Prehospital Practice: hypothetically speaking: From classroom to paramedic practice Volume 1 Second edition

By Jeff Kenneally

Case study based text intended for student, novice and experiened prehospital paramedic and EMT responders. Each chapter focuses on common medical and traumatic emergencies.  The easy to read blend of case study, theory and question/answer approach identifies relevent knowledge to explain and support current clinical practices.  The te

• Language: English
• Publisher: Prehemt
• Release date: Jan 15, 2017
• ISBN: 9780992552640

Jeff Kenneally

Intensive Care Paramedic of over thirty years experience Clinical effectiveness manager of a major ambulance service Senior University Lecturer Road Accident Rescue team leader and trainer

Book preview

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Volume 1

Second edition

Pre-Hospital Practice Hypothetically Speaking

Jeff Kenneally

Published in Melbourne by:

PrehEMT Pty Ltd

[e-mail]

www.prehemt.com

First published 2014

Second edition 2017

National Library of Australia

Cataloguing-in-Publication entry:

Kenneally, Jeff author.

Pre-hospital practice : hypothetically speaking . Volume 1 Second Edition

Jeff Kenneally.

Medical emergencies—Australia—Textbooks.

Trauma emergencies—Australia—Textbooks.

First aid in illness and injury—Australia—Textbooks.

ISBN 978-0-9925526-4-0 eBook edition

Copyright ©2017 Jeff Kenneally

All rights reserved. Reproduction of any part of this book without the publishers written permission is prohibited.

This material is intended for educational use by pre-hospital medical emergency responders. It should be read in conjunction with traditional relevant educational programs that provide for Australian first aid and emergency medical and trauma response. It does not intend to replace other education or training.

Every effort has been made to ensure the quality and currency of this information. It intends to provide guidance to applying appropriate pre-hospital emergency care to common medical and traumatic emergencies. It cannot cover every situation specifically as each patient and circumstance can vary from case to case. Before implementing any clinical practice or patient care the appropriate clinical practice guidelines, protocols and work instructions for the relevant organisation should be consulted and deferred to in all situations.

2017

Pre hospital Emergency Medical Trauma

contents

5 Pre-hospital emergencies hypothetically speaking

Hypotheticals

6 Managing the airway

20 Respiratory assessment

31 Anaphylaxis

41 Asthma

51 Conscious state assessment

61 Hypoglycaemia

69 The hypothermic patient

79 The child with croup

87 Managing cardiac pain

95 Pre-hospital anti-emetics

107 Left heart failure

117 The narcotic drug overdose

125 The car ‘accident’

135 Penetrating trauma

145 The burnt patient

157 Seizures and convulsions

167 Hypertensive emergencies

177 The patient with hyperglycaemia

187 Beware the syncope

197 Obstetric emergencies

209 COPD hypothetical

224 glossary of abbreviations

Pre-hospital emergencies

hypothetically speaking

Pre-hospital responders come in a variety of forms ranging from enthusiastic first aider through to intensive care paramedic. For each, the specific roles can vary widely but always with a common shared core. It is challenging. It can be daunting. It is often tiring. it can be emotionally demanding. Most commonly it can be incredibly satisfying. It is unique in many ways. It is a bit first aid, a bit doctor, a bit social worker and almost always jack of all trades. Being master to any is often the greatest challenge. Yet the question stands, is being a master of any necessary.

University education is common in the modern pre-hospital era but that only prepares you to start your learning. When you finally start you would once have been an ambulance driver or officer but now more likely a paramedic or emergency medical technician. Whatever you get called there is one certainty – you will be a novice in this working world that is like few others. You have precious few diagnostic tools, language barriers, extremes of emotion, the elements against you with uncertainty your constant companion.

There is an expression that says experience is something you get just after you need it. Experience is something every pre-hospital responder needs. You will gain a lot of it over the years of a career. Much of it will come under duress and the hard way through error or your partner putting you right just before. But what if you could learn through sharing the experience of others? You might avoid some of those errors or close call moments. You would certainly be much better prepared for the differing situations as they arise.

These hypotheticals are all based on real call outs, real patients and real situations. These are the cases where experience came just after it was needed the first time. It doesn’t have to be this way for others though. They encompass typical medical and traumatic emergencies as confront pre-hospital responders and look beyond the simple written guidelines and protocols provided. They are not based on the practices of any one organisation and reference to the applicable specific guidelines should be sought before putting these experiences into action.

Jeff Kenneally

Managing the airway

hypothetical

You have no sooner arrived at the address of your next callout when you are met by an obviously distressed elderly lady. Standing in the doorway of her house waiting, she hastily beckons you to come inside. Her distress tells you immediately that something is very seriously wrong at this call.

Following her directions, you very soon find her equally elderly husband lying supine on the kitchen floor. From the look of the not yet finished meal on the table and from what you are frantically being told by the breathless woman it appears that he had just finished eating his lunch when he tried to stand up before collapsing suddenly to the floor..

Kneeling quickly for your assessment you find him to be unresponsive and appearing quite lifeless. Immediately, you frown as you see considerable vomitus in his mouth. You confirm the absence of a pulse and with no more than a knowing nod, your partner immediately starts performing chest compressions. You also set yourself into action.

(1) What immediate action do you take?

The rhythm on the monitor printer is ventricular fibrillation and the moment you have recognised it the automatic mode voice advises shock. You have your partner stand clear and, after confirming with eye contact, you push the flashing illuminated button to defibrillate. Immediately your partner recommences performing chest compressions without any discernible delay. You have two minutes before the next rhythm analysis where you plan to swap roles with your partner to allow some relief.

Now you choose to move quickly back to the airway. For years airway has always been the ‘A’ in ‘ABC’ resuscitation and taken priority over everything. You have been with the patient for more than a minute now and haven’t done anything more than slightly adjust the position of his head in regard to airway. Worse, you have acknowledged the considerable vomitus in his mouth.

(2) Should you have attended to the airway more comprehensively before moving on?

You partner is continuing effective chest compressions but will be insisting on changing places with you before much more time goes by. You have administered the required shock. Now is the time for you to return quickly to the airway. There is obvious vomitus in the mouth so you elect to quickly suction what you can see. The airway is only the opening to allow ventilation to occur. The big concern with this airway was the vomitus and the potential foreign body obstruction and soiled lungs it would cause. Airway obstructions from foreign bodies can be expelled during chest compressions with the force produced able to replicate a good cough1.

The most effective method to clear a foreign body in the airway is to cough it back out. This of course requires the affected person to be wide awake. Where cough is inadequate, the equal next best simulated cough is the application of chest thrusts and back slaps. Back slaps involve a sharp, firm blow with a clenched fist or heel of the hand between the shoulder blades mid upper back. The intent is enough force to achieve a cough effect.

Chest thrusts can be applied when the patient remains conscious and these have superseded abdominal thrusts or Heimlich manoeuvre in Australia. If possible, the rescuer can reach around the patient from behind, clasp hands over the sternum and pull inward sharply with the arms. This should produce an artificial ‘cough’. If it isn’t possible to reach around the patient they can be stood against a wall or firm surface and the sternum pressed like providing a chest compression. A word of warning with this approach is that you would want to avoid being in the firing line if the object was coughed out! Of course the other option to provide firm ‘back slaps’ between the shoulder blades in the back1.

These methods require the affected person to be conscious and able to support themselves upright. When consciousness is lost, these methods, including back slaps, all fall away in practicality. You can’t wrap your arms around a person lying on the floor unresponsive. You may be able to perform back slaps but this isn’t what is advised. However chest thrusts aren’t ruled out completely. They can still be performed with the patient supine only you have to do them somewhat differently now. Chest thrusts in the unconscious patient are effectively now the same as short salvos of CPR style chest compressions on the sternum with the patient supine. This is for the patient who somehow still has a pulse to be felt. If the pulse is lost at any time the salvos simply become continuous chest compressions as this is now a pulseless patient1.

Airway and breathing are important but you cannot stop everything else whilst you attend to them when the patient has no pulse. For those first few seconds, attending to effective chest compressions not only improves cardiac arrest outcomes but also provides for foreign body expulsion. Even though it appears that airway has been ignored, in fact the compressions have been helping considerably with initial airway clearing of any foreign body material. This initial cursory clearance will now become your next priority to build from post that first defibrillation.

On this occasion you elect to suction under laryngoscopy as this is the only way to truly visualise the oropharynx. This will allow you a better view but the price will be that you could spend more time doing it. Like everything, you have to work out if you have that time and whether you really need to do it at all. You have been told that the patient has just been eating so foreign body obstruction seems possible. This will not be the case in the vast majority of cardiac arrests. You remove from your airway bag the Magill’s forceps in case such a foreign body needs to be removed. Not seeing anything particularly solid, apart from the obligatory mushy peas and carrots, you do suction out copious fluid. For the moment, the airway appears clear, but you can’t actually see any vocal cords.

(3) What is the most likely reason for not being able to visualise cords?

More often than not does not mean always. Uncommonly the glottis and vocal cords will remain out of view no matter what you do. Being able to sight only a glimpse of the elusive cords, you reposition the patient’s head by extending it forward into a neutral position with a cushion under the occiput. By lifting the head forward, rather than hyper-extending the neck backward, the airway is straightened bringing the cords better to operator view5.

The neutral position varies with individuals but the aim is to have the opening of the ear approximately on the same plane as the middle of the patient’s clavicle. That is, a line between the ear opening and the mid clavicle is parallel to the floor the patient is lying on. Generally this will require about two to five centimetres of padding under the back of the head. There is no way to measure this in advance. You simply have to move the patient’s head until it looks right.

A cushion, a rolled up towel or pillow will be suitable for this purpose. You can get another person to hold the patient’s head up. Older veterans of prehospital practice would recall how you could stick the toe of your boot underneath and balance the head on your foot. This sort of practice is not really in keeping with today’s professionalism nor is it completely reliable. Or you could use your medical or airway bag that is at hand but risk spending the rest of the week picking bits of vomitus out of the pockets if something goes wrong.

(4) Can you ventilate the patient with the head in a neutral position?

Some people, particularly the elderly, have disease of the spine that can greatly reduce movement possible and head positions that can be selected. If the spine is curved with the head clearly higher than the neutral position then it should not be forced backward at all. In this case padding is simply placed under the head as found.

You reflect on this supine versus neutral position for a moment. Recently you were watching an intensive care paramedic intubate a patient and she asked you to get a larger pillow from the bed than the one that you had already placed under the patient’s head. She pushed the pillow under the patient’s head and you couldn’t help but notice that the ear opening was well above the middle of the clavicle. You asked about this and she referred to it as the ‘sniffing position’ but was too busy to explain any further.

(5) What is the ‘sniffing position’?

The ‘sniffing position’ is so named because the head appears to be pushing forward as if the nose is trying to ‘sniff’ the air. Just as with the neutral position, there is no way to predict how much padding will be required. The correct position is to raise the ear opening until it is now in line with the angle of the sternum5. Clearly this is several centimetres higher than the neutral position. It is also very important to ensure that the chin isn’t simply being pushed down onto the chest. The patient’s face must still point directly forward with the neck angling first upward from the floor then changing again where it joins the head. This makes this position advantageous for advanced airway methods but not suitable for suspected cervical spinal injury.

The other way to position the head to improve the view of the cords and straighten out the airway is known as ‘ramping’. This is essentially placing considerable padding beneath the upper back, shoulders and the back of the patient’s head. Instead of just the head being lifted the whole plane of the upper body is raised. This has some popularity as a technique but can be difficult to achieve realistically. A lot of padding is required and the patient has to be able to be moved to place it underneath. Typically it is useful for obese or pregnant patients. Unfortunately the patient who this position would be most useful for is also the patient whom will be the most difficult to place them in it.

(6) What alternative options to head movement are available to help improve the view of the glottis and cords?

You find yourself now kneeling over the patient’s head pondering your next move. Frustratingly, the oropharynx is filling up again with gastric fluids. You think immediately of cricoid pressure and ask your partner to apply it. Knowing that you shouldn’t stop the cardiac compressions, he suggests that you ask the next door neighbour who has just arrived to help. Instinctively you know that this isn’t a good idea. You can and sometimes must seek help from others at cardiac arrests.

But whatever help is provided it has to be useful and correct help. Likely many pre-hospital responders do not know how to perform cricoid pressure correctly having never been shown. There is also the similar appearing technique of laryngeal pressure that you have been asked to perform when helping intensive care paramedics to intubate.

(7) What is the difference between the two techniques?

Cricoid pressure can be applied to any unconscious patient as long as there is no coughing, gagging or vomiting. If any of these were occurring, the oesophagus can be torn if a rising gastric pressure pushes against an upper blockage. It is applied by pinching the thumb and forefinger together and pushing them gently into the soft part of the front of the neck just above the top of the sternum. Move them upward until the hard cricoid cartilage is met. The fingers are then gently moved onto the top of that hard ring. Push down firmly until the fingers blanch white. This will probably move the ring downward a centimetre or more. The exact force being used is difficult to define but must be firm.

Even though both of these methods seem simple in theory, in practice they are not ideal for the novice to perform. Insufficient force applied will not work whilst excessive or incorrectly directed force may only make it more difficult to view the glottis, insert other airway devices or assist ventilation3.

You quickly suction again, then move back to ventilate the patient. Even in cardiac arrest you must make attempts to provide some effective ventilation. Positive pressure ventilation is needed to produce air movement for gas exchange. However this positive pressure has been implicated in increasing intrathoracic pressure and reducing venous return. Thiscan be counter productive during CPR. Venous return into the chest is maximised during expiration when intrathoracic pressure is lowest. This is quite the reverse during positive pressure ventilation.

You can still ventilate with cricoid pressure correctly applied as the trachea should not be occluded by this procedure. Applying cricoid pressure during assisted ventilation may even reduce the volume of gas being forced down the oesophagus as well as reducing gastric content that can passively return back up.

Making sure that you don’t forget the two minute rhythm checks and changeover to keep strong effective compressions available, you decide now to insert a laryngeal mask airway (LMA). The patient remains in cardiac arrest and the intensive care paramedics are still a few minutes away. This will allow you to not have to worry about trying to regain a seal with the bag/valve/mask each time and will provide you with greater confidence with the airway.

(8) Can you insert an LMA with cricoid pressure applied?

The LMA is a great device provided the patient does not have any airway reflexes. This is typically the case in cardiac arrest but can also be suitable at any other time airway reflexes are absent such as drug overdose. The beauty of the LMA is that it is relatively easy to insert, fairly reliably provides a seal to both oesophagus and over the glottis and can be ventilated through. Some newer generation devices have silicone cuffs instead of air inflated making them even simpler to insert.

Given that the provision of bag/valve/mask ventilation is likely to inevitably push some air into the oesophagus and stomach, the likelihood of both abdominal distension impacting on lung expansion as well as gastric content aspiration will increase over time. Insertion of an LMA, or any suitable supraglottic device, is desirable early in any resuscitation attempt3.

Let’s return to the basic tenet of airway care. All clinical guidelines start with the encompassing ‘ensure a patent airway’ statement. Airway means keep the airway tube open for the business of allow air to move in, out and through it. There is a whole range of adjuncts to assist with this and you choose from those available to your skill set and to suit the likely patient need.

(9) What are the most common airway obstructions?

The oropharyngeal airway and the nasopharyngeal airway are useful at keeping the tongue clear of the trachea but do little else. In fact, rolling the patient on the side may allow you to achieve much the same thing. The tongue can also be moved forward using manual methods such as jaw thrust and chin lift. Since the tongue is attached to the jaw, manipulation forward of it will pull the tongue as well. This is an ideal first method when there is a partial tongue airway obstruction such as is suspected in the snoring patient. These methods are also useful in displacing the tongue forward to better allow insertion of an OPA or NPA.

What these adjuncts do not do is assist with keeping gastric content out of the airway. Like any airway device, using an oropharyngeal airway is not mandatory, only one more useful adjunct in the airway armoury. It is also not much help where there is a gag reflex or teeth clenching as in trismus. On these occasions the nasopharyngeal option may prove more beneficial. The nasopharyngeal airway is still positioned in the pharynx and is less likely to produce a gag than the oropharyngeal airway can. It can also bypass any biting obstruction the mouth can pose.

The airway adjunct selected not only has to address the severity of the problem, it also has to match the duration of the problem. It would not make good sense to intubate a person who is likely to be unconscious for only a short time, such as a hypoglycaemic or narcotic overdose patient. Basic measures would be far more appropriate in such cases. Conversely it may not be the best option to persist with an oropharyngeal airway when the patient will confidently remain unconscious for a longer period, such as during prolonged cardiac arrest3.

The intensive care paramedics have arrived and you have just provided a briefing on what has happened so far. She asks how the airway is and says to her partner she may have to intubate. There is no necessity in most cases to hurriedly replace the supraglottic device with an endotracheal tube. The cuff of an LMA still provides good confidence in securing the airway and providing an effective seal to allow positive pressure ventilation. Inserting an endotracheal tube often disrupts effective CPR and can in fact prove counter productive. Where there is a return of spontaneous circulation after cardiac arrest it is common then to replace the LMA with an endotracheal tube3.

Between you all, there has been a successful return of spontaneous circulation. The patient has not had a return of any breathing or any airway reflexes. He is still accepting the LMA in place without any difficulty. However the intensive care paramedic decides that intubation will be the better option to look after the patient for the time being. After several minutes of good pre-oxygenation, you remove the LMA then reapply the cricoid pressure to allow this procedure to occur.

(10) Can cricoid pressure and laryngeal pressure be applied at the same time?

The intensive care paramedic attaches a laryngoscope blade and you notice a range of blades of assorted sizes and shapes in the airway bag. Correctly, you assume that bigger and smaller blades are designed for bigger and smaller patients. Very uncommonly, in fact, is the entire range necessary. A standard size three adult blade can be used even on small children; just remembering not to insert it in as far. And the huge size five has the look about it of clearly being some sort of agricultural implement that has been mislaid!

Along with the common curved Mackintosh blades you notice a couple of smaller, straighter blades.

(11) What is the purpose of the straight blade?

Young children, of course, don’t benefit from having the head pushed forward. The flat supine position works well for them. Infants and small children have a relatively larger occiput which actually forces the chin forward and onto the chest when supine. A thin layer of towel or cushion under the shoulders instead of the head can bring the airway back into its best alignment. This is the small child neutral position with the likewise intention of returning the ear opening and the mid clavicle into the same plane.

The smaller the child, the more beneficial this can be with maximum need in the newborn and early infancy. This position remains through early childhood with a progression to flat in the early to middle primary school years. Eventually an age around eight to ten years will be best served with neither padding beneath head or shoulders to gain correct alignment. From then on the small head padding elevation will become applicable as the child progresses into adult age and anatomy.

The newborn is most unlikely to need any sort of airway adjunct outside of basic positioning. Suction is only required where there is respiratory distress or failure together with meconium stained liquor. Oropharyngeal airways are usually only needed when the newborn airway is deformed which is uncommon. Intubation may rarely be required when resuscitation efforts persist.

That said, the role of ventilation is far more important in the resuscitation of the non vigorous newborn. Unlike all other patients where ventilation is minimal compared to chest compressions (30 compressions to 2 ventilations) the newborn maintains a 3 to 1 ratio of compressions to ventilations. This reflects the desperately important role of ventilation in bringing about essential cardiovascular changes post birth. In contrast to the adverse impact of positive pressure ventilation during usual cardiac arrest management, the positive pressure in the alveoli of the newborn is essential. Reliance on chest compressions over ventilation in the newborn is likely to produce an almost futile movement of blood through the foetal circulation.

Maintaining a clear and patent airway is a structured but not a robotic task. There are logical steps in order to follow to provide for airway needs at a particular time in resuscitation or patient care. There are multiple adjuncts and the option(s) that most suit the problems are the ones to choose with escalation only as needed.

Suggested Answers

You have, for the moment, more tasks than people and you cannot reasonably expect the elderly wife to assist. On other occasions you will invite to help whoever is present, able and willing. For now, prioritising is the word. You have the soiled airway to sort out, his breathing to re-establish and a defibrillator to apply. You know that chest compressions are essential in any cardiac arrest particularly if it is unwitnessed. Immediately commencing effective chest compressions in cardiac arrest is a BIG ticket item1. As soon as you acknowledge no effective breathing and no palpable pulse you nodded to your partner who immediately commenced compressions. He won’t be able to maintain hard and fast compressions as required for long and you will have to relieve him unless backup help arrives. So you call for that back up help on your radio. You also know that a defibrillator is likely to be more effective the sooner it is applied2. Early defibrillation is the other BIG ticket item to any successful outcome. You decide that the airway appears to be a big problem but you take the view to come back to it as soon as you can. With limited people, compressions and defibrillation are the priorities in the first instance. Normally a lateral position would be helpful in clearing an airway, followed by suctioning. You cannot roll him as your partner is performing chest compressions. You also decide not to do anything other than gently tilt the patients head back slightly and move straight to applying the defibrillator.

Attending to airway, breathing, circulation and defibrillation are all important. With limited rescuers, you have to make sacrifices and cut a few corners until more help arrives. If an ideal resuscitation requires four or five people, it cannot be ideal with only two. Prioritise is the word. Chest compressions are essential for good outcomes, as is rapid defibrillation. These must take priority according to the evidence and best consensus opinion2. Airway and breathing are also important but must give way in the first few precious seconds of the cardiac arrest if there are only two rescuers. No, it is important to not get dragged into airway at the start when there are other essential tasks taking priority. Come back to the airway as soon as possible. In