New Emergency Half Way Example

8/3/2019 New Emergency Half Way Example

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EmergencyProcedures


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PREFACE

The Emergency Procedures is written by the fourth years medical students of

University Malaya .The book has been prepared during our A&E posting .Procedures that

are usually done in A&E department has been focused and are written in the simple and

easy understanding way .With the advent of the internet, a direct link to the video has been

added to help the reader to be more understanding of the procedures. We wish that this

book can be a guide for our junior that will enter A&E posting later .

We wish to thank Dr Rishyaman(Head of department of A&E at UMMC) who has

helped in many ways for guiding the preparation of this book.

Editor

NOV 2011 TOK ERN LAI


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CONTENTS

1. Oxygen mask by Tok Ern Lai4

2. Draw blood by Leong Ya Shan.6

3. Taking vital signs by Chiew Ai Wen.8

4. AED by Mohd Luqman bin Sahar11

5. Cervical collar by Yvonne Ling.13


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Oxygen Mask

Purpose

Deliver low to moderate levels of oxygen to relieve hypoxia.

Indication

Cardiac and respiratory arrest

Hypoxaemia with PaCO2


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Precedures

1. Explain procedure to patient and review safety precautions necessary when

oxygen is in use. (Dont smoke)

2. Perform hand hygiene.

3. Attach face mask to oxygen setup with humidification. Start flow of oxygen to fill bag

before placing mask over patients nose and mouth.

4. Position face mask over patients nose and mouth. Adjust it with the elastic strap so

mask fits snugly but comfortable on face.

5. Use gauze pads to reduce irrigation on patients ears and scalp.

6.

Perform hand hygiene.

7. Remove mask and dry skin every 2 to 3 hours if oxygen is running continuously.

8. Assess and chart patients response to therapy.

Complication

Discomfort

Dryness of the skin cause by O2


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EQUIPMENT REQUIRED USING THE VACUTAINER SYSTEM

A Tourniquet which should be applied at a pressure which is high enough to impede venousdistension but not restrict arterial. This allows blood to flow into the arm but stops it from leaving,causing the veins to fill with blood and become prominent.

A sterile alcohol swab to clean the puncture site. The area must be allowed to dry first otherwise thealcohol base may seep into the puncture site causing the patient discomfort. Research has shownthat although cleansing of the skin reduces the number of bacteria present on its surface, it is notnecessary to prevent infection prior to parenteral procedures

A vacutainer system sample bottle holder

An appropriately sized needle designed for use with the vacuum system

Cotton wool to apply to the puncture site following the procedure

A sterile plaster or hypoallergenic tape to secure the cotton wool

Specimen bottles and requisition form correctly filled in with the patients details, Diagnosis, G.Ps/Consultants details and signed.

Sharps disposal bin for the safe disposal of the specimen tube holder and needle

PREPARATIONS PRIOR TO CARRYING OUT THE PROCEDURE

It is important that patient distress and inconvenience is minimised, and it mustalways be remembered that painful venepuncture and unsightly bruising can leavea lasting impression. Careful and unhurried preparation will all help to alley the

patients fears/anxieties

With the patient seated, begin by explaining the procedure to him/her, answeringany questions they may have and ensuring that the patient has given their verbalconsent for you to carry out the procedure.

The patient should be asked whether or not they have had any blood taken in thepast, and when (as any recent sites should be avoided). Whether they are awareof any particular problems encountered and of the best sites available.

After checking that the light is adequate and all the written information has beenobtained, the procedure can be carried out.

CARRYING OUT THE PROCEDURE

After washing her hands, the practitioner should apply the tourniquet to thepatients upper arm. If the arm is placed in a dependent position and the patientasked to clench and release their fist this will help to increase the prominence ofthe veins.

we should then palpate the area with our index and middle finger to select a veinand also to allow us to distinguish such structures as arteries, tendons etc. Theselected vein should be firm and bouncy.

The needle should be inserted along the length of the vein at an angle of


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approximately 30 degrees. The tip of the needle should be inserted through theskin into the vein in one continuous movement with the bevel of the needle facingupwards.Check for back flow of blood into needle. Once the needle is in thecorrect position, the required vacuumed bottles are then attached will each thendraw up the required amount of blood for each test.

Once the required amount of blood has been collected into the bottles, and the lastbottle detached from the needle, the tourniquet should then be released and acotton wool ball placed over the point of entry. At the point the needle should thenbe removed and discarded. DO NOT recap needle. pressure should be appliedover the entry site for approximately 2 minutes to stop any further bleeding. Thearm should be kept straight and not bent, as the latter enlarges the entry holecausing more bleeding and bruising. A sticking plaster or hypo-allergenic dressingmay then be a applied to the site once the bleeding has stopped.

NB. Care should be taken with patients who have a history of bleedingdisorders or who have been taking warfarin or other anti-coagulants, as thismay increase the time it takes for the bleeding to stop.

IMPORTANT POINTS TO REMEMBER

If the tourniquet has been on for longer that 2 minutes prior to insertionof the needle, then it should be released to allow blood to return to thehand before reapplying, and attempting the procedure again.

If a venous valve is entered during the procedure the patient willexperience sudden, acute pain. The procedure should be thendiscontinued immediately.

If after 2 attempts the procedure has been unsuccessful, thenassistance should be sought from a colleague.

The Patient should be observed throughout the procedure for signs ofdizziness or fainting.

BE AWARE, the Brachial Artery is sited near the sites mostcommonly used for venepuncture.Procedure is the same by using a syringe.

http://www.youtube.com/watch?v=_8ZsqXFqvQM&feature=related

http://www.youtube.com/watch?v=9pIWn6i1VZs
http://www.youtube.com/watch?v=_8ZsqXFqvQM&feature=relatedhttp://www.youtube.com/watch?v=_8ZsqXFqvQM&feature=relatedhttp://www.youtube.com/watch?v=9pIWn6i1VZshttp://www.youtube.com/watch?v=9pIWn6i1VZshttp://www.youtube.com/watch?v=9pIWn6i1VZshttp://www.youtube.com/watch?v=_8ZsqXFqvQM&feature=related


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Taking Vital Signs

Measurement of Temperature (Digital Thermometer,Mercury Thermometer)

For Oral Temperature

1. Turn on the thermometer and wait for the display to flash indicating that it is ready.Shake the thermometer using a vigorous wrist movement until the mercury reading is

below 35 degree celcius.

2. Do not hold the thermometer at the measurement portion3. Put the thermometer in the thermometer sheath.4. Check patient has not taken any warm/hot drinks/food at least 15 mins prior to the

measurement. (if yes, give water or measure axillary temperature or wait)

5. Instruct the patient to open his/her mouth and lift his/her tongue and insert thethermometer as far back as possible under the tongue

6. The patient is to close his/her lips tightly.

7. Wait for completion beeps.Leave the thermometer in place for at least 1min but no longer than 2mins.

8. Remove the sheath, hold the thermometer horizontally at your eye level.9. Read the display and record the temperature reading and switch off the

thermometer.

Read and record the temperature reading.10.Clean the thermometer with soapy water or alcohol swab.

For Axillary Temperature

1. Start with steps 1-3 above.2. Ensure the axilla is dry.3. Place the measurement end of the thermometer high in the axilla, against the torso and

perpendicular to the length of the body.

4. Use the patients arm to hold the thermometer in place.5. Leave the thermometer and wait for completion beeps.

Leave the thermometer completely covered for 3mins, but not longer then 5mins.

6. Read and record the temperature reading.

For Rectal Temperature

1. Start with steps 1-3 above.2. Ensure privacy and keep patient comfortable.

3. Position the patient in the left lateral position.4. Apply lubricant to sheathed thermometer and insert into anus. 5. Leave the thermometer and wait for completion beeps.

Leave the thermometer for 2-3mins then record the reading.

Normal Temperature RangeArmpit: 34.737.3 C (94.599.1 F)

Mouth: 35.537.5 C (95.999.5 F)

Ear: 35.8

38 C (96.4

100.4 F)Rectum: 36.638 C (97.9100.4 F)


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Measurement of Pulse Rate

1. Place your index and middle fingers over the radial artery at the wrist, or the brachial

artery at the ante-cubital fossa or the carotid artery in the neck.2. Count the number of beats over 60 seconds.3. Describe the rate, rhythm, strength and characteristic of the pulse.4. Consider comparing pulses on the right with those on the left (radi0-radial delay).5. Compare radial pulse and femoral pulse for radio-femoral delay.

Normal Heart Rates by Age Group at Rest

Newborns 100-160 bpm

Infants 80-150 bpm

Preschool children 80-130 bpm

Older children 70 100 bpm

Adults 60

100 bpm

Measurement of Respiratory Rate1. Place 2 fingers on the patients radial artery.2. While still palpating the patients pulse, observe the patients breathing (by observing

the patients chest wall movement) (if cant see chest wall movement, put your hand

at the back of patient).

3. Ensure that the patient is unaware of the actual observation.4. Count respirations for one minute.5. Record the result.

Normal Respiratory Rate Newborns 30-50 breaths per minute

Infants 20-40 breaths per minute

Preschool children 20-30 breaths per minute

Older children 16-25 breaths per minute

Adults 12- 20 breaths per minute

Measurement of Blood Pressure

1. The patient should be seated with their arm resting on a table so the brachial srtery is

level with the heart (4th

intercostals space at the sternum).

2. Ensure no tight clothing is constricting the arm.3. Select the blood pressure cuff which is long enough to nearly encircle the arm.

4. Select the blood pressure cuff of appropriate width (2/3 of the length of the upper

arm).

5. Place the centre of the cuffs bladder medially over the brachial artery (dont use

thumb the locate the brachial artery).

6. The cuff should be positioned so that the lower edge is about 2cm above the elbow.

7. Wrap the cuff snugly around the patients upper arm.

8. Check that the mercury column of the manometer is vertical.

9. Close the valve on the pump tubing.

10.Palpate the brachial artery or the radial artery.


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11.Inflate the cuff until the pulse disappear and inflate to a further 20mmHg.

12.Deflate the cuff at a rate of 1-2mmHg per second and the pressure at which the pulse

is palpable is the estimated systolic blood pressure.

13.Deflate till 0mmHg immediately.

14.The bell of the stethoscope is placed medially in the ante-cubital fossa, over thebrachial artery. The stethoscope should not be placed under the cuff.

15.Inflate the cuff to 20mmHg above the estimated systolic blood pressure reading that

you made.

16.The valve on the pump is loosened slowly to allow the pressure of the

sphygmomanometer cuff to decrease slowly at about 1-2mmHg/sec.

17.The scale should be read at eye level.

18.Record the level at which you first hear the pulse (first Korotkoff sound = systolic) to

the nearest 2mmHg.

19.Continue allowing the pressure to decrease and record the disappearance of sound

(fifth Korotkoff sound = diastolic) to the nearest 2mmHg.

20.Record whether patient was standing, sitting or lying during BP measurement and

which limb is used.

http://www.youtube.com/watch?v=q4A1uLNzNOc&feature=related

By Chiew Ai Wen
http://www.youtube.com/watch?v=q4A1uLNzNOc&feature=relatedhttp://www.youtube.com/watch?v=q4A1uLNzNOc&feature=relatedhttp://www.youtube.com/watch?v=q4A1uLNzNOc&feature=related


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AUTOMATED EXTERNAL DEFIBRILLATOR

Portable electronic device that can audibly prompt and deliver an electric shock that

will disrupt or stop the heart's dysarhythmic electrical activity.

Treat sudden cardiac arrest (SCA).

PURPOSE

To analyze a heart rhythm

Identify shockable or nonshockable heart rhythms

Guide an AED operator to initiate defibrillation

Delivers an electric shock which is will discharge all electricalactivity of cardiac to stop the useless quivering of the heart.

INDICATION

Adult and children 1 year old and above that are:

Unresponsive

Non breathing

Pulseless

* AED not recommended for infant less under 1 year old.

CONTRAINDICATION

Present of pulse

Conscious patient Touching patient

Wet patient

Implanted defibrillator

SAFETY CONSIDERATION

No metal

No water

Remove medication patches

At least 1 inch away from pacemaker and implanted defibrillator

Remove excessive chest hair Remove electrical device

LANDMARKS FOR ELECTRODE PLACEMENT

Adults :

Upper : right sternal border directly below the clavicle

Lower : left midaxillary line 5th-6th intercostal space with topmargin below the axilla.

SCA

Condition in which the heart

suddenly and unexpectedly

stops beating.

Most common cause is

ventricular fibrillation and

ventricular tachycardia.

Sign and Symptoms

Fainting

No pulse*Palpitation

*SOB

*Chest pain

*Dizziness

*within 1 hour before fainting

Shockable rhythm

Ventricular fibrillation

Ventricular tachycardia

Nonshockable rhythm

Normal sinus

Pulseless electrical activity(PEA)

Asystole

Sign of shock has been

delivered

Arching of the back

Brief straightening of arm

*muscular contractions reduce

with each shock

*no contractions noted in

patient that already arrest for

prolonged period.


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Small child :

Anterior : one pad over sternum between nipples Posterior : one pad between shoulders blade

Large child :

Anterior and posterior as above

Anterior and anterior- pads must not toucha. Right padwrap over childs shoulderb. Left pad left anterior to cover midclavicular and

midaxillary line

PROGNOSIS AFTER SHOCK DELIVERED

Pulse present + breathing- place patient in recovery room

Pulse present w/o breathing- ventilate patient

No pulse + AED indicates no shock- continue CPR

No pulse + AED indicates shock- clear and follow voice prompt

EQUIPMENT

Following supplies are maintained in each AED unit :

1. One AED

2. One users guide

3. Two sets of electrodes4. One installed battery and one spare5. One installed PC data card

6. One carrying case

7. One mouth barrier device

8. One pair of scissors

9. Two sets of gloves

10. One razor11.44 gauze

Normal sinus

Ventricular fibrillation

Ventricular tachycardia

PEA (electrical activity normal

but patient cardiac muscle

problem or severe

hypovolemia)

Asystole

Artifact (loose leads or patient

move)


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CERVICAL COLLAR

WHAT IS CERVICAL COLLAR?

A cervical collar (also neck brace) is an orthopaedic medical device used to support a patient's neck and head.

It is also used by emergency personnel for victims of traumatic head or neck injuries, and can be used to treatchronic medical conditions.

WHAT ARE THE INDICATIONS FOR USE ?

Neck Extension Injuries (Whiplash)

Cervical Spondylitis

Cervical Spondylosis

R/A & O/A Cervical Spine

Herniated Cervical Disc

WHAT ARE THE INSTRUCTION FOR CERVICAL COLLAR APPLICATION?

1. Size the collar

-Use your fingers to size by putting your hand as shown with the small finger on the

trapezium and count your fingers to jaw line.

2. Put your hand on the side of the collar, your small finger to the bottom edge, and the

correct number of fingers to the marker pin.

3. Get some one to support the head so there is no movement while it is fitted. Always

explain to the patient what you are doing.

4. Immobilisation can be constructed from several different materials. It needs head blocks and

sufficient straps to make it effective

WHAT ARE THE TYPES OF CERVICAL COLLAR?

There are four types of cervical collar :

1. Aspen Collar

2. Miami-J Collar3. Soft Foam Collar

4. Philadelphia Collar

1 2 3 4


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ALL CERVICAL COLLARS:

1. Must be worn moderately snug to limit motion.

2. Must be worn according to specifics outlined above based on type of collar used.

3. May be washed and/or liners may be changed.

4. Must be kept clean and dry to protect skin integrity.

5. Duration of time wearing the collar and amount of time during the day

wearing the collar are always patient specific and will be determined by your physician.

WHAT ARE THE COMPLICATIONS OF CERVICAL COLLAR?

Development of skin pressure points and ulcer formation

Possible delay in weaning from ventilator

Potential to exposure for blood borne disease

REFERENCES:

1.http://www.med.umich.edu/op/Patient%20Education%20Forms/5A/Cervical%20Collars.pd

f

2.video:

http://www.youtube.com/watch?v=rkDTnFOic9w&feature=autoplay&list=ULknAMhmmg5gU&lf=mf

u_in_order&playnext=1(with immobilisation)

3.video:http://www.youtube.com/watch?v=knAMhmmg5gU&feature=mfu_in_order&list=UL
http://www.med.umich.edu/op/Patient%20Education%20Forms/5A/Cervical%20Collars.pdfhttp://www.med.umich.edu/op/Patient%20Education%20Forms/5A/Cervical%20Collars.pdfhttp://www.med.umich.edu/op/Patient%20Education%20Forms/5A/Cervical%20Collars.pdfhttp://www.med.umich.edu/op/Patient%20Education%20Forms/5A/Cervical%20Collars.pdfhttp://www.youtube.com/watch?v=rkDTnFOic9w&feature=autoplay&list=ULknAMhmmg5gU&lf=mfu_in_order&playnext=1http://www.youtube.com/watch?v=rkDTnFOic9w&feature=autoplay&list=ULknAMhmmg5gU&lf=mfu_in_order&playnext=1http://www.youtube.com/watch?v=rkDTnFOic9w&feature=autoplay&list=ULknAMhmmg5gU&lf=mfu_in_order&playnext=1http://www.youtube.com/watch?v=knAMhmmg5gU&feature=mfu_in_order&list=ULhttp://www.youtube.com/watch?v=knAMhmmg5gU&feature=mfu_in_order&list=ULhttp://www.youtube.com/watch?v=knAMhmmg5gU&feature=mfu_in_order&list=ULhttp://www.youtube.com/watch?v=knAMhmmg5gU&feature=mfu_in_order&list=ULhttp://www.youtube.com/watch?v=rkDTnFOic9w&feature=autoplay&list=ULknAMhmmg5gU&lf=mfu_in_order&playnext=1http://www.youtube.com/watch?v=rkDTnFOic9w&feature=autoplay&list=ULknAMhmmg5gU&lf=mfu_in_order&playnext=1http://www.med.umich.edu/op/Patient%20Education%20Forms/5A/Cervical%20Collars.pdfhttp://www.med.umich.edu/op/Patient%20Education%20Forms/5A/Cervical%20Collars.pdf


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Nebulizers

Tan Chen Long

Aim

- deliver a therapeutic dose

of desired drug as an aerosol

in the form ofrespirable

particles within a fairly short

period of time, usually 5-10

minutes.

Types

1) Jet nebulizers (most common): a nebulizing chamber 2) Ultrasonic nebulizers: self-contained electrical

in which an aerosol is generated with a flow of gas devices in which an aerosol is generated by vibrating

provided either by an electrical compressor or fluid placed within them; nebulize larger volumes of

compressed gas (air or oxygen). fluid& are quiet.

Indications

1) Most common: emergency treatment of

asthma and exacerbations of COPD.

2) Less frequently:-long term treatment of chronic air flow

obstruction with bronchodilators.

-prophylactic drug tx- e.g. corticosteroids in

asthma.

-antimicrobial tx in cystic fibrosis,

bronchiectasis, AIDS.

-symptom relief in palliative care

Drugs for nebulization

1) Bronchodilators: agonists (salbutamol,

terbutaline); anticholinergics ( ipratropium

bromide).2) Steroids: budesonide

3) Antibiotics: colistin& gentamicin for cystic fibrosis

4) Pentamidine: prophylaxis for Pneumocustis carinii

pneumonia in HIV positive patients.

5) Lignocaine: in terminal care to relieve cough.

N.B. Water should not be used as it may cause

bronchoconstriction when nebulized.

Method of inhalation

-Patient should sit upright or in a

chair

-Take normal steady breaths (tidal

breathing)

-Not to talk during nebulization-Keep the nebulizer upright

Demonstration of nebulizer use:

http://www.youtube.com/watch?v=svG5S2wn4xQ
http://www.youtube.com/watch?v=svG5S2wn4xQhttp://www.youtube.com/watch?v=svG5S2wn4xQhttp://www.youtube.com/watch?v=svG5S2wn4xQ


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New Emergency Half Way Example

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