockable rhythm is detected the unit will prompt STAND CLEAR, ANALYSING ECG and begin to auto charge to 200 joules emitting a continuous light buzzer sound.
7.
Stop CPR and state STAND CLEAR.
8.
The assisting Officer must reply ALL CLEAR after confirming no one is in contact with the patient.
9.
Once the unit is fully charged the unit will flash 200J READY, emits a loud buzzer sound and the number 3 Shock Button begins illuminate and flash. The display prompts SHOCK ADVISED – and voice prompts PRESS SHOCK.
10. Officer operating the defibrillator states DELIVERING SHOCK NOW and presses the 3 shock button. The unit will prompt the number of shocks delivered and prompts IF NO PULSE PERFORM CPR (do not check pulse unless there are signs of life). 11. Recommence CPR for two minutes if no signs of life.
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Skill 515 Zoll M Series AED Biphasic Manual Defibrillation 1 of 3
12. The unit will prompt continuously, flashing for 2 minutes IF NO PULSE—— PERFORM CPR. An analysing sequence will automatically begin after the 2 minutes.
Witnessed Arrest with Monitoring Electrodes attached prior. 1.
The unit will auto analyse when it detects possible shockable rhythm and prompt CHECK PATIENT.
2.
CPR must be started immediately as per CPR skills.
3.
Expose the chest.
4.
Remove Multi Functional Electrodes from unit. Open electrode packaging by tearing at top of packet using the notches provided.
5.
Attach Multi Functional Electrodes to bare chest as per Skill 501.
6.
Stop CPR and press the ANALYSE Button number 2.
7.
Follow voice prompts as before from point 7.
8.
The unit will prompt CPR on screen for 2 minutes of CPR then auto analyse again. Starting another sequence of defibrillation and CPR.
Caution 1.
If the unit is switched off and restarted again within 10 seconds during a CPR defibrillation cycle the unit will return to the previous program and ask you to press the ANALYSE button number 2. Follow these prompts.
2.
If the unit is switched back on after 10 seconds the unit will auto analyse beginning as if it were a new patient sequence.
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Skill 515 Zoll M Series AED Biphasic Manual Defibrillation 2 of 3
PERFORMANCE CRITERIA SKILL 515 ZOLL M SERIES AED BIPHASIC DEFIBRILLATION CONDITIONS Provide:
Defibrillation manikin and rhythm simulator.
Zoll M Series AED Biphasic Defibrillator and accessories.
Assistant.
STANDARDS 1.
Officer to understand and demonstrate defibrillation using the Zoll M Series AED Biphasic Defibrillator as per Skill 515.
2.
Joule settings default only:
3.
Adult MFE 200J.
4.
Paediatric MFE’s 50J, if not available use adult MFE’s front and back.
5.
Use only approved single use, multifunction electrodes within expiry date.
6.
Place multifunction Electrodes as per skill 501.
7.
Defibrillation / CPR as per Clinical Practice Guidelines.
8.
NO status checks between shocks unless there are signs of life. If there is a change in rhythm without signs of life, wait to do a status check at the end of the 2 minute CPR cycle.
9.
If any of the defibrillations are successful at converting the rhythm to a non– shockable rhythm, stop defibrillation and support the patient as required to treat the presenting problem (e.g. continue CPR, support ventilation etc).
10. Recommence the Clinical Practice Guideline ONLY if, after Return of Spontaneous Circulation (ROSC), the patient again reverts to a non–perfusing shockable rhythm. 11. Any attempted Defibrillation, a summary of events must be attached to the Patient Care Record form and forwarded to the Medical Director for analysis.
KEYPOINTS 1.
Ensure chest is clean and dry before attaching multifunction electrodes.
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Skill 515 Zoll M Series AED Biphasic Manual Defibrillation 3 of 3
SKILL 516 PHILIPS AED HEARTSTART FRX DEFIBRILLATION August 2010 FIGURE 1
FIGURE 2
Once the FRX is on, the operator should follow all voice prompts. The FRX is designed to complete its program and assist the operator to complete tasks if they have not already completed i.e. if the pads are not placed on the patient the unit will advise to do it, before it continues. For CPR help the unit’s Help delivered.
(i) button can be activated once the shock is
The FRX can be provided with a child / Infant key which when inserted into the unit converts the joule setting to 50 joules.
Adult Defibrillation (Not to be used for children under 8 years / 25kgs) 1.
Commence CPR as per CPR skills.
2.
If possible continue CPR whilst the AED is setup.
3.
Open the red carry case.
4.
Check that the unit’s green flashing LED power on light is operating (Figure 1).
5.
Turn on the unit at display 1 by pressing the green On / Off button (Figure 1). The unit will beep loudly and follow with voice commands as below: FIGURE 1
•
REMOVE CLOTHES FROM PATIENT’S CHEST.
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Skill 516 Philips AED Heartstart FRX Defibrillation Review date August 2015 1 of 8
•
PEEL WHITE PADS FROM GREY PLASTIC CASE (Figure 2). Open grey case at the side. FIGURE 2
•
ATTACH PADS TO BARE SKIN EXACTLY AS SHOWN (on pad case, adhesive pads or diagram on unit at number 2 (Figure 3). FIGURE 3
•
PRESS FIRMLY TO BARE SKIN
•
WHEN THE FIRST PAD IS IN PLACE PEEL SECOND PAD PLACE
•
PLACE PAD EXACTLY AS SHOWN
•
PRESS FIRMLY TO BARE SKIN
Note: If the pads are not successfully applied the unit will repeat the steps to apply pads and give further explanatory advice. 6.
Once the pads are placed correctly the unit will automatically continue with further audible commands STAY CLEAR OF PATIENT / ANAYLISING HEART RTHYHM x 2. Cease CPR and ensure no one is in contact with the patient.
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Skill 516 Philips AED Heartstart FRX Defibrillation Review date August 2015 2 of 8
7.
If a shock is indicated the number 3 button will eliminate and flash (Figure 3). FIGURE 3
The unit will command: SHOCK ADVISED STAY CLEAR OF PATIENT followed by PRESS THE ORANGE FLASHING BUTTON NOW. Caution: Do not press the shock button until operator complies with the stay clear commands below: •
Officer operating the defibrillator must state ‘STAND CLEAR’.
•
The assisting Officer must reply ‘ALL CLEAR’ after confirming no one is in contact with the patient.
•
Confirm ‘ALL CLEAR’.
•
State ‘ALL CLEAR DEFIBRILLATING NOW’.
•
Press the number 3 shock button. Note: The shock button must be pressed before 30 seconds before the shock is internally dumped.
•
If the shock is not given immediately the unit will alternatively command: PRESS THE ORANGE FLASHING BUTTON NOW / DELIVER SHOCK NOW until the shock is delivered or timed out.
8.
Once the shock is delivered the unit will respond: SHOCK DELIVERED / BE SURE THE AMBULANCE SERVICE HAS BEEN CALLED. Note: Officer to ensure that aback up paramedical crew has been called. IT IS SAFE TO TOUCH THE PATIENT START CPR / FOR HELP WITH CPR PRESS THE BLUE i BUTTON.
9.
Once the operator has pressed the help i button, the unit will advise how to: •
Start compressions and will omit a metronome to guide the operator to the compression rate.
•
Ventilations will also be described when required.
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Skill 516 Philips AED Heartstart FRX Defibrillation Review date August 2015 3 of 8
•
CPR will continue for two minutes before the unit will restart to analyse the patient repeating the process already described.
10. If no shock is advised then CPR must be continued for two minutes until the unit advises to STAY CLEAR ANALYSING HEART RHYTHM. 11. If the patient has a return of pulse, breathing or signs of life reassess the patient. Continue any support required i.e. oxygen assisted ventilation or recovery position etc., and turn the defibrillator off by pressing the On / Off button (1 button) down until the green light turns off. 12. If the patient again becomes pulseless, non breathing and no signs of life commence CPR and begin the defibrillation process again.
CHILD / Infant defibrillation (under 8 years / 25kgs) 1.
Commence CPR as per CPR skills.
2.
If possible continue CPR whilst the AED is setup.
3.
Open the red carry case.
4.
Check that the unit’s green flashing LED power on light is operating (Figure 1).
5.
Before turning the unit on insert the Child / Infant Key (Figure 5). Note: Laerdal provides a key that when inserted changes the joule settings to 50 joules.
6.
Note the pads maybe applied front and back.
7.
The continued defibrillation process is the same once the pads are applied.
FIGURE 5
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Skill 516 Philips AED Heartstart FRX Defibrillation Review date August 2015 4 of 8
After using the defibrillator 1.
Check the FRX for signs of damage etc.
2.
Clean if required.
3.
Replace used pads and connect pads plug.
4.
Replace any other consumables associated with the unit.
5.
Remove the battery for 5 seconds and reinsert battery to start a self test.
6.
Follow verbal instructs.
7.
When the self test is complete the green indicator light above the on off button will blink.
Trouble shooting 1.
The FRX‘s green blinking light is your guide to knowing if the unit is ready for use.
2.
The FRX‘s green blinking light LED also your guide that the FRX has passed a battery insertion test.
3.
If the green ready light is solid the FRX is in use or running a self test.
4.
If the green ready light is off, the FRX is chirping, and the i button is flashing. A self-test error has occurred, there is a problem with the pads, the infant / child key has been left installed, or the battery power is low. Press the i button for instructions.
5.
If the green ready light is off but the FRX is not chirping and the i button is not flashing there is no battery inserted; or the battery is depleted; or the defibrillator needs repair. Insert / replace battery and run the self test. As long as the FRX passes the self test you can assured it is ready for use. Monitoring.
6.
If the FRX turns off when you install the battery instead of running the battery insertion self test, check to be sure that the pads case is not open. If the pads case is open, the FRX will not run the self test as it assumes that it may be in use.
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Skill 516 Philips AED Heartstart FRX Defibrillation Review date August 2015 5 of 8
Voice activated instructions that must be followed 1.
To replace the battery immediately: •
2.
To plug in pads connector: •
3.
4.
6.
The pads connector has been unplugged. Check plug connection.
To replace pads: •
The pads have been damaged. Replace pads.
•
The pads have been peeled from the case, but have not been successfully attached to the patient. There may be a problem with the pads. Reposition or replace pads.
To press the pads firmly to the skin: •
5.
The battery is nearly depleted. The FRX will turn off unless a new battery is installed. Replace battery.
The pads have not been properly applied to the bare chest because of excessive hair or moisture.
The pads should not be touching the patients clothing: •
The pads are touching each other.
•
The pads may not have been removed from the case or may be on the patient’s clothing.
•
Reposition pads.
To make sure the pads connector is fully inserted: • Pads connector is not fully inserted. Check pad connector. If the command continues replace the pads set.
7.
8.
To stop all motion: •
The patient is being moved or jostled. Stop CPR, do not touch patient Minimize patient motion. If patient is being transported, stop the vehicle.
•
Responders and bystanders should minimize motion, particularly in dry environments that can generate static electricity.
•
Check for possible radio or electrical sources that may interfere with ECG analysis.
The shock was not delivered: •
The pads may not be making good contact. Press pads firmly to the chest
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Skill 516 Philips AED Heartstart FRX Defibrillation Review date August 2015 6 of 8
9.
The shock button was not pressed: •
The shock button was not pressed within 30seconds.Wait for next prompt.
10. Unit behaviour Chirps lights etc: Chirps or i button flashes: •
The battery power is low or pads need replacing.
•
Pads case is open.
•
Unit is turned on without a pda set installed.
•
The training pdas set has been left installed.
•
The infant /Child Key may be left installed.
•
Unit stored outside operating temperature.
•
The unit has detected an error during self test or cannot perform a self test or shock button is damaged. Report for service.
11. No chirping and or i button does not flash or no response to pressing i button: •
Battery is missing or depleted.
•
Defibrillator is damaged.
FRX data storage 1.
The FRX automatically stores data about its last clinical use in its internal memory.
2.
The last used data stored in internal memory includes 15 minutes of ECG once the pads have been applied.
3.
The stored data can be conveniently transferred to a personal computer or hand held computer running the appropriate application in the Philips HeartStart Event review data management soft ware suite.
4.
If the unit is used re a defibrillation the data must be downloaded and sent to Clinical Governance for analysis.
5.
Information about the last event can be sourced from the unit by holding down the i information button until it beeps once. The FRX will tell you how many shocks were delivered and how long it has been since it was turned on. Summary data is available anytime the defibrillator is ready for use.
6.
Removal of the battery will erase the summary data for the last use
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Skill 516 Philips AED Heartstart FRX Defibrillation Review date August 2015 7 of 8
PERFORMANCE CRITERIA SKILL 516 PHILIPS HEARTSTART AED FRX DEFIBRILLATION CONDITIONS Provide:
HeartStart FRX trainer and FRX defibrillator with all road accessories.
Suitable manikin.
Assistant officer.
STANDARDS 1.
Officer to understand and demonstrate the checking of the HeartStart FRX as per Skill XXX.
2.
Patient to be non–breathing, pulseless and no signs of life.
3.
Ensure chest is clean and dry before attaching multifunction electrodes.
4.
Adult default Joules 150. When Child/ Infant key is inserted 50 joules.
5.
Place multifunction electrodes as per skill 501.
6.
Warning: Do not touch the patient until the charge is either delivered or dumped internally.
7.
The PTV, crew must call for back up paramedic unit to assist or follow advise as per communications centre. Note: PTV’s cannot be driven under priority one conditions.
8.
Do not check pulse unless there are signs of life. Continue defibrillation / CPR as per Clinical Practice Guidelines.
9.
If any of the defibrillations are successful at converting the rhythm to a non– shockable rhythm, stop defibrillation and support the patient as required to treat the presenting problem (e.g. continue CPR, support ventilation etc).
10. Recommence the Clinical Practice Guideline ONLY if, after Return of Spontaneous Circulation (ROSC), the patient again reverts to a non–perfusing shockable rhythm. 11. For any incident of attempted defibrillation, the recorded data held in the internal memory must be downloaded and forwarded to Clinical Governance Operation Group along with a copy of the Patient Care Record Form. (See Transport Circulars and follow Operational procedures).
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Skill 516 Philips AED Heartstart FRX Defibrillation Review date August 2015 8 of 8
SKILL 601 GLUCOSE ORAL GEL October 2007
Description 1.
Lemon–flavoured 15 grams of Glucose Gel.
2.
Contained within a sealed tube with a twist–off top.
3.
Single Patient use only.
Administration 1.
Decide on use as per Clinical Practice Guidelines.
2.
Wear protective gloves.
3.
Complete a blood sugar level using a glucometer (BSL not required if known diabetic with altered conscious state).
4.
Continue, if the test result is less than 4.0mmol/l.
5.
Select a tube of Glucose Gel.
6.
Check expiry date and correct medication (Single Patient use only).
7.
Check with partner for No’s. 5 and 6.
8.
Explain to patient your intended use of Glucose Gel (patients who have an altered conscious state may understand even if they are non–compliant).
9.
Lay the Patient onto their side if altered conscious state.
10.
Grip the tube near the top and remove the cap by firmly twisting off.
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Skill 601 Glucose Oral Gel 1 of 3
11.
Place the tip of the tube into patient’s mouth on the same side they are laying, take into consideration patient’s size, squeeze proportional amounts of gel onto the buccal mucosa (cheek pouch). The remaining gel may be given as consciousness returns.
12.
Rub the gel into the gums and cheek pouch by placing fingers on the face over the application site and gently rub.
13.
Wait 10 minutes and repeat procedure if Patient still has an altered conscious state or is deteriorating (do not delay transport).
14.
If patient becomes conscious, follow up with glucose drink or food as needed.
15.
Document medication, dose, time administered, route, effect, time of recovery and additional dose given on the Patient Care Record Form. Complete Medication register.
16.
Patient’s that are conscious, may be assisted to use the Glucose Gel as per instructions on the packaging:
Grip the tube near the top and remove cap by firmly twisting.
Place tip of tube in mouth, squeeze slowly and swallow.
If no response in ten minutes, repeat dosage.
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Skill 601 Glucose Oral Gel 2 of 3
PERFORMANCE CRITERIA SKILL 601 GLUCOSE ORAL GEL CONDITIONS Provide:
A tube of Glucose Gel.
A simulated patient lying down (Glucose not to be administered).
A glucometer, with all accessories.
STANDARDS 1.
Officer to understand and demonstrate the use of Glucose Oral Gel as per Skill 601.
2.
All relevant protocols to be adhered to.
3.
Use a glucometer to test for blood sugar level, (which must be below 4.0 mmol/l before administering Glucose Gel).
4.
Where the patient has an altered conscious state and is a known diabetic, a blood sugar level is not required prior to administering Glucose Gel.
5.
Wait 10 minutes and repeat procedure if Patient still has an altered conscious state or is deteriorating.
6.
Patient’s who are conscious may be assisted to use the Glucose Gel as per instructions on the packaging.
7.
Explain intended use and method of administration to patient.
8.
Monitor all vital signs and record.
9.
Document medication, dose, time administered, route, effect, time of recovery and additional dose given on the Patient Care Record Form.
10.
For oral use only.
11.
Single patient use only.
12.
Patient to be transported without delay.
KEY POINTS 1.
Caution: Do not place fingers between teeth of patient, as biting can occur. Diabetic patients may be confused and aggressive.
2.
Should the Glucose Gel liquefy due to heat, cool then use.
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Skill 601 Glucose Oral Gel 3 of 3
SKILL 602 ADMINISTRATION OF SALBUTAMOL BY NEBULISER July 2007
1.
As per Skill 109, measure and record a Peak flow (best of two readings).
2.
Check plastic nebule for contents and expiry date (discard if expired).
3.
Squeeze dose (5mg in 2.5ml) of Salbutamol into nebuliser.
4.
Using a 10ml syringe draw up 10ml of Sodium Chloride injection BP 0.9%.
5.
Add 1.5ml of Sodium Chloride injection BP 0.9% to each dose of Salbutamol within the nebuliser.
6.
Select the appropriate nebuliser mask size (Adult / Child).
7.
Attach nebuliser to nebuliser mask.
8.
Attach oxygen therapy tube to nebuliser mask.
9.
Turn flow meter on to 8 litres per minute.
10.
Fit nebuliser mask to patient’s face, over nose and mouth.
11.
After the nebuliser is finished (normally about 10 minutes), measure and record another Peak flow (as per Skill 109).
12.
Document the time, effect and when dosages were given on the Patient Care Record Form.
13.
Adding further doses:
Remove the mask from the patient.
Turn off the oxygen.
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Skill 602 Administration of Salbutamol (Ventolin) by Nebuliser 1 of 3
Detach the nebuliser from the mask and add in the next dose.
Reattach the mask to the nebuliser.
Turn oxygen back on.
Place back on the patient.
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Skill 602 Administration of Salbutamol (Ventolin) by Nebuliser 2 of 3
PERFORMANCE CRITERIA SKILL 602 ADMINISTRATION OF SALBUTAMOL BY NEBULISER CONDITIONS Provide:
A simulated patient sitting down.
Cardiac monitor (if available).
Oxygen supply with flow meter and tubing.
Nebule of Salbutamol.
1 x vial 10ml Sodium Chloride injection BP 0.9%.
1 x 10ml syringe.
Nebuliser and mask (adult and child).
Patient Care Record forms.
STANDARD 1.
Able to understand and demonstrate the preparation and administration of Salbutamol via a nebuliser and mask as per Skill 602.
2.
Connect cardiac monitor if available.
3.
If the patient’s condition does not improve, continuous nebulising is permitted.
4.
Dose as per CPGs.
5.
Record time, effect and dose on Patient Care Record form.
6.
When opening a new packet, write the new expiry date in the section provided. Add 3 months to the date of opening. Also date each nebule using stickers with the same expiry date.
7.
Consider use of Peak Flow meter where patient is able (as per skill 109).
8.
If patient improves provide continued oxygen therapy.
KEYPOINTS The turning on the oxygen prior to attaching the mask to the patient, is so some patients can benefit from seeing what is about to happen. Patients that have experience with nebulisers, the oxygen can be turned on after applying the mask.
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Skill 602 Administration of Salbutamol (Ventolin) by Nebuliser 3 of 3
SKILL 603 ADMINISTRATION OF METHOXYFLURANE TM VIA PENTHROX INHALER March 2009
Penthrox™ Inhaler FIGURE 1
Description 1.
Lightweight polyethylene green cylinder 15cm long 3cm diameter (Figure 1). It is a disposable single patient use device. The mouth piece incorporates a 22mm male taper which may be used with a resuscitation mask.
2.
There is a diluter hole at the mouth piece end. The concentration of Methoxyflurane can be increased by the patient occluding the hole. The concentration increases from 0.1-0.2% (open) to 0.2-0.4% (closed).
3.
The inhaler contains an ‘S’ shaped wick which absorbs the liquid medication. A one way valve internally at the base allows air and medication vapour to be inhaled through the wick. The valve closes on expiration to prevent exhalations passing back through the wick.
4.
An oxygen supply can be attached to the external nipple in the base. Internally a narrow polypropylene tube extends through and beyond the wick to the mouthpiece. This allows the oxygen flow to bypass the wick.
5.
Oxygen can be delivered via a normal mask and Methoxyflurane used intermittently as required.
Patient use (Administration as per CPGs) 1.
2.
Contraindicated for patients:
Who are unable to understand or co–operate.
With severe renal impairment.
With head injury and altered consciousness that prevents co-operation with use.
With a known sensitivity ie. malignant hyperthermia.
Check expiry date, and then break the plastic seal from the Methoxyflurane ampoule, allowing the cap of the bottle to be unscrewed.
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Skill 603 Administration of Methoxyflurane TM via Penthrox inhaler 1 of 4
3.
Hold the PenthroxTM inhaler at an angle of 10-20 degrees to the vertical with the tapered end of the mouthpiece downwards.
4.
Pour the Methoxyflurane (1 x 3ml ampoule), slowly from the ampoule into the base surrounding the oxygen nipple. Gently roll between hands or shake inhaler. If necessary, wipe the mouth piece to remove excess liquid.
5.
Explain to the patient how to use Methoxyflurane as follows:
Advise patient to expect relief of discomfort rather than total pain relief.
Methoxyflurane has a peculiar, fruity odour. Allow patient to smell the Methoxyflurane to become accustomed to it.
The PenthroxTM inhaler may be tied comfortably to the patient’s wrist.
The patient should carry out administration of Methoxyflurane, by placing the inhaler mouthpiece in their mouth. If the patient is unable to hold the tube then the Officer may assist.
The PenthroxTM inhaler may be attached to a resuscitation mask only if the patient cannot directly use the inhaler by mouth (e.g. with small children or where facial injuries are involved). Note: Oxygen must be attached.
Instruct the patient to breathe in and out at a normal rate, gently at first with the dilutor hole open.
Once the patient is accustomed to the odour and if the pain is not relieved, the patient may cover the diluter hole with their finger thus delivering a higher concentration of Methoxyflurane.
Pain relief:
6.
Usually commences in 6 to 8 breaths / 1-2 minutes.
Maximum level 2 to 4 minutes and lasts 25-30 minutes with continuous use.
1 x 3ml ampoule should provide an effect for up to an hour or more if not used continuously and placed in a plastic zip lock bag when not being used.
A further dose may be repeated once after 15 minutes if pain still severe or returns. This will extend the duration of the analgesic to approximately 50-55 minutes.
Effectiveness of medication is 5 to 6 minutes after ceasing use.
When administered with Methoxyflurane, oxygen supply is connected to the nipple provided at the recessed end of the inhaler.
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Skill 603 Administration of Methoxyflurane TM via Penthrox inhaler 2 of 4
7.
When pain is significantly relieved remove the PenthroxTM inhaler.
8.
Medication life can be extended by placing the inhaler into a plastic zip seal bag during intermittent use. Press out excess air and zip–seal.
9.
When patient’s pain / discomfort increases re–administer the PenthroxTM inhaler.
Activated carbon filter (Figure 2) FIGURE 2
1.
Contains activated carbon made from medical grade polycarbonate.
2.
Disposable, single patient use.
3.
Reduces the expired concentration of methoxyflurane to the atmosphere when attached to the PenthroxTM inhaler.
4.
If required the filter is assembled and fitted into the flute hole on the upper side of the PenthroxTM inhaler as shown in Figure 3. FIGURE 3
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Skill 603 Administration of Methoxyflurane TM via Penthrox inhaler 3 of 4
PERFORMANCE CRITERIA SKILL 603 ADMINISTRATION OF METHOXYFLURANE VIA PENTHROXTM INHALER CONDITIONS Provide:
Simulated patient sitting / lying.
PenthroxTM inhaler and 3ml ampoule of Methoxyflurane.
Activated carbon filter.
Zip lock plastic bag.
Note: Medication not to be used on simulated patients during training (use empty inhalers).
STANDARD 1.
Officer to understand and demonstrate how to administer Methoxyflurane via a disposable PenthroxTM inhaler to a patient as per Skill 603.
2.
No performance errors permitted.
3.
Officer to communicate necessary information to the patient.
4.
Assistance may be given to a patient by holding the inhaler in place if appropriate. The patient should not be left unattended; however, in a multi casualty situation one operator may supervise several patients.
5.
Administration as per CPGs. Initial dose 1 x 3ml ampoule. If the liquid has fully evaporated, a second dose may be used after 15 minutes if pain is still severe or returns.
6.
Do not load inhaler with more than one 3ml dose.
7.
Contraindicated for patients with:
Patients who are unable to understand or co–operate.
Patients with severe renal impairment.
With head injury and altered consciousness that prevents co-operation with use.
Have a known sensitivity ie. malignant hyperthermia.
8.
The PenthroxTM inhaler may be attached to a resuscitation mask only if the patient cannot directly use the inhaler by mouth (e.g. with small children or where facial injuries are involved).
9.
The activated carbon filter is not required for patients. It is available at the discretion of those Officers who cannot tolerate the smell or are otherwise affected by the odour.
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Skill 603 Administration of Methoxyflurane TM via Penthrox inhaler 4 of 4
SKILL 604 FENTANYL INTRANASAL ANALGESIA October 2007 Description 1.
Fentanyl is a Schedule 8 poison (opioid analgesic).
2.
3mls of clear colourless liquid, contained in a glass vial, with a silicon top, covered by a removable protective tamper evident seal.
3.
Each ml contains 300mcg Fentanyl. Total 900mcg per vial.
Equipment 1.
One ampoule Fentanyl.
2.
One blunted, non–bevelled drawing up needle. Size 18G x 1 1/2’, 1.2mm x 40mm.
3.
One Mucosal Atomiser Device (Figure 1). FIGURE1
4.
One 1ml syringe with Luer lock.
Preparation 1.
Assess pain level using a visual analogue pain scale.
2.
Advise patient of intended use and expected outcome.
3.
Ask if patient is allergic to Fentanyl. Only proceed if no known hypersensitivity to Fentanyl exists.
4.
It is preferable to have the patient either reclining at a 45O or sitting position. However if the patient is lying then turn the patient’s head to one side before administering the dose to avoid the solution from trickling into the back of the throat.
5.
Wear protective gloves.
6.
Select a Mucosal Atomiser Device and tear open the packaging as per instructions on the bag. Leave device in the plastic bag for now.
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Skill 604 Fentanyl Analgesic (Intranasal) 1 of 6
Drawing up 1.
Select Iml Luer lock syringe.
2.
Select drawing up needle – blunted, non–bevelled.
3.
Select Fentanyl vial, check expiry date, and ensure content is clear.
4.
Confirm Fentanyl vial check with your partner.
5.
Remove protective, vial cover.
6.
Attach the drawing up needle to the syringe by turning the syringe clockwise until locked.
7.
Remove protective needle cap.
8.
Hold the vial with the non–dominant hand and using the other hand to hold the syringe, push the needle into the vial.
9.
Hold the syringe with the vial attached so that the vial is upside down.
10.
Withdraw the syringe so that the needle tip is fully covered by the Fentanyl solution.
11.
Withdraw the plunger so that the Fentanyl is drawn into the syringe.
12.
When the Mucosal Atomiser Device is used, a portion of Fentanyl is retained within the device; therefore an extra 0.1ml of solution is required to be drawn up for this purpose. The Fentanyl should fill the syringe at least 0.1 ml past the required first dose level. e.g. an initial Child (11-15) dose is 0.15ml plus 0.1ml to prime the atomiser = Total 0.25ml. This is only done for the initial use of the Mucosal Atomiser Device.
13.
Depress the plunger, expelling excess Fentanyl until the required dose is indicated, as per the level marked on the syringe.
14.
Turn the syringe and vial back over, and remove the syringe from the needle by carefully turning the syringe anticlockwise, so as not to alter the level.
15.
Place the vial in a safe place with the needle still in situ.
16.
Hold the Mucosal Atomiser Device whilst in the bag and attach the Luer lock syringe to the base of the atomiser by turning clockwise until secure. Remove the atomiser from the protective bag.
17.
Turn the Mucosal Atomiser Device upright with syringe attached (Figure 2). Carefully depress the plunger to prime the Mucosal Atomiser Device with 0.Iml, bringing the level to the required dose. This action expels air within the atomiser.
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Skill 604 Fentanyl Analgesic (Intranasal) 2 of 6
FIGURE 2
18.
Confirm correct dose of Fentanyl with partner.
Administration 1.
Select a suitable nasal passage, taking into account occlusion of nasal passages; facial injury obstructing nasal passages; or profuse nose bleeding.
2.
Reassure the patient and explain procedure.
3.
Officer to insert the tip of the Mucosal Atomiser Device into the nasal passage so that it fits loosely. The tip of the atomiser should be angled to deliver the atomised drug to the centre of the nasal cavity (i.e. between the floor and roof of the nasal cavity).
4.
Depress the plunger quickly and firmly to enable the Fentanyl to atomise properly.
5.
Withdraw the syringe and Mucosal Atomiser Device from the nasal passage and protect syringe and atomiser from contamination (atomiser / syringe may be placed back into the atomiser plastic bag).
6.
Reassess the visual analogue patient pain scale as per Clinical Practice Guidelines.
Additional doses 1.
If an additional dose is necessary the Mucosal Atomiser Device (MAD) is to be removed. The syringe is to be reattached to the existing vial and needle. A further dose is drawn up as per Clinical Practice Guidelines.
2.
Repeat steps 16 to 29. Note: If the same MAD is used again, an additional 0.1ml is not required to again prime the atomiser. Second or subsequent doses are to be given into alternate nostrils if possible.
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Skill 604 Fentanyl Analgesic (Intranasal) 3 of 6
Disposal and documentation 1.
2.
Unused Fentanyl remaining in the vial following an administration must be disposed of in the following manner:
Both officers to be present and to witness the complete process.
Unused Fentanyl to be drawn up into the syringe.
Fentanyl is then to be flushed down the sink in the Hospital Utility Room.
Dispose of the ampoule, needle and Mucosal Atomiser Device into a ‘sharps’ container after use – completing use for this patient.
Document all uses of Fentanyl (time administered, route, effects, doses, time of relief) in the Drug Register and on the Patient Care Record together with disposal method. Note: Recording of doses is to be either in micrograms used e.g. 60mcg or mls used e.g. 0.2ml of 300mcg.
Storage 1.
Fentanyl is a Schedule 8 poison controlled by legislation.
2.
Schedule 8 medications of dependence.
3.
Must be stored in the station safe when medication pouch not in use.
4.
Records must be kept in a drug register.
5.
All records must be kept by St John Ambulance for seven years.
6.
Illegal supply or possession is subject to the Misuse of Drugs Act.
7.
Medication pouches to be within reach or locked in a locked vehicle at all times when on duty.
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Skill 604 Fentanyl Analgesic (Intranasal) 4 of 6
PERFORMANCE CRITERIA SKILL 604 FENTANYL INTRANASAL ANALGESIC CONDITIONS Provide:
Practice vial.
One blunted non–bevelled needle.
One Mucosal Atomiser Device.
One Iml Luer lock syringe.
A ‘Sharps’ container and gloves.
STANDARDS 1.
Officer to understand and demonstrate the administering of Fentanyl as per Skill 604.
2.
Officers to follow clean techniques.
3.
Officer to advise patient of intended use and expected outcome.
4.
Contraindications.
Altered conscious state.
Known hypersensitivity to Fentanyl.
Females in labour (may cause respiratory depression in newborn), however, it is safe for use in pregnancy.
Occluded nasal passages.
Facial injury obstructing nasal passages or profuse nose bleeding.
5.
NEVER give intravenously! Our service uses 300mcg per ml, compared with hospital IV use of 50 mcg. per ml. ours is 6 times stronger and the solution has not been prepared for intravenous use.
6.
Subsequent doses, as per Clinical Practice Guidelines. Titrate for relief of suffering.
7.
The Mucosal Atomiser Device may be reused only on the same person.
8.
Transport patient without delay. Do NOT wait for drug to take effect.
9.
Officers to treat any adverse reaction to Fentanyl as a Narcotic Overdose and administer Naloxone if required as per Clinical Practice Guidelines.
10.
Administer high concentration or 100% oxygen. Consider ventilation if required.
11.
Officers must adhere to the correct method of disposal of excess Fentanyl.
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Skill 604 Fentanyl Analgesic (Intranasal) 5 of 6
12.
Officer must adhere to the correct documentation and storage of Fentanyl.
13.
Fentanyl prepared for intra nasal use is not IV quality and therefore cannot be diluted for IV use.
KEY POINTS 1.
Titration—administration of incremental doses until desired effect is achieved. Caution: When disconnecting the syringe from the atomiser for additional doses, be careful not to withdraw the plunger or push air into the atomiser. If you suspect that the atomiser has lost it priming solution then re–prime as before using an extra 0.1ml of solution.
2.
Fentanyl is only absorbed by the nasal mucosa. Sniffing or breathing back the atomized drug during the activation of the Mucosal Atomiser Device will diminish the amount of vapour available for absorption by the nasal mucosa.
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Skill 604 Fentanyl Analgesic (Intranasal) 6 of 6
SKILL 605 PREPARATION AND ADMINISTRATION OF MEDICATION VIA INTRA MUSCULAR INJECTION October 2008 Preparation 1.
Ensure hands are clean.
2.
Officer to wear examination gloves and eye protection.
3.
Select correct medication as per Clinical Practice Guidelines.
4.
Check packaging of medication for:
Name of medication.
Expiry date.
Condition of packaging.
5.
Confirm with partner the correct medication is being used by showing the packaging (i.e. vial, ampoule).
6.
Before administration, re–check correct medication type and dosage with partner.
7.
Make ready a cotton wool wad and adhesive strip (i.e. bandaid).
8.
Select a suitable site for the Intra muscular injection. Either Deltoid or Vastus Lateralis muscles are applicable (Figure 1 and 2).
9.
Injection site should be free of oedema, inflammation, hardened areas, bruising or damaged skin.
10.
Use the anatomical landmarks of the selected site to determine the safe point of administration (Figure 1 and 2).
11.
Clean the site with an antiseptic swab, using a circular motion. Starting from the centre and working outward to approximately 5cm. FIGURE 1
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FIGURE 2
Skill 605 Preparation and Administration via Intra Muscular Injection 1 of 8
Preparation of the vial / ampoule Use one medication per syringe. Glass ampoule 1.
Displace any medication trapped in the neck of the ampoule body by rotating ampoule several times end—over—end.
2.
To open a glass ampoule, identify the dot painted on the neck of the ampoule (Figure 3). Hold ampoule firmly. With the other hand break the neck of the ampoule away from the dot (Figure 4). If there is no dot painted on the neck of the ampoule, break the neck as above in any direction. Use a pulling apart movement whilst breaking. If not done correctly the vial or ampoule may break. FIGURE 3
FIGURE 4
Snapping away from you
3.
If using a vial / ampoule breaker (Figure 5), select from the four in built sizes available that matches the vial / ampoule. Slide over the top, use one hand on the breaker and the other on the lower half exposed vial / ampoule. Snap the breaker away breaking the top from the vial / ampoule. Dispose of the vial / ampoule; don’t throw the reusable breaker away. 4.
FIGURE 5
Plastic vials, the protective cap can be twisted off. (i.e. normal saline). Glass vials with protective cap. Lift and remove the cap. (i.e. Glucagon and Ketamine).
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Skill 605 Preparation and Administration via Intra Muscular Injection 2 of 8
1.
Hold the opened vial / ampoule upright in one hand and with the other hand hold the syringe.
2.
Carefully insert needle into vial / ampoule. Adjust the hand holding the vial / ampoule so that both the vial / ampoule and the syringe body is held as one.
3.
Allow a space so the contents and the measurement scale on the syringe can be seen.
4.
Align the units keeping the tip of the syringe fully submerged in the medication being drawn up (Figure 6).
5.
Draw up contents by pulling back on the plunger using measurement marked along the barrel of the syringe.
6.
Either draw up all the contents or expel air and surplus medication back into the vial / ampoule at the drawing up stage.
7.
Caution: Excessive rubbing against the glass vial / ampoule with the point of the needle will blunt the needle. FIGURE 6
8.
Withdraw the needle / syringe from the vial / ampoule. Check air is expelled and dosage is as per Clinical Practice Guidelines.
9.
Show the syringe to your witnesses and confirm dosage and medication to be given.
10.
The needle is now ready to be given.
11.
If not administered immediately recap the needle as per Skill 607 (one handed recapping) until ready.
Administration 1.
Grasp the prepared syringe in the dominant hand, between the thumb and forefinger, with the palm facing downwards. The syringe should be grasped lightly enough to allow the thumb and forefinger to slide partially along the syringe barrel when the needle impacts the muscle tissue (similar to grasping a pen or dart).
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Skill 605 Preparation and Administration via Intra Muscular Injection 3 of 8
2.
Gently bunch the muscle at the selected site between the fingers of the non– dominant hand.
3.
Insert the needle at a 90O angle deep into the muscle in one quick motion.
4.
Transfer non–dominant hand to the barrel of the syringe and dominant hand to the end of the plunger of the syringe.
5.
Slowly pull back on the plunger of the syringe. If blood appears in the syringe, withdraw the needle and administer the medication within the same site area at least 2.5cm away from the previous injection site. A new syringe with medication should be used.
6.
If blood does not appear inject medication slowly.
7.
On completion of injection use appropriate method to remove needle (Figure 6 VanishPoint) and engage the needle locked via the safety mechanism particular to that syringe and dispose of the syringe immediately into a sharps container. Using the other hand apply cotton wool swab over the injection site. Lightly massage the injection site. Note: VanishPoint safety retraction method (Figure 7) Complete injection of medication; continue to depress the plunger fully until needle retracts into the syringe. FIGURE 7
8.
After the injection, inspect the site for bleeding. If bleeding is evident, apply a dressing and direct pressure to the site.
9.
Collect and dispose of all used equipment appropriately.
10.
ENSURE NOTHING IS LEFT BEHIND AT THE SCENE.
11.
Record details on the Patient Care Record form:
12.
Time of administration.
Medication and dosage.
Injection site.
Noted effect of medication.
Record appropriate details in drug register.
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Skill 605 Preparation and Administration via Intra Muscular Injection 4 of 8
Specific needle / syringes used within the service
A
VANISHPOINT™ Syringes 23g (Figure 6 and 7).
B
GlucaGenTM Hypokit (Figure 9).
A
VANISHPOINT™ Syringes 23 (Figure 8) (Deep muscle injection)
1.
For single use only.
2.
Remove needle / syringe from packaging.
3.
Remove needle cap.
4.
Draw up from vial / ampoule as per preparation guidelines.
5.
Inject as general guidelines and CPGs.
6.
After injection is completed (do not remove the needle from the site) activate the needle retraction mechanism by depressing the syringe plunger until the plunger is locked into the syringe. The needle will automatically retract from the tissue into the barrel of the syringe (Figures 8). At the same time support the tissue around injection site. FIGURE 8 BEFORE
AFTER
7.
Ensure needle has been retracted before disposal into a sharps container.
B
GlucagenTM HypoKit (Glucagon) (Figure 9) FIGURE 9
1.
FIGURE 10
Remove the orange cap from the vial (Figure 10).
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Skill 605 Preparation and Administration via Intra Muscular Injection 5 of 8
2.
Inject ALL THE STERILE WATER from the syringe into the vial containing the Glucagon powder while the level of the needle is held above the surface of the medication, remove needle and dispose of in sharps container (Figure 11). Shake the vial gently until the glucagon is completely dissolved. FIGURE 11
3.
Using a 3ml x 23g VanishPoint needle to draw up and administer.
4.
Holding the syringe and vial inverted and at eye level slowly withdraw the correct amount of medication into the syringe (as per Clinical Practice Guidelines).
5.
Depress the syringe plunger to expel any air that may be within the syringe and needle and to adjust the dosage within the syringe to the correct amount. At all times keep the needle level below the level of the Glucagon solution.
6.
Withdraw the needle from the vial.
7.
The medication should be used immediately. Any unused solution should be disposed of and not kept for a possible later dose.
8.
Inject dosage as per CPGs, general injection guide.
9.
Discard syringe immediately into a sharps container.
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Skill 605 Preparation and Administration via Intra Muscular Injection 6 of 8
PERFORMANCE CRITERIA SKILL 605 PREPARATION AND ADMINISTRATION VIA INTRA MUSCULAR INJECTION CONDITIONS Provide: The following items to be available for Officer’s use: Medications and / or trainer replacements.
Infusion equipment including flush and fluids.
Appropriate syringes.
Vial breaker.
Dressings.
Protective eye wear and gloves.
Medication labels if available.
Sharps container.
Antiseptic swabs and packet of cotton wool balls.
Manikins as required.
STANDARD 1.
Officer to understand and demonstrate how to prepare and administer an intra muscular injection as per Skill 605.
2.
The 27g vanishpoint needle is to be used for intra dermal injection only (for administration of lignocaine) and is not to be used for IM injections.
3.
All aseptic and safety procedures are to be maintained.
4.
Eye protection and gloves to be worn.
5.
All medications must be administered as per Clinical Practice Guidelines.
6.
All medications must be confirmed as the correct medication and dose with their partner and then reconfirmed before administration. The original vial source and syringe must be sighted.
7.
Observe all safety precautions when dealing with sharps and contaminated items. Dispose of all sharps or contaminated equipment immediately into a sharps container.
8.
Record details of administration of medication on the Patient Care Record Form and Drug Register.
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Skill 605 Preparation and Administration via Intra Muscular Injection 7 of 8
KEY POINTS 1.
Organise a safe working area where there is sufficient light and equipment is readily identifiable.
2.
Do not rush the process as mistakes can occur especially in drawing up doses and picking up wrong syringes.
3.
A vial breaker can prevent injury to fingers and prevent damage to the glass vial.
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Skill 605 Preparation and Administration via Intra Muscular Injection 8 of 8
SKILL 606 ADMINISTRATION OF AN INTRA–VENOUS INJECTION November 2008 1.
Officer to wear eye protection and gloves.
2.
Cannulate if required.
3.
Expose and check IV Bung or port on giving set is patent (keep infusion running if one is operating).
4.
Select and prepare medication as per Clinical Practice Guidelines.
5.
Draw up medication either using a needleless syringe or drawing up needle. Draw up to dosage required expelling excess medication and air back into the vial / ampoule. Leave the drawing up needle in the vial. Detach syringe.
6.
Place adhesive label along shaft of the syringe matching name to the medication prepared (if available).
7.
Confirm medication and dosage with witness showing the syringe and vial / ampoule that the medication came from.
8.
Use an alcohol swipe and clean the surface of the port and allow drying.
9.
Attach the syringe to the IV bung or giving set port.
10.
Method 1:
11.
With Luer Lock, screw the syringe on clockwise. (Figure 1).
Method 2:
Insert the syringe and give a slight twist until locked.
Reverse method 1 or 2 to release syringe.
12.
Slowly push plunger to administer correct dose as measured against syringe calibrations.
13.
Remove syringe with light positive pressure careful not to withdraw the plunger.
14.
Attach the prepared 10ml Flush and flush the port.
15.
Dispose of any equipment not required check infusion site for swelling and discolouration to ensure the site is patent. Cover site again if required.
16.
Note any change in patient’s condition.
17.
Collect and dispose of all used equipment appropriately.
18.
ENSURE NOTHING IS LEFT BEHIND AT THE SCENE.
19.
Record details on the Patient Care Record form:
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Skill 606 Administration of an Intra-Venous Injection 1 of 4
20.
Time of administration.
Medication and dosage.
Injection site.
Noted effect of medication.
Record appropriate details in drug register.
Preparation of Ketamine for titration 1.
Use a drawing up needle attached to a 20ml syringe. Draw entire contents of vial (200mg-2ml) into syringe.
2.
Place an adhesive label name (Ketamine) along the syringe barrel.
3.
Draw up 18ml of normal saline to dilute the medication to total of 20ml. Important always draw the medication first then the crystalloid solution when using Ketamine.
4.
Remove Blunt Drawing up needle.
5.
Attach syringe to IV bung. Infusion must be running to ensure each dose is delivered into the vein.
6.
Push plunger to administer correct dose as measured against syringe calibrations.
7.
If given via the IV Bung then draw up 10ml of normal saline in a 10ml syringe and flush the IV Bung after IV dose of Ketamine.
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Skill 606 Administration of an Intra-Venous Injection 2 of 4
PERFORMANCE CRITERIA SKILL 606 ADMINISTRATION OF AN INTRA–VENOUS INJECTION CONDITIONS Provide: The following items to be available for Officer use: Appropriate syringes.
Ampoules of Normal Saline.
Antiseptic swabs.
Injection training manikins / aids.
Disposal containers for used equipment.
Copy of Patient Care Record form and Drug Register.
STANDARD 1.
Officer to understand and demonstrate how to administer an Intra–Venous injection as per Skill 606.
2.
All aseptic and safety procedures are to be correctly maintained.
3.
Eye protection and gloves to be worn.
4.
No performance or sequence errors permitted.
5.
All medications must be administered as per Clinical Practice Guidelines.
6.
If medication to be titrated then syringe must be kept clean, protected and ready for further use.
7.
Ensure IV site is patent before and after giving medication.
8.
Do not use a needle into a Needleless IV valve.
9.
If a Baxter type IV is insitu use a needle / syringe for the Intra–Venous injection.
10.
Observe all safety precautions when dealing with sharps and contaminated items. Dispose of all sharps or contaminated equipment immediately into a sharps container.
11.
Record details of administration of medication on the Patient Care Record Form and Drug Register.
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Skill 606 Administration of an Intra-Venous Injection 3 of 4
KEY POINTS 1.
Slow administration allows the effect to be gradual rather than a bolus effect which may severely affect the patient.
2.
Organise a safe working area where there is sufficient light and equipment is readily identifiable.
3.
Do not rush the process as mistakes can occur especially in drawing up doses and picking up wrong syringes.
4.
A vial breaker can prevent injury to fingers and prevent damage to the glass vial.
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Skill 606 Administration of an Intra-Venous Injection 4 of 4
SKILL 607 ONE HANDED NEEDLE RECAPPING TECHNIQUE November 2010 1.
Place tip of the needle cover against a solid immovable object.
2.
With your dominant hand carefully guide the needle into the needle protector.
3.
Using the resistance of the immovable object apply gentle pressure to secure the protector on the needle.
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Skill 607 One Handed Needle Recapping Technique Review date November 2015 1 of 2
PERFORMANCE CRITERIA SKILL 607 ONE HANDED NEEDLE RECAPPING TECHNIQUE CONDITIONS Provide:
Needle / syringe and needle protector. A suitable solid immovable object.
STANDARD 1.
Officer to understand and demonstrate the one hand method of recapping a needle / syringe as per Skill 607.
2.
All aseptic and safety procedures are correctly maintained.
3.
No performance or sequence errors are permitted.
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Skill 607 One Handed Needle Recapping Technique Review date November 2015 2 of 2
SKILL 608 CANNULATION OF A PERIPHERAL VEIN June 2011 Preparation 1.
Reassure the patient by explaining the need and benefits of IV therapy.
2.
Wear eye protection and gloves.
3.
Select appropriate size cannula.
4.
Open and make ready the following items:
5.
Place a Sharps container within easy reach.
A cannula.
A bung.
Place alcohol swabs and tourniquet at the ready.
Prepare two strips of adhesive tape approximately 10cm in length, and have a transparent IV dressing ready (tape may be included with the opsite dressing).
5ml syringe.
Sodium Chloride Injection BP 0.9% (10ml).
Prepare an IV solution and giving set as per skill 609 if required.
Selection and preparation of site 1.
Select the appropriate cannulation site:
Distendable vein, preferably at a ‘Y’ junction.
Radial aspect of lower third of the forearm.
Back of hand.
Antecubital fossa.
External Jugular.
2.
If possible, allow arm to hang down to distend veins.
3.
Apply a venous tourniquet to the mid–upper arm.
4.
Palpate a distal pulse, if not felt, loosen the tourniquet until palpable.
5.
Inspect the arm / forearm / hand. Select a vein that appears straight and preferably end in a ‘Y’ junction.
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Skill 608 Cannulation of a Peripheral Vein Review date: June 2016 1 of 7
6.
Raise a vein in the arm. If the patient is conscious, request them to clench and unclench their fist to increase pressure within the vein. Gently tap the vein to stimulate relaxation of the wall and dilation of the vein.
7.
Swab the site with an alcohol swab.
8.
If required, inject a bleb of local anaesthetic at insertion site using an intradermal injection of lignocaine 1%.
Cannulation 1.
Remove the shield from the cannula and gently loosen the hub of the catheter on the needle (Figure 1). FIGURE 1
2.
Stabilise the chosen vein by applying downward pressure with the thumb or index and middle fingers, about 5cm below the site of entry.
3.
Align the bevel of the needle (Figure 2) uppermost so that it enters the skin at an angle no greater than 300 over the vein. If there is a ‘Y’ junction, locate the tip of the needle approximately 1-2 mm distal to the junction. FIGURE 2
4.
Insert the tip of the cannula through the skin, into the vein.
5.
Look for a flash back of blood in the clear window of the cannula (Figure 2).
6.
Reduce the angle of the cannula so that it is parallel to the skin.
7.
Gently advance the cannula a few more millimetres, to ensure that the cannula is actually in the vein.
8.
Stabilise the needle in the vein whilst holding the cannula body still. Hold the cannula body with the thumb and forefinger. The index finger is then placed behind a plastic tab (located just behind the hub of the catheter), which is then gently pushed forward to slide the catheter from the needle into the vein.
9.
Release the tourniquet.
10.
Once the catheter is in position, hold pressure against the tab with the index finger, whilst allowing the cannula body to slide backward using the thumb and forefinger until the needle is fully retracted into the cannula body.
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Skill 608 Cannulation of a Peripheral Vein Review date: June 2016 2 of 7
11.
A click is heard when the protective cover is fully engaged, apply gentle pressure over the vein in the region of the tip of the catheter, and then remove the needle body directly into a sharps container. Verbally confirm disposal of sharp with partner. Caution: Always treat a needle as being unsafe even if presumably locked. Safety lock devices can malfunction and are only an added precaution.
12.
Attach: an IV bung, IV fluid line or both.
Flushing the cannula 1.
Maintain stabilisation of the catheter.
2.
The IV bung has an injection port at one end and at the other a small tube with a luer lock connection.
3.
With a slight twisting action remove the protective cover from Luer Lock end of the bung.
4.
The bung can now be inserted into the catheter and with a push and twist action locked in place. Note: use the syringe body if both IV bung and syringe are together. Caution: Insert the syringe or attach the giving set connector so that it fully locks into the bung port before trying to inject or run the solution. Trying to inject or run fluids before locking will prevent the solution from entering the port.
5.
Flush the catheter by injecting the 5ml Sodium Chloride Injection BP 0.9% or Open giving set control valve to flush the catheter, and then establish the appropriate IV flow rate. To prevent dehydration run fluids at a minimum of 60dpm or to keep vein open (TKVO) 20dpm.
6.
Monitor the site for any deterioration and take appropriate action if required.
Secure and monitoring site 1.
Further secure the catheter using the transparent IV dressing and adhesive tapes.
2.
Provide support for the limb and or splint the cannula site as required.
3.
Continue to monitor the infusion site and IV solution.
Removal of catheter 1.
Remove the catheter if the infusion site becomes painful, bruised, swollen or fails to run.
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Skill 608 Cannulation of a Peripheral Vein Review date: June 2016 3 of 7
2.
To remove the catheter place a cotton wool pad with downward pressure over entry site. Slide the catheter out leaving a steady downward pressure on the site for approximately 60 seconds then tape cotton wool down.
Maintenance of catheter 1.
If catheter slows or stops:
Check for obstructed tubing.
Check fluids have not run out.
Check site has not become tissued (stop and remove cannula).
Actions Raise height of fluids.
Try flushing the cannula
Use pressure on the tubing to force the fluid down the cannula.
If these fail turn fluids off or remove cannula.
External Jugular Cannulation Location 1.
The external jugular vein is a large, peripheral blood vessel in the neck, between the angle of the jaw and the middle third of the clavicle. It connects into the central circulation’s subclavian vein.
2.
Since the vein lies so close to the central circulation, cannulation here offers many of the same benefits afforded by central venous access. Fluids and medications rapidly reach the core of the body from this location.
3.
Lignocaine should be considered for pain relief.
4.
Cannulation requires essentially the same equipment as other forms of access.
Procedure 1.
Prepare equipment and site as for all normal IV cannulation.
2.
Place patient in supine or Trendelenburg position with head down, feet elevated to increase blood volume to the head / neck and chest region to distend vein making it earlier to identify.
3.
Divert patient’s head to the opposite side away from the cannulation site to enhance access (Figure 3). Note: Do not manipulate the neck if cervical injury suspected.
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Skill 608 Cannulation of a Peripheral Vein Review date: June 2016 4 of 7
Figure 3
4.
If required occlude venous return by placing a finger on the external jugular just above the clavicle. This should distend the vein and may enhance visualisation (Figure 3).
5.
Swab site with an alcohol swab, allow to dry.
6.
Consider Lignocaine intradermally for pain relief.
7.
Position the cannula parallel to the vein, midway between the angle of the jaw and clavicle (Figure 4). Figure 4
8.
Insert cannula into the vein as per usual practice. Look for a flash back of blood in the clear window of the cannula or the syringe barrel. Note: A flash back in the protective cannula may not be seen due to the vein’s low pressure.
9.
Flush catheter with at least 5 to 10mls of normal saline use either use IV fluids or attach syringe and flush.
10. Once correct place confirmed secure cannula. 11. Administer medication / fluids as per CPG’s and Skills.
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Skill 608 Cannulation of a Peripheral Vein Review date: June 2016 5 of 7
PERFORMANCE CRITERIA SKILL 608 CANNULATION OF A PERIPHERAL VEIN USING A PROTECTIV CANNULA CONDITIONS Provide:
Appropriate manikin and necessary equipment. Assistant.
STANDARDS 1.
Officer understands and demonstrates how to perform IV cannulation of a peripheral vein as per Skill 608.
2.
Specific indications and precautions as per CPGs.
3.
Aseptic technique to be used.
4.
Officer to wear gloves and protective eyewear.
5.
Appropriate choice of vein.
6.
Use appropriate size cannula.
7.
Infuse intravenous fluid at the appropriate IV flow rate.
8.
IV bung to be flushed regularly at 20 minute intervals.
9.
What ever the type of cannula is used (safety type or others) the needle must be immediately disposed of into a sharps container and confirmed with partner after removal from the catheter.
10.
Document all attempts. Include volume and type of fluids used, and over what time.
KEY POINTS 1.
Look for a ‘flash back’ of blood in the clear window at the end of the cannula. This will let you know that you are in the vein. Do not advance the cannula further until the cannula is lowered. This will help prevent damage to the blood vessel.
2.
Prior to removal of the needle, apply firm pressure on the skin where the tip of the cannula would be located to prevent back flow of blood.
3.
For hypovolaemia and states of hypoperfusion, the larger bore cannulas (14g and 16g) are preferred to that of a smaller bore.
4.
Preferably select a site free of venous valves. Hitting valves may cause the cannula to exit the vein damaging the blood vessel.
5.
Sites near movable joints may cause the cannula to kink or exit the vein.
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Skill 608 Cannulation of a Peripheral Vein Review date: June 2016 6 of 7
6.
To differentiate a vein from that of tendon, first feel for a possible vein. If in doubt release the cuff. A vein will become less palpable as the blood pressure within the vein is reduced, whereas a tendon will stay the same.
7.
If veins are difficult to access, increase venous pressure by hanging the limb downward.
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Skill 608 Cannulation of a Peripheral Vein Review date: June 2016 7 of 7
SKILL 609 PREPARE, CONNECT AND MAINTAIN AN IV INFUSION December 2003
Preparation 1.
Remove IV bag from the protective plastic envelope by tearing / cutting at the tear notch.
2.
Check IV bag for correct solution, expiry date and cloudiness then squeeze to check for leaks.
3.
Remove giving set from protective plastic envelope by tearing / cutting the top of the plastic envelope.
4.
Ensure control valve is no more than 25cm from the bottom of the drip chamber, slide along IV tube if necessary.
5.
Close control valve by rolling the control wheel away from flange end of control valve as far as possible.
6.
Remove the plastic protective covering from the IV bag portal by pulling the tag on the protective covering.
7.
Remove protective covering from the IV spiked inflow tip maintaining aseptic techniques.
8.
Insert inflow tip into IV bag portal slowly pushing until firmly in place ensuring that it does not perforate the sides of the IV bag portal or theIV bag itself.
9.
Holding IV bag up with the IV tubing hanging below, squeeze and release the top section of drip chamber until the lower section of the chamber is filled to the line indicated on it. (Do not allow end of IV tubing to become contaminated). Hold end of line above level of IV bag.
10.
Fill IV tubing by slowly opening control valve fully until the fluid finds its own level then lower end until line is full. Close off valve.
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Skill 609 Prepare, Connect and Maintain an IV Infusion 1 of 3
11.
Connect IV tubing direct to cannula or IV bung.
12.
Tape cannula and tubing in place.
Maintaining an open IV 1.
Keep the IV bag or cylinder elevated above the patient at all times.
2.
Ensure IV drip rate per minute is maintained at the rate stipulated by slightly opening or closing the IV control valve.
3.
If IV has stopped, carry out the following procedures:
Check infusion site to ensure line is connected correctly.
Check position of patient’s arm and the IV line.
Open the IV control valve fully, if IV starts flowing again, reset control valve to maintain original IV rate drops per minute.
Elevate the IV bag or cylinder higher where practical.
Close off IV control valve and compress the section of IV tubing between the control valve and the patient by winding it over a small round object (e.g. a pen), working towards the patient.
If the above steps fail to restart IV flow, turn IV control valve ‘off’. Note the time and details on the Patient Care Record Form.
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Skill 609 Prepare, Connect and Maintain an IV Infusion 2 of 3
PERFORMANCE CRITERIA SKILL 609 PREPARE, CONNECT AND MAINTAIN AN IV INFUSION CONDITIONS Provide:
Bag containing fluid, giving set, IV stand, scissors and tape.
Assistant, if required as an untrained person.
Evaluator to specify drip rate.
Officer to hand prepared IV infusion to evaluator ready for patient connection.
STANDARD 1.
Officer to understand and demonstrate how to prepare, connect and maintain an IV infusion, for patient connection as per Skill 609.
2.
Officer to maintain sterile conditions when handling connection sites on patient, giving set and IV bag.
3.
Ensure IV tubing is full and contains no significant air bubbles.
4.
Do not allow a prepared IV bag and giving set to be laid down. Always keep it suspended unless the control valve has been closed.
5.
If no IV rate specified, maintain at 60 dpm.
6.
If the IV drip chamber overfills, turn IV control valve ‘off’ squeezing back excess fluid into IV bag by squeezing and releasing drip chamber while the IV bag is temporarily inverted. Re–open IV control valve to maintain original IV rate drops per minute.
7.
If there is swelling / discolouration around the actual infusion site, turn the IV control valve off. Note time and details on Patient Care Record form.
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Skill 609 Prepare, Connect and Maintain an IV Infusion 3 of 3
SKILL 610 EPIPEN AND EPIPEN JR AUTO– INJECTORS October 2008 1.
The EpiPen is manufactured with two dosages:
EpiPen Junior (green or white) = 0.15mg for children 15 to 30kg.
Adult EpiPen (yellow) = 0.3mg (over 30kg).
2.
Ensure hands are clean.
3.
Officer to wear examination gloves and eye protection.
4.
Select correct medication as per Clinical Practice Guidelines.
5.
Whilst medication is being administered continue all basic life support. i.e. (Oxygen—ventilate or give 100%, treat for shock etc).
6.
Make ready the sharps container.
7.
Expose mid lateral thigh, if practicable and clean with alco–wipe. If not practicable, EpiPen can be injected through minimal clothing.
8.
Acquire the EpiPen suited to the patient.
9.
Check protective cover is in tact. Do not remove the grey safety cap until the EpiPen is ready to be used.
10.
Remove outer protective cover by unscrewing the end lid off and sliding out the EpiPen (Figure 1 and 2).
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Skill 610 EpiPen and EpiPen Jr 1 of 4
Figure 1
Figure 2
CHILD
ADULT
11. Check the contents of the EpiPen through the viewing window. Make sure the solution is clear, colourless and sediment free. If the viewing window shows red the Epipen has been used and cannot be used again. 12.
Form a fist around the EpiPen. With the other hand pull off the grey safety cap (Figure 3). Do not hold the unit with your thumb over the end. Figure 3
13. Hold the EpiPen at 900 (right angle) to the fleshy upper outer part of the thigh. Either: or
Hold the black tip of the EpiPen about 5cm away from the thigh. Place the black tip of the EpiPen gently on the thigh (Figure 4) halfway between the knee and the hip. Figure 4
14.
Press the black tip firmly into the outer part of the thigh until a click is heard (Figure 5). Maintain a constant pressure against the thigh for 10 seconds. Figure 5
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Skill 610 EpiPen and EpiPen Jr 2 of 4
15.
Carefully take the EpiPen away from the thigh (Figure 6). Caution: Do not touch the needle, which is now sticking out of the black tip of the EpiPen. Figure 6
16.
Check the viewing window – it should now show red. If it does not show red and the needle is not exposed repeat the injection process.
17.
The EpiPen is only to be used once and must be immediately discarded directly into a sharps container if available. If not available carefully slide your used EpiPen back into its protective carry tube and recap the tube. Caution: Do not bend the exposed needle over and / or replace the grey safety cap. Note: after activation 1.7ml of the liquid will remain within the EpiPen.
18.
Gently massage the injection area for 5 to 10 seconds. If there is any bleeding apply a Band-aid.
19.
If a further dose is required a new EpiPen must be sought.
20.
Do not wait for the patient to improve, use form CPG General 1.9 DeMIST and transport immediately.
21.
Document administration on PCRF.
Storage 1.
The EpiPen is light sensitive and must be protected from light.
2.
Ensure outer protective cover is always in–situ.
3.
Store in a cool dry place at 250. Temperature variations of 15 0 permitted, Do not refrigerate. Extreme heat may cause malfunction.
4.
The contents window must be checked monthly.
5.
The shelf life is approximately 12 months.
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Skill 610 EpiPen and EpiPen Jr 3 of 4
PERFORMANCE CRITERIA SKILL 610 EPIPEN AND EPIPEN JR CONDITIONS Provide:
Suitable manikin and necessary equipment. Assistant.
STANDARDS 1.
Officer to understand and demonstrate how to prepare administer adrenaline via an EpiPen as per Skill 610.
2.
Clean techniques must be used.
3.
Eye protection and gloves to be worn.
4.
For use in life threatening situations, anaphylactic shock.
5.
An Adult repeat dose of the EpiPen 0.3mg may be given if symptoms are unrelieved after 5 to10 minutes.
6.
No repeat doses for children.
7.
Continue basic life support during administration of the EpiPen.
8.
All uses of the EpiPen must be documented stating time given, reason and any after effect. Also and entered in the appropriate medication books.
9.
May be used in conjunction with patient’s own regime.
10.
Sharps must be disposed of immediately after use.
11. EpiPen may be injected through clothing. 12. Always point the black tip away from any part of anybody, except the planned injection site.
KEY POINTS 1.
Caution: Patients that have used their own EpiPen may not have a Sharps Container or have correctly disposed of the EpiPen.
2.
This poses a direct threat of needle stick injury to Officers. If suspected ask if one was used, and if found deposit EpiPen into your sharps container immediately.
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Skill 610 EpiPen and EpiPen Jr 4 of 4
SKILL 611 ADMINISTRATION OF ADRENALINE BY NEBULISER November 2005
1.
Check Adrenaline vial, contents (1mg in 1.0ml) and expiry date. Discard if expired.
2.
Visually confirm the correct medication to be given with partner.
3.
Prepare drawing up needle attached to a 5ml syringe.
4.
Using vial breaker open vial.
5.
Using the drawing up needle / syringe withdraw total contents (1mg).
6.
Open a second vial and draw up contents. Total in syringe to be 2mg of adrenaline 2ml.
7.
Visually confirm the correct dosage in syringe with partner.
8.
Select the appropriate nebuliser mask size (Adult / Child).
9.
Inject syringe (2mg Adrenaline) into the nebuliser.
10.
Attach nebuliser to nebuliser mask.
11.
Attach oxygen therapy tube to nebuliser mask.
12.
Turn flow meter on to 8 litres per minute.
13.
Fit nebuliser mask to patient’s face, over nose and mouth.
14.
Document the time, effect and when dosages were given on the Patient Care Record Form.
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Skill 611 Administration of Adrenaline by Nebuliser 1 of 2
PERFORMANCE CRITERIA SKILL 611 ADMINISTRATION OF ADRENALINE BY NEBULISER CONDITIONS Provide:
A simulated patient sitting down (Child). Cardiac monitor (if available), oxygen supply with flow meter and tubing, sphygmomanometer, 2 vials of Adrenaline, nebuliser and mask (child) and Patient Care Record form are provided.
STANDARD 1.
Officer to understand and demonstrate the preparation and administration of Adrenaline via a nebuliser and mask as per Skill 611.
2.
Only to be administered to patient with severe croup with retractive breathing.
3.
Connect cardiac monitor if available.
4.
Record time, effect and dose on Patient Care Record form.
5.
Provide continued oxygen therapy.
KEYPOINT The turning on the oxygen prior to attaching the mask to the patient, is so some patients can benefit from seeing what is about to happen. Patients that have experience with nebulisers, the oxygen can be turned on after applying the mask.
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Skill 611 Administration of Adrenaline by Nebuliser 2 of 2
SKILL 612 ATOXTM COMBOPEN AUTO–INJECTORS October 2008
1.
The ATOXTM ComboPen is manufactured in one dosage:
2mg atropine sulphate and 220mg obidoxime chloride in 2mL
2.
Ensure hands are clean.
3.
Officer to wear examination gloves and eye protection.
4.
Select correct medication as per Clinical Practice Guidelines.
5.
Whilst medication is being administered continue all basic life support. (i.e. Oxygen—ventilate or give 100%, treat for shock etc).
6.
Obtain authorisation for use as per established Health Department protocol.
7.
Make ready the sharps container.
8.
Explain need and procedure to patient if able (Note: patient may be unconscious or in severe distress).
9.
Expose mid lateral thigh, if practicable and clean with alco–wipe. If not practicable, ComboPen can be injected through clothing.
10.
Slide the sealed plastic bag containing the ComboPen from the protective styrene sleeve as per Figure 1. FIG 1
11.
Check sealed plastic bag is intact (Figure 2). FIG 2
12.
Confirm drug with partner.
13.
Check expiry date. Note expiry date is not on the actual ComboPen but has been stuck onto the sealed plastic bag. Expiry is 5 years after date of manufacture which is printed on the actual ComboPen.
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Skill 612 Atoxtm ComboPen Auto-Injectors 1 of 4
14.
To open, tear the sealed plastic bag above the red marking ‘Pull Quickly’. There are two arrows about 20ml apart, one for each direction. Pull and tear along the weakened area in the direction of either arrow.
15.
Slide the ComboPen out.
16.
Form a fist around the ComboPen and with the other hand pull off the grey activation cap (Figure 3 and 4). Do not touch the end of the injector unit after removing cap. Figure 3
Figure 4
17.
Hold the black tip near the outer mid lateral thigh (Figure 5) (halfway between the knee and the hip). The thigh does not necessarily need to be exposed as the pen can be injected through minimal clothing. Figure 5
18.
With a quick motion push down hard against the skin at a 90o angle into the mid lateral thigh, until a click is felt or heard (this action releases the mechanism that injects the medication) and hold in place for 10 seconds (Figure 7). Figure 7
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Skill 612 Atoxtm ComboPen Auto-Injectors 2 of 4
19.
Remove ComboPen (Figure 8 and 9) and check the content has actually been injected by first looking to see if the needle is visible. The ComboPen is only to be used once and must be immediately discarded directly into a sharps container. The needle may be bent over prior to disposal. FIG 8
FIG 9
20.
Gently massage the injection area for 5 to10 seconds. If there is any bleeding apply a Band–Aid.
21.
Do not wait for the patient to improve.
22.
Where multiple casualties exist, move quickly onto the next patient and begin assessment.
23.
As patients are assessed and removed from the scene, use CPG ‘General 1.9 DeMIST’ and following decontamination procedures, transport immediately.
Storage 1.
The medication contained in the ComboPen is not to be refrigerated but stored below 300.
2.
Availability is as per Health Department.
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Skill 612 Atoxtm ComboPen Auto-Injectors 3 of 4
PERFORMANCE CRITERIA SKILL 612 ATOXTM COMBOPEN AUTO–INJECTORS CONDITIONS Provide:
Suitable manikin and necessary equipment.
Assistant.
Use training device.
STANDARDS 1.
Officer to use and demonstrate how to prepare and administer atropine and obidoxime via a ComboPen as per Skill 612.
2.
Clean techniques must be used.
3.
Eye protection and gloves to be worn.
4.
Sharps must be disposed of immediately after use.
5.
For use in life saving situations—nerve agent poisoning.
6.
Indication for use and dosages as per CPG.
7.
Continue basic life support during administration of the ComboPen.
8.
All uses of the ComboPen must be documented stating time given, reason and any after effect.
9.
Record medication appropriately. Multiple casualty situations may not allow for usual documentation—mark patient with permanent marker pen or document on Disaster Triage Tag.
KEY POINTS Staff to observe precautions to prevent exposure / poisoning from patient off– gassing.
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Skill 612 Atoxtm ComboPen Auto-Injectors 4 of 4
SKILL 613 SALBUTAMOL VIA SPACE CHAMBERTM March 2009 Description: 1.
The Space Chamber™ (Figure 1) is a device which is designed for the easy and efficient use of a Multi Dose Inhaler (MDI, Figure 2) as precise timing (matching inspiration with activating the MDI) is not necessary. By using the Space Chamber™, for both adults and children, more of the right size particles of medication enter deep into the lungs than when using a MDI on its own. Unwanted large particles in the aerosol mist are trapped inside the Space Chamber™ preventing irritation of the mouth and throat.
2.
Manufactured from medical grade polycarbonate with a silicone inspiratory valve and Teflon expiratory valve.
3.
Chamber volume 250ml.
4.
Unit is a single patient use device and can be left with the patient after ambulance treatment.
Space chamber components FIGURE 1
Multi Dose Inhaler (MDI) FIGURE 2
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Skill 613 Space Chamber Aerosol Spacer 1 of 4
Administration of Space Chamber Aerosol Spacer:
Adult and children who are familiar with device or can co–operate. 1.
Administer oxygen immediately.
2.
Advise patient of need and assist if required.
3.
Remove the cap from the MDI (Figure 2), hold upright and shake well. (After initial shake, the MDI will need to be re–shaken after every 20 puffs.)
4.
Push the MDI into the opening at the base of the Space Chamber (Figure 1).
5.
Place the spacer into the patient’s mouth, ensure their lips are closed firmly around it.
6.
If a resuscitation mask is to be used, apply gently but firmly to the face to ensure a good seal around mouth and nose.
7.
MDI regime:
8.
1 puff then 4 breaths ( 4 times) followed by 4 minutes of oxygen.
Instruct patient whilst keeping the space chamber in place to:
Deeply exhale.
Press the MDI / Puffer once (assist if required).
Never spray more than one puff of the medication into the spacer at one time.
Inhale taking a deep breath through the mouth.
Encourage mouth breathing which will increase medication delivery to the lungs.
4 normal breaths via the space chamber after each puff.
Slowly exhale.
9.
If the patient does not improve after the initial MDI regime, wait 4 minutes then repeat another regime. Continue this regime if required.
10.
After the 4 dose regime administer oxygen.
11.
If the patient does not improve after the initial 4 doses wait 4 minutes then repeat another regime of 4 doses. Continue this regime if required.
Paediatrics 1.
Administer oxygen via therapy mask immediately.
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Skill 613 Space Chamber Aerosol Spacer 2 of 4
2.
Assist, advise and encourage patient, as required.
3.
Remove the cap from the MDI, hold upright and shake well (after initial shake, the MDI will need to be re–shaken after every 20 doses).
4.
Push the MDI into the opening at the base of the Space Chamber (Figure 1).
FIGURE 3—INFANT
FIGURE 4—CHILD
Children under 3 years
Gently apply the mask, spacer and MDI on the child’s face holding the mask over the mouth and nose so that they are well covered with no gaps around the edges.
Press down on the inhaler once and wait for the child to take 4 deep breaths.
Children over 3 years and able to use without a mask
Place the spacer into the patient’s mouth, ensure their lips are closed firmly around it.
Encourage patient to deeply exhale.
Press down on the inhaler once.
Never spray more than one puff of the medication into the spacer at one time.
Then inhale, encourage holding their breath for 5 to 10 seconds. If unable wait for the child to take 4 deep breaths.
Encourage mouth breathing which will increase medication delivery to the lungs.
If the patient does not improve after the initial 4 doses repeat regime of 4 doses every 4 minutes.
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Skill 613 Space Chamber Aerosol Spacer 3 of 4
PERFORMANCE CRITERIA SKILL 613 SALBUTAMOL VIA SPACE CHAMBER CONDITIONS Provide:
A simulated patient sitting.
A Space Chamber Aerosol Spacer plus supplied MDI / Puffer.
Cardiac monitor.
Oxygen supply and masks.
Peak Flow Meter.
Patient Care Record forms.
STANDARDS 1.
Officer to understand and demonstrate the correct application and use of a Space Chamber as per Skill 613.
2.
Reassure and inform the patient as to the procedure needed to administer Salbutamol from a MDI via the Space Chamber.
3.
Consider the use of SpO2 monitor and Peak Flow Meter where patient is able (as per Skill 109).
4.
Provide oxygen therapy.
5.
Indications and regime as per Clinical Practice Guidelines.
6.
Never spray more than one puff of the medication into the spacer at one time.
7.
Adrenaline for severe if trained and authorised.
8.
Urgent transfer if severe and not responding to medication.
KEYPOINTS 1.
Be prepared to ventilate patient.
2.
For the first use of inhaler spray 1 puff into the air.
3.
Dispose of as per Infection Control Policy.
4.
Do not store in direct sunlight or heat. Do not puncture.
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Skill 613 Space Chamber Aerosol Spacer 4 of 4
BONE INJECTION GUN (BIG) The Bone Injection Gun (BIG) is a spring-loaded catheter allowing rapid cannulation of the intraosseous space in both adults (blue) and paediatric patients (red for patients 0- 12 years old).
Equipment The procedure should be undertaken in as sterile (or clean) environment as possible. Equipment required includes:
Bone injection gun (appropriate for patient’s age);
Skin cleaning/ preparation;
Gloves;
Adhesive surgical tape;
10 ml syringe
10ml normal saline for injection
Giving set
3-way tap
IV fluid
Application 1.
Select the site for the IO attempt. In adults this can be the proximal tibia, distal tibia (1-2 cm proximal to the base of the medial malleolus) or humerus (humeral head). The proximal tibia, which provides a flat surface with a thin layer of overlying tissue, is the only site to be used in paediatric patients.
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Bone Injection Gun (BIG) 1 of 6
2.
Ensure the appropriate IO site is selected to ensure the correct insertion depth by adjusting the blue barrel (the proximal tibia setting also applies for the humerus).
3.
If using the paediatric BIG ensure the appropriate age is selected by adjusting the red barrel.
4.
Considering the proximal tibia, place a rolled towel under the knee with the foot facing outward. Locate the tibia tuberosity (rounded protrusion distal to the patella) and then the tibia plateau. On adults the tibia plateau is 2 cm medial (towards the inner leg) and 1cm proximal (towards knee) while for paediatric patients+ it can be found 1cm medially and 1 cm distal (towards the ankle).
5.
Prepare the site with alcohol wipe or equivalent. Aseptic techniques should be used throughout the procedure.
6.
Position the BIG at a 90o angle to the surface of the skin, holding the BIG firmly with one hand (figure 1). FIGURE 1
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Bone Injection Gun (BIG) 1 of 6
7.
Still firmly holding the BIG against the skin, pull out the safety latch by squeezing its two sides together. Do not discard the latch (figure 2). FIGURE 2
8.
Under no circumstances should the safety latch be removed before the BIG is correctly positioned at the insertion site.
9.
While continuing to hold the bottom of the BIG firmly against the leg, place two fingers of your other hand under the ‘winged portion’ and the palm of that hand on top. Trigger the BIG by gently but firmly pressing down. It is not necessary to apply extra force to trigger the device (figure 3). FIGURE 3
10.
Remove the stylet trocar so that the cannula only remains in the bone. If correctly sited the cannula should stand unsupported in the bone (figure 4). FIGURE 4
11.
Use the previously removed safety latch to stabilise the cannula with tape (figure 5).
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Bone Injection Gun (BIG) 2 of 6
FIGURE 5
12.
Aspirate venous blood, however, it should be noted that the absence of blood does not mean the IO is incorrectly placed (figure 6). FIGURE 6
13.
Flush the cannula with 10 – 20 ml (5 – 10 ml in paediatrics) saline, before administering fluid or drugs. Fluid should be able to be injected with constant pressure without swelling of the tissues surrounding the cannula. In conscious patients, local anaesthesia should be considered prior to administering fluids (figure 7). FIGURE 7
14.
Fluids and drugs can now be administered. Although fluid may run from an IV line by gravity, the rate is too slow for resuscitation. Faster rates of infusion can be obtained by drawing up 20 ml aliquots from the intravenous bag and administering manual fluid boluses via a 3-way tap (paediatrics) or via a pressure infuser (adult).
15.
Intraosseous cannulae can be removed after good intravenous access is established after resuscitation. While IO cannulae can be left in place for 7296 hours the goal is often to remove it within 3-4 hours, due to the increased risk of infection and dislodgement.
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Bone Injection Gun (BIG) 3 of 6
Complications The risks and complications of IO access are few and the benefits often outweigh the risks in a patient without venous access who needs rapid administration of medication or fluid, however, noted complications include:
Compartment syndrome caused due to fluid entering the calf rather than the venous system. The risk of this complication can be reduced by limiting one IO attempt per tibia as repeated attempts in the same bone will allow fluid to flow through the existing holes;
Osteomyelitis – relatively rare but commonly due to poor aseptic technique;
Local tissue infection;
Pain (particularly infusing fluid in the conscious patient; and
Misplacement can increase the risk of compartment syndrome and in paediatric patients, can result in damage to the growth plates.
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Bone Injection Gun (BIG) 4 of 6
PERFORMANCE CRITERIA BONE INJECTION GUN 1.
Understand the indications for intraosseous access.
2.
Prepare the equipment required.
3.
Position the patient and explain the procedure.
4.
Prepare the site.
5.
Adjust the BIG depending on location or patient age.
6.
Position the BIG at a 90o angle at the correct chosen location.
7.
Remove the safety latch.
8.
Safely trigger the BIG.
9.
Remove the stylet trocar
10.
Attempt to aspirate venous blood
11.
Flush the cannula with normal saline and explain the consideration for a local anaesthetic
12.
Administer fluid and / or drugs in accordance with CPGs.
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Bone Injection Gun (BIG) 5 of 6
EZ-IO The EZ-IO is a sealed, hand-held battery powered medical drill capable of producing a minimum of 500 insertions of an intraosseous needle into bone.
Specific contra-indications The only absolute contraindication is a fracture of the tibia or long bone, however there are several relative contra-indications for the EZ-IO:
Excessive tissue and/ or absence of adequate anatomical landmarks;
Infection at the area of insertion;
Previous, significant orthopaedic procedure at the site (IO in past 48 hours, prosthetic limb or joint).
Equipment The procedure should be undertaken in as sterile (or clean) environment as possible. Equipment required includes:
Ez-IO (with appropriate needle for patient and location);
Skin cleaning/ preparation;
Gloves;
EZ-Connect extension set (primed with saline);
10 ml syringe
10ml normal saline for injection
Giving set
3-way tap
IV fluid
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EZ-IO 1 of 2
Application (see also manufacturer’s information) 1.
Select the site for the IO attempt. In adults this can be the proximal tibia, distal tibia (1-2 cm proximal to the base of the medial malleolus) or humerus (humeral head). The proximal tibia, which provides a flat surface with a thin layer of overlying tissue, is the only site to be used in paediatric patients.
2.
Select the appropriate needle for the patient and location: 15mm (pink), 25mm (blue) & 45mm (yellow). The needle choice is dependent on the patient’s weight and amount of tissue. The 15mm needle is for patients weighing 3 – 39 Kg and with patients with minimal tissue over insertion sites. The 25mm and 45mm needles are for patients over 45 Kg and selection will depend on the amount of tissue over the site. The 45mm needle is also ideal for the humerus site in patients over 39 Kg;
3.
Ensure that the driver and needle are securely seated;
4.
Considering the proximal tibia, place a rolled towel under the knee with the foot facing outward. Locate the tibia tuberosity (rounded protrusion distal to the patella) and then the tibia plateau. On adults the tibia plateau is 2 cm medial (towards the inner leg) and 1cm proximal (towards knee) while for paediatric patients it can be found 1cm medially and 1 cm distal (towards the ankle);
5.
Prepare the site with alcohol wipe or equivalent. Aseptic techniques should be used throughout the procedure;
6.
Position the driver at the insertion site with the needle at a 90 degree angle to the bone. Push the driver/ needle or gently power until the needle tip touches bone;
7.
Ensure that at least 5mm of the needle is visible (at least one black line).
8.
Penetrate bone cortex by squeezing the driver’s trigger and apply gently, downward pressure;
9.
Release the driver’s trigger and stop insertion when:
A sudden ‘give’ or ‘pop’ is felt upon entry into the medullary space;
The desired depth is obtained.
10.
Remove power driver and stylet;
11.
Confirm catheter stability, consider attempting to aspirate blood to confirm placement;
12.
Attach the primed EZ-Connect extension set;
13.
Flush the cannula with 10 – 20 ml (5 – 10 ml in paediatrics) saline, before administering fluid or drugs. Fluid should be able to be injected with constant pressure without swelling of the tissues surrounding the cannula. In conscious patients, local anaesthesia should be considered prior to administering fluids;
14.
Fluids and drugs can now be administered. Although fluid may run from an IV line by gravity, the rate is too slow for resuscitation. Faster rates of infusion
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EZ-IO 2 of 2
can be obtained by drawing up 20 ml aliquots from the intravenous bag and administering manual fluid boluses via a 3-way tap (paediatrics) or via a pressure infuser (adult). 15.
Intraosseous cannulae can be removed after good intravenous access is established after resuscitation. While IO cannulae can be left in place for no longer than 24 hours the goal is often to remove it within 3-4 hours, due to the increased risk of infection and dislodgement.
Complications The risks and complications of IO access are few and the benefits often outweigh the risks in a patient without venous access who needs rapid administration of medication or fluid, however, noted complications include:
Compartment syndrome caused due to fluid entering the calf rather than the venous system. The risk of this complication can be reduced by limiting one IO attempt per tibia as repeated attempts in the same bone will allow fluid to flow through the existing holes;
Osteomyelitis – relatively rare but commonly due to poor aseptic technique;
Local tissue infection;
Pain (particularly infusing fluid in the conscious patient; and
Misplacement can increase the risk of compartment syndrome and in paediatric patients, can result in damage to the growth plates.
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EZ-IO 3 of 2
PERFORMANCE CRITERIA EZ-IO 1.
Understand the indications for intraosseous access.
2.
Prepare the equipment required.
3.
Position the patient and explain the procedure.
4.
Prepare the site.
5.
Correctly assembles EZ-IO Driver and needle set.
6.
Stabilises the insertion site, inserts EZ-IO needle set, removes stylet and confirms placement.
7.
Demonstrates safe stylet disposal.
8.
Connects primed extension set and flushes the catheter.
9.
Explain the consideration for a local anaesthetic.
10.
Administer fluid and / or drugs in accordance with CPGs.
11.
Flush the cannula with normal saline and explain the consideration for a local anaesthetic.
12.
Administer fluid and / or drugs in accordance with CPGs.
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EZ-IO 1 of 2
SKILL 701 CHILDBIRTH November 2008 1.
Reassure mother, place in a position of comfort.
2.
Remove all constrictive clothing.
3.
Consider pain relief (Methoxyflurane).
4.
Place sheet under the mother’s pelvis.
5.
Arrange required equipment.
6.
Officer to put on eye protection and a fresh pair of examination gloves.
7.
As the baby’s head delivers provide resistance with one hand to prevent an over rapid delivery, tell mother to pant and not push. Use the other hand to support the perineum with a dressing pad.
8.
Once the head is delivered the officer checks the baby’s neck for loops of umbilical cord, if present and:
9.
Loose, slide the cord over the baby’s head prior to the next contraction.
The cord is too tight place two clamps on the cord approximately 3cms apart and cut between the clamps.
The officer guides the baby’s head downwards to deliver the upper shoulder, and then gently guides the head upwards to deliver the lower shoulder. The baby is never pulled.
10. Support baby’s head, neck and body and place on mother’s chest. 11. Second officer assumes responsibility for management and care of the newborn.
Dry and stimulate.
Put newborn to breast
Use a sterile gauze pad to wipe blood and mucus from around the newborns mouth and nose.
Aspirate using the baby mucus extractor, only if the airway is obstructed i.e. thick mucus / muconium. Suction down the nose only.
Assess respiratory effort.
Record time of delivery.
Record APGAR score at 1 and 5 minutes post birth.
12. Massage fundus to prevent bleeding. Do not await delivery of placenta. DO NOT pull on umbilical cord.
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Skill 701 Childbirth 1 of 3
13. Preferably clamp the cord in two places, 20cm and 25cm from newborn. If the cord is short or only part of the cord is available, attempt to leave some cord length with the newborn. 14. When the cord stops pulsating, cut between the two clamps. Ensure cord for the newborn is not bleeding, if so rectify by placing another clamp on the cord. 15. Delivery of the placenta:
Do not pull on the cord or delay transport.
If placenta delivers, place placenta with cord attached into an appropriate container and cover. Take to the hospital for further examination.
The placenta may take some time to deliver but usually delivers 20 minutes or so after birth.
Place pad over vagina and instruct mother to hold in place by keeping her legs flat and together. This action also helps with a torn perineum.
Remove soiled sheet and wipe any fluid from mother’s legs and buttocks.
Cover mother and keep her warm, wipe her face, neck and hands with a damp clean cloth, then dry.
16. Monitor both mother and baby during transport to hospital. APGAR APGAR Score
2
1
0
Appearance
Normal colour all over
Normal colour
Bluish-gray
(Skin coloration)
(hands and feet are pink)
(but hands and feet bluish)
or pale all over
PULSE
Normal
Below 100bpm
Absent
(Heart Rate)
(above 100bpm)
Grimace
Pulls away, sneezes or coughs with stimulation
Facial movement only
Absent
(grimace with stimulation)
(no response to touch)
Activity
Active,
No movement
(Muscle tone)
Spontaneous movement
Arms and legs flexed with little movement
Breathing
Normal
(Rate and effort)
rate and effort
Slow or irregular breathing,
good cry
weak cry
(Responsiveness or reflex irritability)
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(no pulse)
(“floppy” tone) Absent (no breathing)
Skill 701 Childbirth 2 of 3
PERFORMANCE CRITERIA SKILL 701 CHILDBIRTH CONDITIONS Provide:
Childbirth manikin.
Maternity and any other equipment.
Evaluator to guide baby through birthing manikin and provide any other information necessary to perform simulation.
STANDARDS 1.
Officer to understand and demonstrate correct childbirth techniques as per Skill 701.
2.
Officer to put on eye protection and a fresh pair of gloves.
3.
Consider pain relief, (only Methoxyflurane).
4.
Stimulate newborn by drying (rubbing action will stimulate) and put baby to breast.
5.
Aspirate using the baby mucus extractor, only if the airway is obstructed i.e. thick mucus / muconium. Suction down the nose only.
6.
Once the head is delivered the officer checks the baby’s neck for loops of umbilical cord, if present and:
If loose, slide the cord over the baby’s head prior to the next contraction.
If the cord is too tight place two clamps on the cord approximately 3cms apart and cut between the clamps.
7.
Massage the fundus immediately after birth to prevent and help stop bleeding
8.
If excessive bleeding occurs, consider suprapubic compression or MAST as a last resort.
9.
If baby delivers with amniotic sac unbroken, carefully puncture with a blunt instrument.
10. If respiration and pulse inadequate, carry out resuscitation of newborn (as per Skill 401). Do not attempt resuscitation if stillbirth expected (known death). 11. Document time of delivery and record APGAR score at 1 and 5 minutes post delivery. 12. Do not wait for delivery of the placenta. DO NOT pull on the cord or delay transport. If the placenta delivers, take to hospital for further examination. 13. Transport as per mother and baby’s condition. © Copyright St John Ambulance Australia (Western Australia) Inc.
Skill 701 Childbirth 3 of 3
SKILL 702 SHOULDER DYSTOCIA November 2008 1.
Reassure mother.
2.
Provide oxygen – high concentration or 100%.
3.
Anticipate possible tearing of the perineum and need for neonatal resuscitation.
4.
With the aid of an assistant on either side of the mother, place the mother in the Mc Roberts (flat on her back with knees to chest) position, the thighs are abducted and hyper flexed onto the abdomen (Figure 1). Figure
5.
With the assistance of maternal pushing on the next contraction, attempt to deliver the impacted (anterior) shoulder by using gentle downward traction. This manoeuvre should be attempted for 30 seconds.
6.
If the above manoeuvre does not deliver the impacted (anterior) shoulder then with out waiting for the next contraction immediately move onto the first suprapubic pressure manoeuvre Rubin 1 (Figure 2). Figure 2
7.
Rubin 1
An assistant adopts a “hand over hand” position (Figure 2), placing hands on the scapula (shoulder) of the baby. Continuous pressure is then applied in an attempt to roll the impacted shoulder towards the baby’s chest.
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Skill 702 Shoulder Dystocia 1 of 4
8.
The attending officer applies gentle downward traction whilst coaching the mother to push at the same time as the assistant attempts manipulation of the baby’s shoulder.
If delivery is unsuccessful attempt a Rocking Rubin 1 manoeuvre (Figure 3).
The attending officer and assistant perform the Rubin 1 manoeuvre as above, with the exception of the pressure being applied to the impacted shoulder is in a rocking motion. Figure 3
9.
If delivery is unsuccessful place the mother in a Reverse Mc Roberts (Figure 4) position, by rotating her onto all fours. Figure 4 McRoberts Position Protect Mother’s Privacy
10. Attempt delivery of the non-impacted shoulder (which is now the uppermost shoulder). 11. If delivery is unsuccessful position mother in an exaggerated Simms position (Figure 5).
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Skill 702 Shoulder Dystocia 2 of 4
Figure 5
12. Instruct mother to resist pushing by panting and breathing through contractions. 13. Advise receiving hospital. 14. Transport Priority 1.
If delivery is successful: 1.
Provide neonatal care as per Skill 701.
2.
Assess APGAR score at 1 and 5 minutes and record.
3.
Record events on PCRF (time of each manoeuvre and time of birth).
4.
Transport as per mother and / or newborn’s condition.
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Skill 702 Shoulder Dystocia 3 of 4
PERFORMANCE CRITERIA SKILL 702 SHOULDER DYSTOCIA CONDITIONS Provide:
Childbirth manikin.
Maternity and any other equipment.
Evaluator to guide baby through birthing manikin and provide any other information necessary to perform simulation.
STANDARDS 1.
Officer understands and demonstrates how to assist mother in delivery of a baby with Shoulder Dystocia as per Skill 702.
2.
Specific indications and precautions as per CPG’s.
3.
Consider pain relief (only Methoxyflurane).
4.
Move mother into Mc Roberts position and on the next contraction apply gentle downward pressure for 30 seconds in an attempt to deliver shoulder.
5.
If no resolution attempt Rubin one manoeuvre for 30 seconds.
6.
If no resolution attempt rocking Rubin manoeuvre.
7.
If no resolution roll mother onto all fours and attempt delivery.
8.
Transport priority one if baby not delivered.
9.
Assess and record APGAR score at 1 and 5 minutes post delivery.
10. Enroute coach mother to pant and breath through contractions (this helps avoid pushing). 11. Maintain mother in an exaggerated Simms position during transport. 12. Document events of each position.
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Skill 702 Shoulder Dystocia 4 of 4
SKILL 703 BREECH BIRTH October 2008 Delivery of a breech should not be attempted in the pre-hospital setting unless it is absolutely inevitable. Under no circumstances attempt delivery of a footling presentation. Breech Presentation The baby lies longitudinally with buttock presenting in the lower pole of the uterus. (The anterior buttock appears at the vulva. With further uterine contractions the buttocks distend the vaginal outlet). Delivery 1.
Offer to wear PPE (gloves mask and eye protection).
2.
Reassure the mother.
3.
Provided 100% oxygen.
4.
Position the mother in a lithotomy position with her buttocks at the edge of the stretcher / bed. This position is to allow for the baby to hang free. The mother may have to be moved to the first attendant seat (close the door). This can be laid flat or inclined so the mother’s buttock is at the edge.
5.
Place incontinence sheet/s under mother’s buttocks.
6.
Prepare delivery kit and neonatal resuscitation equipment.
7.
Do not attempt to push the baby back in.
8.
Encourage the mother to push during contractions. Active pushing is not encouraged unless baby’s buttock is on the perineum.
9.
Allow breech to deliver spontaneously. NEVER pull on a breech.
10. Only offer Methoxyflurane between contractions. 11. Hands off the breech. Allow the legs, abdomen and trunk to deliver by maternal effort. Once the buttock is born external rotation of buttocks is seen whereby the baby’s back becomes uppermost. 12.
If legs are extended: slide two fingers along the anterior leg and apply steady gentle pressure in the popliteal fossa. Deliver the leg by flexion and abduction. Repeat on the other leg. Note: Active efforts to deliver the legs are not mandatory, as the legs will deliver spontaneously and the feet will “spring” free eventually. However if extended legs in a frank breech are obstructing the process of the birth then attempt to deliver the legs.
13. As the umbilicus is born gently bring down a loose loop of cord (approximately 15cm) by sliding and hooking two fingers anteriorly on the cord.
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Skill 703 Breech Birth 1 of 4
Note: A loop of umbilical cord may be gently pulled down. This prevents tension on cord as the body delivers, and also allows easy monitoring of the baby’s pulse by palpation. Sudden or rough handling of the umbilical cord can cause vasospasm thus resulting in hypoxia. 14. If the shoulders do not spontaneously deliver place a single layer towel over the buttocks (optional) and grasp the pelvic girdle only with thumbs on the sacrum and index and mid fingers on the hips. The officer is now ready to assist with the delivery of the shoulders. 15. Once the tip of the scapula comes into view, gently rotate the posterior shoulder anteriorly into the oblique by rotating the baby through 1800. The sacrum is kept anterior at all times (keep back uppermost). With the next contraction and maternal effort apply gentle downward traction to deliver the shoulder. 16. The newborn is then gently rotated through 1800 in the opposite direction to bring the anterior shoulder in to the other oblique plane. Deliver the anterior shoulder by using gentle downward traction. The sacrum is kept anterior at all tines (keep back uppermost). 17. If arm is extended and obstructs progress: Slide two fingers along the anterior arm and apply steady gentle pressure in the cubital fossa. The arm is then flexed and swept across the chest and out of the introitus. The baby is then rotated to original position of back facing uppermost. The baby is then allowed to hang down under it own weight until the nape of the neck is visible (usually takes approximately 10 seconds). 18. Once the nape of the neck is visible, place one hand/forearm under the baby to provide support (ensure the attendant’s fingers are positioned ready to flex the head via the modified Mariceau – Smellie Veit manoeuvre as per Figure 1. Do not place fingers into the birth canal). FIGURE 1
19. Delivery of the head then commences with the next contraction. The head is then flexed through the pelvis by the Mariceau – Smellie Veit manoeuvre. 20. The newborn is then raised upwards towards the mother’s abdomen. 21. Note and later record time of birth on PCRF. © Copyright St John Ambulance Australia (Western Australia) Inc.
Skill 703 Breech Birth 2 of 4
22. Proceed with normal neonatal care as per Skill 701. 23. If the baby’s head dose not deliver within 3 minutes:
Transport the mother in an exaggerated Simms position (Figure 2) with the V hold on the baby’s face if practical.
FIGURE 2
Advise receiving hospital.
Monitor and record mother’s vaginal blood loss. Breech birth is a predisposing factor for postpartum haemorrhage.
Transport immediately Priority 1.
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Skill 703 Breech Birth 3 of 4
PERFORMANCE CRITERIA SKILL 703 BREECH BIRTH CONDITIONS Provide:
Childbirth manikin.
Maternity and any other equipment.
Assistant.
STANDARDS 1.
Officer understands and demonstrates how to deliver a breech birth as per Skill 703.
2.
Specific indications and precautions as per CPG’s.
3.
Officer to wear PPE (gloves mask and eye protection).
4.
Management of mother and baby as per Skill 701.
5.
Do not place fingers into birth canal.
6.
Do not attempt to push baby back in.
7.
Allow breech to deliver spontaneously. Never pull on a breech.
8.
Offer Methoxyflurane only between contractions.
9.
Hands off breech. Allow legs, abdomen and trunk to deliver by maternal effort.
10. A loop of umbilical cord may be gently pulled down. This prevents tension on cord as the baby delivers, also allows easy monitoring of the baby’s pulse by palpation. Sudden or rough handling of the umbilical cord can cause vasospasm thus resulting in hypoxia. 11. If the baby’s head dose not deliver within 3 minutes:
Transport the mother in an exaggerated Simms position with the V hold on the baby’s face if practical.
Advise receiving hospital.
Monitor and record mother’s vaginal blood loss. Breech birth is a predisposing factor for postpartum haemorrhage.
Transport immediately Priority 1.
12. Note and later record time of birth on PCRF. 13. Document all events on PCRF.
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Skill 703 Breech Birth 4 of 4
SKILL 801 APPLICATION OF MEDICAL ANTI–SHOCK TROUSERS (MAST) November 2003 1.
Decide on use as per Clinical Practice Guidelines.
2.
Remove sharp objects from patient’s pockets and belts.
3.
Remove MAST from carry bag / case.
4.
Unfold MAST and lay it flat, separate the sections if required.
5.
Both officers ensure placement of MAST under patient (in supine position) with top of garment just below the lowest rib (approximately 50mm). The suit may be applied in separate sections. The pelvic region may overlap the leg sections so the correct position on the patient can be achieved.
6.
Wrap garment around legs—left leg and waist strap first, followed by right leg and waist strap—and secure with Velcro. Ensure that the garment does not interfere with the genital region of the patient.
7.
Re–adjust garment around abdominal area and secure with Velcro.
8.
Attach pump tubing to valves on the legs and abdominal sections of the MAST.
9.
Open both pressure valves on leg sections of MAST Close pressure valve on abdominal section.
10.
With sole of foot on rear portion of foot pump, inflate leg sections of MAST first until air exhausts through pressure relief valves.
11.
Close both valves on leg sections of MAST.
12.
Re–check patient’s systolic BP. If you suspect internal abdominal bleeding then continue inflating the abdominal section of the suit without taking the BP.
13.
Abdominal section to be inflated following inflation of the leg section if systolic BP does not exceed 100 mmHg.
14.
If indicated, open abdominal section pressure valve and inflate abdominal section until air exhausts through relief valve.
15.
Close the valve on the abdominal section.
Application for the purpose of splinting 1.
The garment should be separated and only the required section be applied.
2.
If applied for fracture management to the limb or limbs, traction needs to be applied until the garment is correctly inflated and has immobilised the limb sufficiently to remove traction. Turn off the valve once inflated.
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Skill 801 Application of Medical Anti-Shock Trousers (MAST) 1 of 4
3.
Pump up the garment only to provide immobilization or enough pressure to secure the limb or the pelvic region. Effective perfusion is required at the fracture site. Caution: This application is not for blood pressure control, however if both fracture and blood pressure management is required then increase the pressure as per Skill.
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Skill 801 Application of Medical Anti-Shock Trousers (MAST) 2 of 4
PERFORMANCE CRITERIA SKILL 801 APPLICATION OF MEDICAL ANTI–SHOCK TROUSERS (MAST) CONDITIONS Provide:
A simulated patient lying in supine position. MAST and sphygmomanometer.
STANDARD 1.
Officer to understand and demonstrate the application of the MAST suit as per Skill 801.
2.
Abdominal section is to be inflated immediately following inflation of the leg sections, when there is abdominal injury / bleed.
3.
Abdominal section to be inflated following inflation of the leg section if systolic BP does not exceed 100mmHg.
4.
MAST to be considered if falling trend is evident in BP. (indicative of shock) even if not below 90mmHg (not including Cardiogenic Shock).
5.
If respiratory distress is evident, partially deflate abdominal section until patient relief is achieved.
6.
Once inflated do not deflate MAST in the pre–hospital environment as it will cause a sudden and potentially fatal drop in BP.
7.
Sections of the MAST may be used for splinting purposes.
8.
Contra–indications.
9.
For whole use of MAST:
10.
Suspected bleeding into the chest.
Pulmonary oedema.
Cardiogenic shock.
Unless the severity of other injuries are overriding.
For abdominal section of MAST:
Pregnancy.
Impaled objects in the abdomen.
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Skill 801 Application of Medical Anti-Shock Trousers (MAST) 3 of 4
KEY POINTS 1.
The MAST is very effective for splinting fractures of the pelvis and lower limbs and also for controlling local external bleeding.
2.
In applying the MAST, abdomen and leg sections may be separated and applied individually.
3.
For patients with short legs, the leg sections may be flared back at the foot end and triangular bandages applied to replace Velcro.
4.
In large patients where the Velcro does not hold, triangular bandages may be used to supplement the Velcro.
5.
In small patients the abdominal section may be too large, use a pillow to fill the space between the suit and patient to allow the Velcro of the abdominal section to be secured.
6.
Remove sharp objects from patient’s pockets and belts before application of the MAST.
7.
Do not inflate on students or others for training purposes.
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Skill 801 Application of Medical Anti-Shock Trousers (MAST) 4 of 4
SKILL 802 APPLICATION AND MAINTENANCE OF ROTATING TOURNIQUETS October 2002
1.
Explain procedure and reassure patient.
2.
Sit patient upright.
3.
Palpate distal pulses in all four extremities.
4.
Apply broad triangular tourniquets to both legs and left arm. Tighten gently and knot bandage to occlude venous flow without causing pain. Tourniquets should be positioned as close to the trunk as practicable. Ensure there is padding placed under any knots.
5.
Confirm that arterial pulses remain palpable after initial application and subsequent rotation.
6.
Make a note of the time of application and to which limbs applied on the Patient Care Record form.
7.
Working anti–clockwise remove one tourniquet every 20 minutes and apply to the free limb. Begin by moving left arm tourniquet to right arm. After 20 minutes move left leg tourniquet to left arm, continue rotation until arrival at medical facility. Never place tourniquets on all limbs at once. ROTATING TOURNIQUETS ORDER OF ROTATION
Start
After 20 minutes
After 40minutes
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After 60 minutes
Skill 802 Application and Maintenance of Rotating Tourniquets 1 of 2
PERFORMANCE CRITERIA SKILL 802 APPLICATION AND MAINTENANCE OF ROTATING TOURNIQUETS CONDITIONS Provide:
A simulated patient is lying / sitting down. Triangular bandages and a blood pressure cuff.
STANDARD 1.
Officer to understand and demonstrate the application and maintenance of Rotating Tourniquets as per Skill 802.
2.
Officer to communicate with patient.
3.
Removal of tourniquets using the established plan of rotation. Tourniquets should be removed in an anti–clockwise direction, one limb at a time at 20 minute intervals.
4.
When this skill is being performed on a live simulated patient, the bandages will be loosely applied to the appropriate limbs. One arm may be properly bandaged to demonstrate the correct application. This is to be removed when swelling and/or discolouration occurs or sooner if desired.
KEY POINTS 1.
An effective venous tourniquet may cause the limb to discolour and swell.
2.
In place of a broad bandage, a BP cuff can be used if applicable. If used inflate to 50 mmHg and check for pulse.
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Skill 802 Application and Maintenance of Rotating Tourniquets 2 of 2
SKILL 804 WOUND CLOSURE SUTURING AND USE OF STERI STRIPS November 2005 Wound management: 1.
Control the bleeding as per CPGs and relevant Skills.
2.
Contact appropriate M.O. and give full status of patient and description of the wound. Send photo if equipment available (e.g. computer, email or fax).
3.
Follow and record advice given.
Suturing equipment 1.
Items required or contained in a sealed sterile Suturing Kit:
2.
Sterile dressing pack.
3.
5 or 10ml syringe (for Lignocaine).
4.
10ml ampule of 0.5% or 1% Lignocaine.
5.
Drawing–up needle 18g / or blunt needle.
6.
Giving needle 23g.
7.
Suture material (sterile) silk or nylon.
8.
Sterile normal saline 30ml steritube.
9.
Sterile Chlorhexidine 30ml steritube.
10.
Sterile dissecting forceps (tweezers).
11.
Sterile needle holder.
12.
Curved reverse cutting needle.
13.
Sterile Fine sharps (scissors).
14.
Alcohol swabs.
15.
Sterile surgical gloves.
16.
Sharps container.
17.
Adequate sterile dressing material.
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Skill 804 Wound Closure Suturing and use of Steri Strips 1 of 11
Cleaning solutions: 1.
Normal saline, use first if wound unclean.
2.
Chlorhexidine – may be spirit or water based.
3.
Iodine – commonly used as ‘Povidone Iodine’ (Betadine).
4.
Savlon or similar antiseptic – not as irritating to tissues, but may be less effective. Caution: Do NOT use strong disinfectants such as Betadine, Hibitane or Hydrogen Peroxide in wounds.
Anaesthetic 1.
Before suturing, a local anaesthetic must be given.
2.
0.5% or 1% plain lignocaine. Dose 5mls up to a maximum dose 20mls.
Preparation 1.
Check right patient / right wound.
2.
Obtain necessary equipment.
3.
Wash hands.
4.
Prepare equipment—open all packaging.
5.
Make patient comfortable, ideally lying down.
Anaesthesia 1.
Wash hands.
2.
Place gloves on (non sterile).
3.
Select lignocaine and check with another person for correct drug then open ampoule.
4.
Draw up 5mls of lignocaine using a18g needle using 5 or 10ml syringe, place on zone of transference outer edge 5cms of sterile dressing field.
5.
If lignocaine is supplied in plastic ampoule, draw the drug using the 23g giving needle.
6.
Dispose of drawing up 18g needle and replace with a 23g giving needle.
7.
Alcohol swab around the edges of the wound.
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Skill 804 Wound Closure Suturing and use of Steri Strips 2 of 11
8.
Using lignocaine syringe with bevel up on a slight angle insert the needle with a short sharp movement into the end of the wound (Point 1 Figure 1). Draw back, if clear, inject local anaesthetic whilst slowly withdrawing the needle.
9.
Continue injections as per numbered area (Figure 1) placing the needle in the direction of the arrows. Depending on the length and shape of the wound numbers 2,3,5,6 may not be necessary or more injections may be required. FIGURE 1
10. Place unused lignocaine onto zone of transference in case it is required later. 11. Allow 10 minutes for lignocaine to work. 12. Remove and dispose of dirty gloves.
Suturing procedure
Caution: suturing is a high risk procedure for needle stick injury 1.
Wash hands.
2.
Open sterile glove (inner packet).
3.
Gloves are marked left and right. Place dominant hand into correct glove. Use other hand to pull on the glove by holding the glove from the inside of the cuff of the glove. Then do the same with the other hand, except pull the glove on by grabbing the cuff from the outside face of the glove. This method keeps the surface of the gloves sterile.
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Skill 804 Wound Closure Suturing and use of Steri Strips 3 of 11
Cleaning Methods: (Figure 2) 1.
Using sterile forceps and swab balls soaked in chlorhexidine clean the wound. Pick up soaked swab balls with forceps and change to dirty hand, clean wound edges as in Figure 2a. A sterile scrubbing brush (Figure 2b) may be useful in wounds more than 3-4 hours old.
2.
Excision or debridement of necrotic tissue (Figure 2c) – paramount to reduce risk of infection.
3.
Irrigate with eg 20ml syringe(s) of sterile saline until all visible particles removed (Figure 2d).
4.
Gauze, cottonwool – less desirable, due to the potential of fibres being left behind. FIGURE 2
6.
Cleaning and preparation of the wound before closure is the key to prevention of infection and good wound care.
7.
When finished, dispose of forceps and swabs, as necessary.
8.
Using a sterile sheet provided, find the middle and tear / cut a small hole through which the wound can be visualised.
9.
Open sheet over the wound with the wound exposed in the middle of the hole.
10. Now the wound can be explored. Ensure it is numb, if not more anaesthetic may be required. 11. Using saline and gauze explore with fingers and remove all debris.
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Skill 804 Wound Closure Suturing and use of Steri Strips 4 of 11
Suturing 1.
Select suture size. Sutures of gauge 2.0 (3 metric) would be used in scalp laceration. Finer 4.0 (1.5 metric) sutures in hand lacerations and 5.0 or 6.0 (0.7) sutures in facial wounds.
2.
The thicker the gauge of suture, the greater the amount of foreign body introduced into the wound and correspondingly increased scarring potential.
3.
Inappropriately thick sutures will result in more tissue disruption and local necrosis.
4.
Using a sterile needle holder (as held in Figure 3) pick up the suturing needle as per Figure 4. FIGURE 3
FIGURE 4
The needle must NOT be held near the end, or it will bend and possibly break in the tissues. 5.
Match the wound edges looking for identifying marks. Place one suture somewhere near the middle of the wound and observe how the wound ‘comes together’. If this does not ‘look right’ then cut the suture and try again.
6.
Using a curved reverse cutting needle, the further the distance from the edge of the wound, the deeper the ‘bite’ of the suture. If the wound is shallow, puncture the skin relatively close to the skin edge.
7.
Throw the first stitch. Aim to close the wound fully by placing the suture at the deepest part of the wound (Figure 5). FIGURE 5
8.
Bite deep into the wound down to the base of the wound and go through to the other side, and out at the same diameter from middle as the first side.
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Skill 804 Wound Closure Suturing and use of Steri Strips 5 of 11
FIGURE 6
9.
FIGURE 7
Distance from the needle entry / exit points to the wound edge. The greater the distance from the wound edge to the needle entry point, the deeper the bite of the needle. AB must equal CD (Figure 6 and 7) otherwise a step will occur at the adjoining edges of the laceration.
10. Assume the suture has been placed from the right to left across the wound (as in Figure 8). Take the needle in the left hand with the needle holder in the right. FIGURE 8
11. As per Figure 9, the needle holder lies against the suture. Wrap the suture over and around the instrument three times away from you. FIGURE 9
12. Take hold of the end of the suture with the jaws of the needle–holder as per Figure 10. FIGURE 10
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Skill 804 Wound Closure Suturing and use of Steri Strips 6 of 11
13. Pull this first ‘throw’ down. The left hand goes to the right and vice versa (cross the hands). The knot should now lie ‘flat’. Tension the suture to align the wound edges (approximate) as per Figure 11. FIGURE 11
14. Let the end of the suture go. The ‘short end’ should now lie to the LEFT with the knot flat across the wound as per Figure 12. 15. Bring the suture against the needle–holder. Wrap the suture around the needle three times toward you as per Figure 12. FIGURE 12
16. Take hold of the ‘short end’ with the needle–holder. 17. Pull this second ‘throw’ down onto the first. The left hand pulls to the left, the right to the right as per Figure 13. Tension the knot off so that the knot lies to the left of the wound as per Figure 14. FIGURE 13
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FIGURE 14
Skill 804 Wound Closure Suturing and use of Steri Strips 7 of 11
18. Cut the suture at 0.5cm from the wound. Take care with nylon, which will tend to slip—leave longer or put an extra knot on. 19. Continue stitches until wound fully closed tying off to the left of wound as per Figure 14. 20. Cover with appropriate sterile dressing and bandaging. 21. Detail follow–up, any abnormalities or complications, appointments and care of the wound with the patient. 22. Record all details.
Suture removal procedures: 1.
Sutures may be placed in–situ by medical staff and need to be removed when authorised by medics at a later date.
2.
The location of the wound and the state of wound healing determine when sutures are removed. In general: Eyelids Eyebrows Face Lips Ears
– – – – –
2 days 4 to 5 days 3 to 5 days 3 to 5 days 4 to 6 days
Scalp Trunk Hands and feet Arms and legs Over joints
– – – – –
7 to 10 days 7 to 10 days 10 to 14 days 10 to 14 days 14 days
Removal of the suture: 1.
Expose the wound.
2.
Examine for possible infection or other problems. Contact Medical Officer if problems exist.
3.
Using forceps / tweezers grab hold of the knot. Pull slightly up allowing for one side of the suture to be exposed.
4.
Using scissors cut the suture directly under the knot closest to the skin as per Figure 15. FIGURE 15
5.
Pull, removing the suture though the wound.
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Skill 804 Wound Closure Suturing and use of Steri Strips 8 of 11
6.
Clean surface of wound if necessary with normal saline only.
7.
Reapply dressing and bandaging if required.
8.
Record details, instruct patient to return if any further problems occur.
9.
Inspect at 1, 3 and 5 days for swelling, pain or bleeding.
Skin closure strips (Steri Strips™) (Figure 16) 1.
These paper adhesive strips are widely used in ED departments. They are less painful to apply, they are less likely to cause tissue ischaemia and they save time. They are very useful in:
2.
Conjunction with sutures.
3.
Children.
4.
Flap lacerations, especially in pre–tibial lacerations in the elderly.
5.
Some finger injuries—take care not to place tightly around a finger.
6.
Skin closure in wounds where a deep layer of sutures has approximated the skin edges.
7.
However, make sure that they are not used as a ‘short cut’ in wound care. It is essential that proper wound cleaning and exploration be carried out if indicated. FIGURE 16
FIGURE 17
10. Clean the wound. 11. Apply Tincture Benz Co. (Figure 16) around the area of the wound and allow drying. Caution: If allowed to enter the wound it will sting. 12. Apply Steri strip (Figure 17) to one edge of the wound and align and bring the wound together. Use as many strips as necessary. 13. Protect wound with appropriate sterile dressings and bandaging. 14. Inspect at 1, 3 and 5 days for swelling, pain or bleeding. © Copyright St John Ambulance Australia (Western Australia) Inc.
Skill 804 Wound Closure Suturing and use of Steri Strips 9 of 11
Steri strip removal Remove strips by lifting the edges from either end of the strip, (Figures 18 and 19) bringing the two ends together carefully, then continue to lift away carefully, changing direction along the wound (Figure 20), continue to pull away until free. FIGURE 18
FIGURE 19
FIGURE 20
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Skill 804 Wound Closure Suturing and use of Steri Strips 10 of 11
PERFORMANCE CRITERIA SKILL 804 WOUND CLOSURE SUTURING AND USE OF STERI STRIPS CONDITIONS Provide:
All equipment necessary for suturing and Steri Strips. Simulated wound using butcher meat.
STANDARD 1.
Persons authorised to perform Wound closure as per Skill 804 must have direct permission from the duty physician, as directed by the Ambulance Control Centre, or the physician directly covering that work place to perform the procedure on each wound prior to proceeding.
2.
Be able to understand and demonstrate wound closure techniques as per Skill 804.
3.
Recognise the suitability of a wound for suturing.
4.
Perform a physical assessment of the wound to assess damage to internal structures.
5.
Demonstrate and justify approved methods of preventing cross infection and infection.
6.
Demonstrate and justify sterile techniques for wound dressing and suturing.
7.
Describe the indications and demonstrate the use of adhesive wound closures, to include the use of Tincture of Benzoin.
8.
Demonstrate an approved method of suture, Steri Strip removal and state the time frame involved.
9.
State the review procedures for a patient following treatment.
10.
Record all details and problems incurred.
11.
Inspect at 1, 3 and 5 days for swelling, pain or bleeding.
12.
The suturing of facial regions and hands should be avoided and left to the experts.
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Skill 804 Wound Closure Suturing and use of Steri Strips 11 of 11
SKILL 805 VALSALVA MANOEUVRE April 2006 Definition The Valsalva Manoeuvre is a technique designed to raise intra–thoracic pressure temporarily and induce a reflex response of increased vagal tone. Purpose Increased vagal tone is useful for reverting narrow complex regular atrial tachycardias such as SVT and atrial flutter. It does not work for irregular rhythms e.g. atrial fibrillation (AF). Contraindications The Valsalva Manoeuvre should not be performed on patients who have severe coronary artery disease, have experienced recent heart attack, or where there is haemodynamic instability i.e. the patient should be conscious, normo–tensive, and no chest pain or signs of ventricular failure. Preparation 1.
Check for contraindications.
2.
Patient must be conscious and able to follow commands.
3.
Position patient horizontal.
4.
Connect Patient to a monitor / defibrillator and oxygen.
5.
Analyse rhythm.
6.
Describe procedure to patient. Patient may already have attempted this themselves or experienced similar treatment. Ask what was successful.
Attempt Valsalva Manoeuvre 1.
Position patient supine.
2.
Disconnect the blood pressure cuff from a sphygmomanometer.
3.
Attach oxygen therapy tube to the sphygmomanometer.
4.
Ask the patient to blow into the other end of the oxygen therapy tube and maintain a pressure of 40 mmHg for 15-20 seconds.
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Skill 805 Valsalva Manoeuvre 1 of 3
OR 1.
Position patient supine.
2.
Disconnect the bulb from a sphygmomanometer.
3.
Attach either a 5 or 10ml syringe without the plunger to the tube where the bulb was attached.
4.
Ask the patient to blow into the plunger end of the syringe and maintain a pressure of 40 mmHg for 15-20 seconds.
Risks: The patient may feel dizzy or faint during the procedure, but serious consequences are uncommon. The Valsalva Manoeuvre may precipitate other arrhythmias and so should only be performed with cardiac monitoring and resuscitation facilities available.
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Skill 805 Valsalva Manoeuvre 2 of 3
PERFORMANCE CRITERIA SKILL 805 VALSALVA MANOEUVRE CONDITIONS Provide:
Simulated Patient. Oxygen therapy tubing or 5 or 10ml syringe. Other similar equipment may be used.
STANDARD 1.
Officer understands and demonstrates Valsalva Manoeuvre as per skill 805. Caution: The simulated patient need not actually apply the pressure required (act only).
2.
Patient must be conscious and able to follow commands.
3.
Only to be used for reverting narrow complex regular atrial tachycardias such as SVT and atrial flutter.
4.
Patient must be positioned horizontal, not sitting up.
5.
Patient must be Monitored and given oxygen (high concentration—100%).
6.
Resuscitation and defibrillation equipment must be at the ready.
KEY POINTS 1.
Success rate is much lower in patients sitting up.
2.
Other similar methods and equipment may be used to produce a Valsalva Manoeuvre.
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Skill 805 Valsalva Manoeuvre 3 of 3
SKILL 806 NON – INVASIVE PACING (FIST PACING) November 2010 Percussion pacing is capable of producing an adequate cardiac output with minimal trauma to the patient. Fist pacing is used when bradycardia becomes severe and perfusion is inadequate. The patient must have a monitor attached and a defibrillator available. If percussion does not produce an effective circulation promptly, regardless of whether or not it stimulated QRS complexes, start CPR without further delay. How to deliver the percussion pacing 1.
Attach monitor and ensure defibrillator available..
2.
Use a closed fist to deliver blows lateral to the lower left edge of the sternum to pace the heart at the physiological rate 50 – 70 per minute.
3.
Each blow should be delivered from a height of approximately 100mm above chest.
4.
These blows should be gentle enough to be tolerated by a conscious patient.
5.
Whilst observing the rhythm on the monitor look for a QRS associated with each blow.
6.
If the initial blow does not produce a QRS complex try to find the best position for percussion by moving, until a site is found that produces repeated ventricular stimulation with the best size QRS complex.
7.
If necessary, reduce the force of the blows to the minimum force necessary to stimulate a QRS complex.
8.
Continue until either an external pacemaker is attached or patient is handed over at hospital.
9.
If percussion pacing does not produce a complex and the patient is clinically dead start CPR.
10. Transport priority one. 11. Advise hospital as per CPG General 1.9 De MIST.
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Skill 806 Non-Invasive pacing (First Pacing Review date November 2015 1 of 2
PERFORMANCE CRITERIA SKILL 806 NON INVASIVE PACING / FIST PACING CONDITIONS Provide:
An appropriate manikin and necessary equipment.
Monitor / defibrillator.
Assistant.
STANDARDS 1.
Officer to understand and demonstrate how to perform Fist Pacing as per Skill 806.
2.
Specific indications and precautions as per CPG’s.
3.
Patient must have a monitor attached, defibrillator available.
4.
Fist pacing is used when bradycardia becomes severe and perfusion is inadequate.
5.
Deliver blows with closed fist lateral to the lower left edge of the sternum to pace heart at the physiological rate 50 -70 per minute.
6.
Each blow should be delivered from approximately 100mm above the lower edge of the sternum.
7.
In conjunction with the monitor determine the most effective position to improve output.
8.
If percussion pacing does not produce a complex and / or adequate perfusion is not restored start CPR.
9.
Document events of Fist Pacing.
10. Transport Priority 1. 11. Advise hospital as per CPG General 1.9 DeMIST.
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Skill 806 Non-Invasive pacing (First Pacing Review date November 2015 2 of 2
COMBAT APPLICATION TOURNIQUET (CAT®) June 2011 The Combat Application Tourniquet (CAT®) consists of a strap that is placed around an injured limb (extremity) and then tightened with a tension rod (windlass) that can effectively occlude arterial blood flow by applying even circumferential pressure to an extremity. The windlass is secured in place so that the victim can be transported for emergency care.
Indications The use of a tourniquet is a LAST RESORT and should only be employed when bleeding cannot be stopped and the situation is life-threatening. Majority of cases external haemorrhage can be controlled by applying direct pressure, however, immediate application of a tourniquet may be justifiable in the following examples: Extreme life‐threatening limb haemorrhage, or limb amputation/mangled limb with multiple bleeding points, to allow immediate management of airway and breathing problems. Following treatment of any airway or breathing problems the need for a tourniquet can be reassessed in the circulatory assessment and may be converted to a simple method of haemorrhage control;
Life threatening limb haemorrhage not controlled by other methods;
Point of significant haemorrhage from limb is not peripherally accessible due to entrapment and therefore it is not possible to initiate other methods of haemorrhage control such as direct pressure;
Major incident or multiple casualties with extremity haemorrhage and lack of resources to maintain other methods of haemorrhage control; or
Benefits of preventing death from hypovolaemic shock by cessation of ongoing external haemorrhage are greater than the risk of limb damage or loss from ischaemia caused by tourniquet use.
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®
Combat Application Tourniquet (CAT ) Review date: May 2016 1 of 5
The tourniquet should be applied as distal as possible, but at least 5 cm proximal to injury, avoiding joints as much as possible and ideally applied directly on to exposed skin to avoid slipping. Effectiveness of tourniquet use will be determined by cessation of external haemorrhage and not by the presence or absence of a distal pulse. If it is ineffective the tourniquet should be tightened or repositioned. Slight oozing may still occur in a limb amputation despite effective application if there is medullary bone blood flow. The time of application should be recorded and handed over to the receiving emergency department staff. Assuming that the tourniquet has been applied for the correct indications a decision will need to be made regarding its continued use. This will depend on several factors including: whether the external haemorrhage is from an isolated injury; if the other injuries have been stabilised; the current haemodynamic status of the patient; estimated journey time to hospital; and the medical resources available. If transit time is expected to be less than one hour, the tourniquet should remain in situ until the patient is in the operating theatre where direct surgical control of haemorrhage can be undertaken. If the transit time is greater than one hour and if there is an isolated injury (or the other life‐threatening injuries have been managed adequately) and the patient has stable vital signs, a ‘trial of tourniquet conversion’ may be attempted. It is possible that after a period of time of reduced arterial flow from tourniquet use, clotting will have occurred sufficiently to arrest haemorrhage, allowing simpler methods to be effective and reducing the complications from continued tourniquet use. Before release of the tourniquet the practitioner should have applied direct pressure over the bleeding point. If careful release of the tourniquet results in a return of uncontrollable external haemorrhage, the tourniquet should be replaced and not removed until the patient is in the operating theatre. Application 1.
Remove the tourniquet from the packaging.
2.
Slide the extremity through the loop of the self-adhering band or wrap the band around the extremity and reattach to the friction adapter buckle (figure 1). FIGURE 1
3.
Position the tourniquet above the wound; leaving at least 5cm of uninjured skin between the tourniquet and the wound.
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®
Combat Application Tourniquet (CAT ) Review date: May 2016 2 of 5
4.
Secure the tourniquet:
Arm wound: Pull the free running end of the self-adhering band tight and securely fasten it back on itself. Do not adhere the band past the windlass clip (figure 2).
Leg wound: The self-adhering band must be routed through both sides of the friction adapter buckle and fastened back on itself. This will prevent it from loosening when twisting the windlass clip (figure 3). FIGURE 2
5.
FIGURE 3
Twist the windlass rod until the bleeding stops and ensure that a distal pulse is no longer palpable (figure 4). FIGURE 4
6.
Lock the rod in place with the windlass clip. For added security (and always before moving the casualty), secure the windlass rod with the windlass strap. For smaller extremities, continue to wind the self-adhering band across the windlass clip and secure it under the windlass strap (figure 5). FIGURE 5
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®
Combat Application Tourniquet (CAT ) Review date: May 2016 3 of 5
7.
Grasp the windlass strap, pull it tight and adhere it to the Velcro on the windlass clip (figure 6). FIGURE 6
8.
Record the date and time the tourniquet was applied.
9.
Dress the wound and transport, where possible, to definitive care.
10. After 1 hour consider a ‘trial of tourniquet conversion.’ Apply direct pressure over the bleeding point and carefully release the tourniquet. If uncontrolled haemorrhage occurs, replace the tourniquet and do not attempt to remove it again. 11. The handover (at hospital or to other health care professional) must include tourniquet location and time of application.
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®
Combat Application Tourniquet (CAT ) Review date: May 2016 4 of 5
PERFORMANCE CRITERIA COMBAT APPLICATION TOURNIQUET (CAT®) CONDITIONS Provide:
An appropriate manikin and necessary equipment. Assistant.
STANDARDS 1.
Officer to understand the indications for the tourniquet.
KEY POINTS 1.
Slide the extremity through the loop of the self-adhering band or wrap the band around the extremity and reattach to the friction adapter buckle.
2.
Position the tourniquet above the wound leaving at least 5cm of uninjured skin between the CAT® and the wound.
3.
Secure the tourniquet.
4.
Twist the windlass rod until the bleeding stops.
5.
Lock the rod in place with the windlass clip.
6.
Grasp the windlass strap, pull it tight and adhere it to the Velcro on the windlass clip.
7.
Record the date and time the tourniquet was applied.
8.
After 1 hour consider ‘a trial of tourniquet conversion.’
9.
Handover must include details of tourniquet location and the time of application.
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®
Combat Application Tourniquet (CAT ) Review date: May 2016 5 of 5
SKILL 901 GENERAL PERFORMANCE CRITERIA FOR FRACTURE AND DISLOCATION MANAGEMENT November 2007
CONDITIONS Provide:
A simulated conscious patient lying / sitting as appropriate.
A variety of splints and bandages.
A full description of patient’s injury / injuries.
Evaluator assistance as an untrained, co–operative person, only if asked to do so.
STANDARDS 1.
To understand and demonstrate how to immobilise fractures / dislocations as per Skill 901.
2.
Reassure and inform the patient as to the procedure you will be carrying out in managing their fracture.
3.
Carefully cut away clothing that lies over the fracture site. Remove footwear in instances of lower limb fractures.
4.
All open fractures and associated wounds must be covered / dressed prior to splinting. Direct pressure may be required to control bleeding.
5.
Assess circulation by palpating the pulse distal to the injury. Palpate the radial pulse on upper limbs, the pedal pulse on lower limbs, and also apply blanch test. Splint firmly, but not so tightly that circulation is impaired. Continue to monitor circulation frequently thereafter.
6.
Check for nerve impairment by assessing the patient’s ability to move extremities where appropriate and the possible loss of sensation or numbness distal to the injury, both prior to and after splinting.
7.
All splints to be padded to accommodate natural body hollows, deformities and bony processes.
8.
Apply slight traction during splinting and until splinting is completed.
9.
Do not cover fracture site with bandages or fastening straps intended to hold the splint in place.
10.
Elevate simple fractures where possible.
11.
Immobilise joints above and below the fracture site.
12.
Immobilise dislocated joints as they are. Do not attempt to reduce or straighten any dislocation or fracture at a joint.
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Skill 901 General Performance Criteria for Fracture and Dislocation Management 1 of 2
13.
In the case of two or more fractures of the same limb, immobilise the fracture nearest the extremity first, and then work up the limb maintaining traction on each fracture.
KEY POINTS 1.
Manage the whole patient ensuring that DRABCDE is adhered to and that the patient’s status (time critical potential) is taken into account. A thorough Secondary Survey should be carried out in order to determine all injuries.
2.
Suspect a spinal fracture in any situation where the mechanics of injury support such a precaution, or where obvious fractures or dislocations have occurred elsewhere (pattern of injury).
3.
Administer oxygen to all patients with fractures.
4.
Prior to managing a fracture, administer analgesic with oxygen for pain relief (check for contra–indications first).
5.
Immobilise all fractures / dislocations even if only suspected, prior to moving a patient.
6.
Always pre–plan your procedure and prepare all equipment prior to managing a fracture or dislocation.
7.
Whilst managing a simple fracture, avoid breaking the skin and the possibility or subsequent contamination.
8.
Straighten any severely angulated fractures where it is safe to do so, excluding those that involve joints.
9.
In cases of compound fractures, do not attempt to push exposed fractured bones back into soft tissue.
10.
Consider the use of the MAST as an option for managing bi–lateral fractures of lower limbs, especially in instances where hypovolaemic shock is possible.
11.
Be prepared to adjust / loosen splinting if circulation is compromised.
12.
Re–check splinting periodically to ensure it is firmly applied, and where appropriate, that traction is maintained.
13.
Transport carefully, (consider using a pillow to support injured limb) avoiding jolts, sudden braking and coarse acceleration.
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Skill 901 General Performance Criteria for Fracture and Dislocation Management 2 of 2
SKILL 902 LOG ROLL October 2007 1.
At least three persons will be needed to complete this skill.
2.
The person at the head end controls the head / neck and coordinates patient movement.
3.
With patient supine, take position at the head end of the patient: From a stretcher or similar height: Lay both forearms either side of the head of the patient, so that both hands reach and support the shoulders. The thumbs should be upward over the trapezius muscles with the fingers and hand under the shoulder. Enough inward pressure should be exerted by the forearms to firmly secure the head (Figure 1). Caution: An excessive turning angle may cause the head to fall forward. Roll only enough to achieve the purpose of the roll. FIGURE 1
On the ground Kneel at the head end, support and control the head from both sides (Figure 2). FIGURE 2
4.
Assistant to be positioned to one side of the patient, between the shoulder and hip regions. Reach over the patient and grasp the patient’s shoulder and hip (Figure 3).
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Skill 902 Log Roll 1 of 3
5.
A third person is also positioned on the same side as above but between the feet and hip region. Reach over the patient with the arm closest to the hip region and cross over the other assistants arm to secure the hip. Then with the other hand reach over the nearest leg and scoop up the opposite ankle (Figure 3). When given the command to roll the patient the leg held is to be supported and lifted up and in normal alignment. (Note: the feet will not be held together but slightly apart). FIGURE 3
6.
Give the command of ‘1, 2, 3, roll’. Roll the patient toward assistants on the word ‘roll’ (Figure 4). FIGURE 4
7.
Give the command of ‘1, 2, 3, roll’ and roll the patient back to the supine position on the word ‘roll’.
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Skill 902 Log Roll 2 of 3
PERFORMANCE CRITERIA SKILL 902 LOG ROLL CONDITIONS Provide:
Simulated patient supine on the ground.
A minimum of two people to assist.
STANDARDS 1.
Officer to understand and demonstrate a Log Roll as per Skill 902.
2.
The commands must be clear and concise.
3.
The patient’s spine must be maintained in anatomical alignment at all times.
4.
Officer at head end controls the movement of the patient.
KEY POINTS 1.
Log roll should be used for any suspected spinal injury where practicable.
2.
The log roll may also be used for passing slide boards, carry canvas etc. under the patient.
3.
Ensure all persons involved understand the commands and purpose of the manoeuvre.
4.
A fourth person may also assist with the roll. This person should take position at either the shoulder or the hip to assist with the roll.
5.
Care should be taken to maintain control of the patient’s head and neck alignment during the roll.
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Skill 902 Log Roll 3 of 3
SKILL 903 REMOVAL OF A MOTOR CYCLE HELMET October 2004 OFFICER A 1.
OFFICER B
Caution patient not to move. 2.
Place hands on each side of helmet to prevent movement, extend fingers under lower jaw to maintain airway if needed.
7.
Prepare to remove helmet. Expand sides of helmet laterally so helmet clears patient’s ears. Slowly tilt helmet backwards, slightly raising it so patient’s nose will not impede removal. Whilst continuing to remove the helmet, ease the back around the occipital region of patient’s head.
9.
Complete removal of the helmet.
3. Remove / lift helmet face shield if attached. Remove patient’s sunglasses / spectacles if worn. 4. Explain removal procedures to patient. 5. Cuts / undo chin strap. 6. Apply and maintain neutral alignment of patients’ head with one hand grasping under part of lower jaw, thumb on one side, long and index fingers on the other, and other hand under the patient’s head, supporting the weight in the region of the base of skull.
8. As helmet is removed follow the helmet with the hand under patient’s head until the hand fully cradles the occipital region.
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Skill 903 Removal of a Motor Cycle Helmet 1 of 3
10. Once helmet is removed, take over in–line support. Officer places hands on either side of patient’s head with palms over patient’s ears, fingers extended.
11. Gently adjust the patient’s head, maintaining a neutral head / neck alignment. Use appropriate cervical stabilisation e.g. firm padding, blanket, sandbags, towel.
NEUTRAL HEAD / NECK POSITION Patients have different curvatures of the spine, the head and neck is not directly aligned when laid flat (supine). Neutral head and neck position is the position that we hold our heads in compared with the body’s position. To find this position in adults will require lifting the head until it is neither hyper extended nor hyper flexed. Look along the patient from the side to determine this. Maintain alignment of the head using firm support e.g. folded blanket, then use the appropriate cervical stabilisation methods e.g. Cervical collar, towel and sandbags. Note: Children’s heads are generally larger compared with their bodies and may require support under the shoulders and back as shown in Figure 1. FIGURE 1
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Skill 903 Removal of a Motor Cycle Helmet 2 of 3
PERFORMANCE CRITERIA SKILL 903 REMOVAL OF MOTOR CYCLE HELMET CONDITIONS Provide:
A simulated patient lying. Motor Cycle helmet, firm support padding, 2 sandbags, cervical collar and towel to be provided.
STANDARD 1.
Officer to understand and demonstrate the correct removal technique of a motorcycle helmet as per Skill 903.
2.
Due to varying helmet designs, this skill may require slight modification.
3.
When demonstrating this skill while under assessment, full spinal precautions should also be demonstrated.
4.
If a spinal injury is suspected, neutral head and neck position must be maintained and supported. A cervical collar should be applied along with sandbags and towel.
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Skill 903 Removal of a Motor Cycle Helmet 3 of 3
SKILL 905 C-SPINE COLLAR APPLICATION October 2010 Stifneck Collar
Patriot Collar
1.
Adult and child collars are fitted the same way. Children should never be forced to wear a collar where the child’s agitation / stress is increased due to application. Padding may be required underneath the child/infants shoulders in order to achieve neutral alignment due to large occipital region.
2.
An assistant should align and stabilise the patient’s head / neck in the neutral position using both hands.
3.
To measure the size of the collar hold an open hand on its edge, close to the neck on the patient’s shoulder and align the chin against the fingers. Estimate the position that will comfortably fit the patient without altering the patient’s neutral head / neck position. (Figure 1) FIGURE 1
4.
Transfer the size (estimated by your hand) to the collar (Figure 2) (do not include the foam sections when measuring). Secure the collar size by depressing the locking tabs (Figure 3). FIGURE 2
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Skill 905 C-Spine Collar Application Review date October 2015 1 of 3
FIGURE 3
Patient application:
5.
Maintain the patient’s neutral head / neck position.
Measure and size the collar as described above.
Position the chin section under the jaw.
Whilst holding the chin section in position, wrap the collar securely around the neck of the patient. Check that clothing, jewellery and / or hair will not obstruct the fitting of the collar (Figure 4). FIGURE 4
6.
Check for comfort, firmness and correct positioning (nose, chin and collar centrally aligned) before attaching the velcro strap to secure the collar. Do not over tighten. (Figure 5). FIGURE 5
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Skill 905 C-Spine Collar Application Review date October 2015 2 of 3
PERFORMANCE CRITERIA SKILL 905 C-SPINE COLLAR APPLICATION CONDITIONS Provide:
Hard cervical spine collar (Laerdal).
A simulated Patient either lying or sitting.
Two sandbags with towel.
An assistant.
STANDARDS 1.
Officer to understand and demonstrate the correct technique and patient management when applying the C-Spine collar as per skill 905.
2.
Children should never be forced to wear a collar where the child’s agitation / stress is increased due to application. Padding may be required underneath the child/infants shoulders in order to achieve neutral alignment due to large occipital region
3.
Officer to communicate necessary information to the patient.
4.
Correct airway management to be adhered to.
5.
Used correct sized collar to suit patient.
6.
Hard C-Spine collars must not be applied where it is not possible to achieve neutral alignment
7.
The head / neck should remain in the neutral position. Do not hyperextend or hyperflex the head / neck.
8.
All patients suspected of cervical injury should be supine on the stretcher. Cervical immobilisation is to be applied together with neutral head alignment using firm padding and towel / sandbags.
9.
The collar is to be removed if it is likely to interfere with the patient’s condition or does not fit properly, however manual head / neck stabilisation should still be maintained..
10.
Consider prophylactic administration of an anti-emetic when transporting a suspected spinal patient. If the airway is compromised, consider transporting patient lateral.
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Skill 905 C-Spine Collar Application Review date October 2015 3 of 3
SKILL 906 BODY SPLINTING November 2006 1.
Remove any patient clothing that is restrictive to splinting. Remove patient's shoe and sock for any fractures to the lower limbs.
2.
Check injured limbs for circulation (pulse / blanch test) and nerve impairment before and after completion of splinting.
3.
Place sufficient padding between the injured limb and the body and / or other limb to fill natural hollows and retain patient’s normal alignment.
4.
Apply broad bandages or similar around the limbs securing above and below injury sites. Where possible tie off over good or unaffected limb or body region.
5.
Refer to General Performance Criteria for Fracture and Dislocation Management.
© Copyright St John Ambulance Australia (Western Australia) Inc.
Skill 906 Body Splinting 1 of 1
SKILL 907 RIGID SPLINTING October 2002 Examples:
Wood, Cardboard.
1.
Select an appropriate splint, it must be strong enough to support the fracture.
2.
Must be long enough to immobilise the joint above and below the fracture site.
3.
Must be padded to accommodate natural body hollows, deformities and bony points e.g. padding under palm of hand.
4.
Apply splint with roller, triangular or Allsafe / Easton bandages.
5.
If necessary, use sand bags to prevent rotation of the limb with rigid splint attached.
6.
When used on the upper limbs, ensure hand is maintained in the position of function (i.e. palms down).
7.
Remove Patient's shoe and sock for any fracture to the lower limbs.
8.
When applying the wooden back splint, ensure that the sole of the Patient's foot is flat against the foot section of the back splint to prevent foot drop.
9.
Cardboard splints may be cut to the desired shape and size.
10.
Check injured limbs for circulation (pulse / blanch test) and nerve impairment before and after completion of splinting.
11.
Refer to General Performance Criteria for Fracture and Dislocation Management.
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Skill 907 Rigid Splinting 1 of 1
SKILL 908 SOFT SPLINTING—PILLOW October 2002
May be used for ankle injuries. 1.
Remove patient's shoe and sock.
2.
Check circulation (pulse / blanch test) and nerve impairment before and after completion of splinting.
3.
Mould pillow carefully around the foot and ankle allowing access to the toes and pedal pulse.
4.
Secure pillow with bandages.
5.
Refer to General Performance Criteria for Fracture and Dislocation Management.
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Skill 908 Soft Splinting – Pillow 1 of 1
SKILL 909 FERNOTRAC TRACTION SPLINT October 2007 Exclude boxed regions:
Traction splint FIGURE1
1.
Traction Splints may vary slightly but they are still basically the same splint.
2.
The task of securing a traction splint is a two–person task. In this skill we will list the given tasks required in order of priority.
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Skill 909 Fernotrac Traction Splint 1 of 7
Preparation 1.
Pain relief should be given as authorised and given sufficient time to work.
2.
Move the good leg away from the injured leg if possible.
3.
Stabilise the injured leg, expose and examine the injury site.
4.
When the traction splint is used the whole leg needs to be exposed removing the necessary clothing.
5.
The traction splint is stored in a collapsed position and needs to be extended to allow the operation of the ratchet (Figure 2).
6.
Ensure heel stand is not jammed onto the tapered section of the frame. FIGURE 2
7.
The splint has two telescopic tubes. Turning the locking collars anti clockwise to loosen, pull out or in to adjust the length required.
8.
To adjust the splint length to the patient place against the uninjured leg. The ischial pad of the splint is to be placed alongside the ischial fold of the patient (the fold created where the patient’s buttock meets the leg).
9.
With heel stand in a collapsed position as shown in Figure 2 extend the splint so the base of the heel stand is in line with the sole of the foot (this extends the splint approximately. 35cm past the sole of the foot), lock the locking collars in a clockwise direction. Do not over tighten.
10. Move the heel stand down against the locking collars. Release the heel stand and swing the stand out to lock in its support position as shown in Figure 3. 11. Extend the Ratchet strap fully and release the lock by pulling on the ring and pin which needs to be held out whilst the strap is extended.
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Skill 909 Fernotrac Traction Splint 2 of 7
FIGURE 3
12. There are 4 patient leg straps looped and attached to the splint. These need to be checked for completeness and order of size. The largest should be closest to the ischial pad end of the splint. They may also be numbered 1 to 4 (Figure1). 13. The leg straps (Figure 1 and 7) have two sections with the attachment to the splint being of non–stretch material and attached via velcro. This needs to be applied across the two–parallel tubes firmly to take the patient’s weight but not too tight as to bend the tubes inward. 14. The upper patient portion of the strap is elastic and opens around the leg and attaches over the leg with Velcro. To make ready, these straps should be passed under the splint for now and attached via the velcro. 15. The leg straps now need to be adjusted along the tubes so that they will support the injured leg either side of the fracture site (where possible) and / or along the leg where suitable. 16. If practicable, DO NOT place leg straps over the knee as this pulls the knee downward causing misalignment of traction. 17. It is not advisable to move the leg straps down past the locking collars, as this position is rarely needed. 18. The ankle harness (Figure 4—supplied by St John Ambulance) has two extension straps with rings attached. The Fernotrac ankle harness (Figure 6) is supplied with a foam padded harness with a single looped extension strap also other variations exist. These may be used in similar way as described. Lay harness on the ground next to the injured leg with the two extension straps laid toward the sole of the foot. These will later attach to the ratchet strap.
Application 1.
Make ready the ankle harness. The harness is of vinyl and cannot be directly wrapped around the ankle unless protected. Use a 20cm x 30cm dressing or a triangular bandage to wrap around the ankle.
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Skill 909 Fernotrac Traction Splint 3 of 7
2.
Slide the harness under the injured leg using the ‘natural hollow’ between the leg and ankle (Figure 4 and 5). Wrap the padding and ankle harness around the ankle and secure with velcro.
3.
Ensure the harness is firmly applied and that the dressing is exposed along the edge of the harness.
4.
Ensure the part of the harness under the sole of the heel protrudes a little. As the harness takes on weight, the edges will tend to dig into the skin of the ankle, particularly if one edge is applied loosely.
5.
Check the two side straps are opposite each other and of equal length (Figure 6)
FIGURE 4
FIGURE 5
FIGURE 6
6.
Advise patient of the next step, as traction and lifting of the leg is required (Traction method Figure 7). Once traction is applied do not release until the traction splint has taken on the traction. Be prepared for the effort required.
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Skill 909 Fernotrac Traction Splint 4 of 7
Traction method 1.
Remember the traction splint can be placed under from either side of the leg providing there is enough space.
2.
The officer applying traction should be positioned at the foot end of the splint.
3.
Kneel on one knee.
4.
Place other leg in a bent position along side of the patient’s leg.
5.
Hold one hand under the patient’s knee and the other onto the ankle extension straps behind the foot or hold with one hand under the ankle strap with the other on top of the foot where shoe laces would be (ensure extension straps are hanging free at the sole of the foot).
6.
The officer should apply traction by leaning back whilst simultaneously lifting the leg up. FIGURE 7
Ensure that rings on heel straps are accessible to the other Officer
7.
Lift the leg high enough for the traction splint to slide under the leg, carefully placing the ischial pad of the splint into the Ischial Fold on the patient.
8.
Lower the leg onto the splint maintaining traction.
9.
The Ischial Strap can now be gathered from around the patient’s upper leg and the ends pulled clear. Ensure the Ischial Straps attached to the splint are located next to the Ischial Pad (Figure 8). Otherwise, when traction is applied the ischial strap will slide up the tubes allowing the Ischial Pad to slide beneath the patient’s buttock.
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Skill 909 Fernotrac Traction Splint 1 of 7
FIGURE 8
10. Before attaching the Ischial Straps a triangular dressing or similar should be laid across the leg directly where this strap is to be fastened. This will protect the leg. 11. Secure the ischial strap firmly but not over tight. This strap stops the splint from sliding beneath the patient’s buttock when traction is applied. 12. Attach the ratchet strap onto the rings of the ankle harness (Figure 7).
Traction 1.
Using the ratchet, turn clockwise so the ratchet strap shortens and begins to provide traction. The person supporting the leg should monitor the traction pressure applied and provide directions for appropriate adjustments.
2.
Once traction is applied the leg straps can be secured around the injured leg. Apply firmly but not so tightly as to act as a tourniquet. If practicable, DO NOT place over the knee as this can cause misalignment, pain or ineffective traction. Do not place a leg strap around the ankle as this also acts against the direction of the ankle strap.
Shortening the splint 1.
Before extrication the traction splint should be shortened so that the extra length doesn’t create problems on the stretcher or in the ambulance.
2.
First reapply the traction with one hand holding at the extension straps at the back of the ankle strap. Use the other hand to operate the ratchet. The other person should then loosen both locking collars in the same direction (anticlockwise) simultaneously.
3.
The person holding traction should now operate the ratchet, shortening the ratchet strap to about 75mm before the S hook. The telescopic tubes will shorten inward; beware of obstacles to the heel stand.
4.
The locking collars can now be tightened simultaneously in a clockwise direction and the traction checked.
5.
Re–check traction.
© Copyright St John Ambulance Australia (Western Australia) Inc.
Skill 909 Fernotrac Traction Splint 1 of 7
PERFORMANCE CRITERIA SKILL 909 FERNOTRAC TRACTION SPLINT CONDITIONS Provide:
A traction splint.
A simulated conscious patient in the supine position.
Assistant.
Protective dressings as required.
STANDARDS 1.
Officer to understand and demonstrate the application of the traction splint as per Skill 909.
2.
In determining the need for the traction splint, the officers must consider the location of the fracture, and exclude its use where injury has occurred at the:
Hip joint.
Top one third of the femur (due to the closeness of the ischial pad the splint will force the femur upward and out of alignment).
Knee joint (fracture may be either side of the knee).
Foot and up to 100mm above the ankle (sufficient to allow for the ankle strap placement).
3.
The traction splint is ideal for multiple fractures above and below the knee.
4.
Officers to ensure that the patient is maintained in a supine position throughout the skill.
5.
Adhere to General Performance Criteria for Fracture and Dislocation Management.
6.
The patient’s injured leg should be checked regularly for comfort, appearance, blanch and adjusted to ensure traction is maintained (the quadriceps will stretch with traction and in doing so may reduce the traction).
KEY POINTS 1.
If leg straps are too short to attach to a large limb, bandages may be used to secure.
2.
Ensure the leg stand is movable prior to application on the patient.
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Skill 909 Fernotrac Traction Splint 2 of 7
SKILL 910 APPLICATION OF SANDBAGS October 2008 Sandbags used by St John Ambulance are of a particular size, weight and construction. The sandbags are disposable and must not be reused when contaminated. Sandbags may be utilised to: Support limbs.
Provide head and neck stabilisation in conjunction with neutral anatomical head / neck alignment.
Basic head / neck stabilisation 1.
Explain to the patient the need to support their head / neck with sandbags.
2.
Provide head support by kneeling behind the patients head and with your hands placed on either side support the head whilst maintaining neutral head / neck alignment.
Note: To provide neutral head / neck alignment, a rolled blanket or towel may be used. 3.
Place the sandbags either side of the patients head, starting where the neck and shoulders join a mould them along and around the side of the head.
4.
Ask patient not to move their head / neck.
Stabilisation of sandbags (optional) 1.
Fold a towel in half to a simular length as the sandbags.
2.
Lay the folded towel on a firm clean surface. Roll a sandbag in 1/3rd from each end.
Note: Rolling the sandbags in a towel should be firm but not tight. Rolling too tightly will cause the “sling effect” which is not conducive to neutral head / neck alignment. 3.
Turn the towel and sandbags over (optional).
4.
Lay the towel and sandbag combination above the patients head and adjust sandbags / towel slightly so that the distance between the sandbags is slightly greater than the width of the patient’s head.
5.
Gently slide the sandbags / towel combination beneath the patient’s head, once in position lower their head onto the towel.
Note: The head should be lowered onto the towel, snugly in the space between the two sandbags, ensure the head is on firm support. Do not rest the head between the two sandbags unsupported (sling effect). 6.
Adjust the sandbags by rolling them inward against the head from both sides, until the desired support is achieved.
7.
Ask patient not to move their head / neck.
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Skill 910 Application of Sandbags 1 of 2
PERFORMANCE CRITERIA SKILL 910 APPLICATION OF SANDBAGS CONDITIONS Provide:
Disposable sandbags.
Towel
Blanket.
A supine patient or suitable manikin and one assistant.
STANDARDS 1.
Officer to understand and demonstrate the application of sandbags as per Skill 910.
2.
Explain purpose and use of sandbags.
3.
Maintain stabilisation of head and neck in patient’s normal anatomical neutral head / neck alignment.
4.
St John Ambulance sandbags are disposable and should not be reused when contaminated.
KEY POINTS 1.
Application of sandbags is to stabilise and immobilise the head and neck.
2.
When in a moving vehicle the use of the towel and sandbag combination will make the sandbags more secure.
3.
Sandbags can be utilised for various applications:
4.
To provide support to limbs.
To provide weight on a flail chest patient.
Can be placed under the head to provide natural alignment in the lateral position or assist in attaining ‘Sniff the Breeze’ position.
Sandbags used by St John Ambulance are of a particular size, weight and construction.
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Skill 910 Application of Sandbags 2 of 2
SKILL 911 APPLICATION OF SAGER SPLINT MODEL 304 June 2008
Description 1.
Weighs 2.5kgs
2.
Provides inline traction.
3.
Able to provide traction within the confines of the patient’s body length.
4.
May be applied by a single Officer.
Parts as per Figure 1 FIGURE 1
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Skill 911 Application of Sager Splint – Model 304 1 of 7
Elastic Support Straps (Figure 2) 1.
12 x short straps.
2.
1 x medium length strap.
3.
1 x long length.
4.
1 x long length Figure eight strap. FIGURE 2
4 5.
2 x ankle harnesses (left and right are indicated on the straps). (Right ankle strap shown) Figure 3. FIGURE 3
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Skill 911 Application of Sager Splint – Model 304 2 of 7
Preparation 1.
Pain relief as authorised, allowing time to take effect.
2.
Move good leg away from the injured leg if possible.
3.
Expose injury site and remove any other necessary clothing from injured leg. Note: The whole leg needs to be exposed.
4.
Examine injury check pedal pulses, movement and sensation.
5.
Stabilise injury site (stop bleeding, applying bandaging if required).
6.
Realign injured leg as necessary (assistance may be required to hold in place).
7.
Recheck pedal pulses, movement and sensation.
Application of Sager splint For single leg injuries 1.
Position the Sager between the patient’s legs resting the ischial perineal cushion (saddle) against the ischial tuberosity, with the shortest end of the articulating base towards the ground and towards the same side as the injured limb. FIGURE 4
2.
Secure the thigh strap around the upper thigh of the injured limb by holding the splint firmly in place at the same time tightening the strap so that it is firm but comfortable and allows adequate blood flow.
3.
Lift the spring clip and extend inner shaft until crossbar is in-line with patient’s heel.
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Skill 911 Application of Sager Splint – Model 304 3 of 7
4.
Lay the ankle strap out (Figure 5). Folding down the required amount of cushioning. FIGURE 5
5.
Lay the base of the harness so the large cushion is under the ankle with both looped traction straps facing toward the base of the foot.
6.
Wrap the harness snugly around the ankle above the medial and lateral malleoli. FIGURE 6
7.
Connect looped traction strap attached to the ankle harness to the splint cross bar.
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Skill 911 Application of Sager Splint – Model 304 4 of 7
FIGURE 7
8.
Pull adjusting control tabs / straps to shorten the ankle harness traction straps tightly between the ankle harness and crossbar (Figure 7).
9.
Hold traction handle (Figure 7) with one hand and padded inner shaft with other, gently extend inner shaft until both legs are aligned, being guided by patient comfort.
10. Adjust the traction using the guide below:
10% of patient’s body weight per femur. (Max 7kg of traction, 3½ kg per femur for children). e.g. 70kg patient x 1 Femur = 7kg traction. 70kg patient x 2 Femur = 14kg traction.
For bilateral fractures 1.
For bilateral fractures attach splint to the side with the greatest degree of injury with the articulating base of the ischial cushion toward the injured leg. (Figure 6) FIGURE 6
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Skill 911 Application of Sager Splint – Model 304 5 of 7
2.
Traction required:
10% of patient’s body weight per femur. (Max 7kg of traction, 3½ kg per femur for children). e.g. 70kg patient x 1 Femur = 7kg traction. 70kg patient x 2 Femur = 14kg traction.
Using the leg support straps 1.
Straps are to be positioned around both legs for single leg injuries or bilateral leg injuries.
2.
The Sager splint comes with four reversible elastic straps:
3.
Two ankle lower leg straps.
One medium length strap for lower leg or just above the knee.
One large strap for securing the thighs.
The straps may be carefully slid under the legs by pushing the strap under the legs from one side and then pulling through from the other side as per Figure 7 & 8. FIGURE 7
FIGURE 8
4.
As these are elastic do not tighten so as to become restrictive to blood flow or cause undue pain. Only tighten to provide a stabilising effect limiting leg movement below and above a fracture site.
5.
Recheck patient before and after any patient movement for :
6.
Comfort and Pain management.
Distal pulses and sensation (regularly).
Adjust tension as necessary as per traction guides.
The Figure eight strap may be used to secure the feet and prevent internal or external rotation of the leg distal to the fracture.
Cleaning - Clean as per Clinical practice Guidelines, Infection Control Policy. © Copyright St John Ambulance Australia (Western Australia) Inc.
Skill 911 Application of Sager Splint – Model 304 6 of 7
PERFORMANCE CRITERIA SKILL 911 APPLICATION OF SAGER SPLINT MODEL 304 CONDITIONS Provide:
A sager splint and any bandaging required.
A simulated conscious patient in any position.
Assistant.
STANDARDS 1.
Officer to understand and demonstrate the application of the Sager splint as per Skill 911.
2.
Preferably applied by two persons but can be applied by one person.
3.
In determining the need for the traction splint, the officers must consider the location of the fracture, and exclude its use where injury has occurred at the:
Hip joint (Neck of femur).
Knee joint (fracture may be either side of the knee).
Foot and up to 100mm above the ankle (sufficient to allow for the ankle strap placement).
4.
Adhere to General Performance Criteria for Fracture and Dislocation Management.
5.
The patient’s injured leg should be checked regularly for comfort, appearance, blanches and pedal pulse(s) especially after patient movement.
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Skill 911 Application of Sager Splint – Model 304 7 of 7
SKILL 912 PROVISION OF COMPLETE SPINAL IMMOBILISATION January 2011 Method 1.
Move patients head into a proper inline position. Contraindicated if: Resistance to movement is noted.
Neck muscle spasm.
Increased pain to movement.
Airway compromise is evident.
There is commencement or increase of a neurologic deficit (numbness, tingling,
