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As part of the Priority Action Approach to the critically ill patient, the steps of the Scene Assessment include:
- Asess the scene for Hazards: First priority is to check for danger to yourself and the patient
- Determine the Mechanism Of Injury: What happened?
- Are they in RTC? How much force was applied
- What part of body was force applied
- Number Of Victims: If there is more than one victim get help immediately. Remember golden rule. Don't do it all yourself
The Priority Action Approach to the Walk In Patient Scene Assessment includes:
- Initial Appearance: Dyspnea / Skin Color / Anxiety
- What Happened
- Force: Did you fall / hit head / neck
- Anyone else hurt
The Secondary Survey Should not take longer than:
a) 5 minutes
b) 10 minutes
c) 15 minutes
d) take as long as you need while waiting for rapid transport
The Secondary Survey is completed for a RTC patient only:
a) at the scene after assessing abc's
b) while en route to the hospital
c) after packaging patient and awaiting transport
d) after the primary survey
- b) en route to the hospital
- c) after packaging patient and awaiting transport.
- The golden hour is critical, rapid transport is the priority. For a patient not in the rapid transport criteria, the secondary survey can be conducted at the scene.
List the primary steps in the Priority Action Approach:
- Scene Assessment
- Primary Survey
- Critical Interventions /Transport Decision
- Secondary Survey
List the Primary Steps In The Secondary Survey:
- Vital Signs
- History Taking
- Head To Toe Examination
List the order of steps taken for assessing vital signs during the secondary survey?
- Respiration: rate and quality of breathing
- Pulse: check for rate, strength, irregular (arrhythmia).
- LOC: Glasgow Coma Scale
- Skin: Colour, temperature, condition
When assessing the skin colour, temperature, and condition you look for:
- Color - normal, red, cool, cold
- pallor - pale skin (sign of shock)
- cyanosis bluish discolouration (sign of cardiorespiratory emergency, gray
- Temperature - hot, warm, cool, cold
- condition - dry, moist, sweaty, clammy
Primary Survey, Critical Interventions, and Patient Packaging should be completed in less than:
a) 10 minutes
b) an hour
c) 15 minutes
d) 20 minutes
- a) 15 minutes
- Rapid, safe transport is the priority.
The Primary Survey itself should take no longer than:
a) 5 minutes
b) 10 minutes
c) 2 minutes
- c) 2 minutes.
- The primary survey is a rapid assessment to determine the presence of any immediate and obvious life threatening injuries.
After the primary survey, ABC Reassessments must be done for all patients at regular intervals.
a) For RTC patients, and urban setting requiring stretcher transport, the ABC's are assessed every ___ minutes.
b) For non RTC patients, and urban settings ABC's are assessed every ___ minutes.
- a) 5 minutes.
- b) 10 minutes.
What are the main steps in the Primary Survey?
Airway, Breathing, Circulation and Rapid Body Survey
While assessing circulation on a non breathing patient, what is the next best action to take?
a) apply oxygen
b) begin compressions
c) after the 2 initial ventilations, immediately check the carotid pulse
- Correct answer: c)
- Immediately after the initial 2 ventilation's, you must check the carotid pulse to ensure oxygen entering the lungs is being circulated. If the carotid pulse is absent, it means they are in cardiac arrest, and you must start chest compressions to circulate the blood.
What important information can you receive from the first step in assessing the airway?
- Level of consciousness and airway status.
- The first step of assessing the airway is introducing yourself as a first aid attendant, providing emotional support, and asking what happened, you immediately
- gain the crucial above information.
What do you do immediately after upon finding out the patient is unable to reply and/or has decreased level of consciousness?
- Open the airway, with either a head tilt chin lift (non trauma patient) or a jaw thrust (trauma patient).
- If mechanism of injury (or unwitnessed unresponsive patient) suggests possible head, neck or spinal trauma, you must apply C Spine Control and do a jaw thrust.
The primary survey, airway, breathing, circulation, level of consciousness, and performing most critical interventions, are best done in what position?
correct answer: c) supine
When assessing the breathing rate, and pulse rate, what is the correct amount of time to assess, and the number multiplied to find amount of breaths, or heart beats per minute?
Count number of breaths or pulse for 15 seconds, and multiply by 4 to find amount of breaths per minute.
a)If you find out a patient is breathing less than 3 breaths in 15 seconds, the attendant must count the breaths for:
b)If breathing rate turns out to be less than 10 breaths per minute, what should you do?
- a) 30 seconds and multiply by 2 for a more accurate count.
- b) If the breathing rate is less than 10 breaths per minute, you must give assisted ventilations with oxygen using a pocket mask.
choose 2 answers:
Upon asessing breathing during the primary survey the attendant must expose the chest if:
a) the attendant must always expose the chest during the primary survey
b) Dyspnea (respiration is irregular)
c) if there is an airway obstruction
d) there has been trauma to the chest
- correct answers:
- b) Dyspnea (respiration is irregular)
- d) there has been trauma to the chest
While assessing circulation on a breathing patient, what is the first best thing to do?
a) check the skin, colour, temperature, condition
b) check the radial pulse
b) Checking the radial pulse is the first step. Absence of the radial pulse is a sure sign of shock. Note: If one radial pulse is absent, must check the opposite wrist as it may be due to an upper extremity injury. If both radial pulses are absent must check the Carotid pulse to determine if heart is beating, if so apply critical interventions. Then you check for further signs of shock (skin).
As part of the primary survey, the Rapid Body Survey must not take any longer than:
a) 30 seconds
b) 1 minute
c) 2 minutes
- a) 30 seconds.
- All you are doing is palpating for massive external hemorrhage and obvious fractures, move quickly, but carefully all over the body.
During the Primary Survey, you only interrupt with critical interventions for:
- airway obstruction
- severe respiratory distress
- an open chest wound
- cardiac arrest
- severe bleeding
Upon approach you can also use AVPU to determine the casualties level of consciousness quickly. AVPU stands for:
- A - Alert: patient seems alert
- V - Verbal: can speak, and can open eyes to verbal stimuli
- P - Pain - responds only to painful stimuli
- U - Unresponsive
While determining level of consciousness, what are the three different functions ( in order) of the nervous system used in the Glasgow Coma Scale?
- Eye Opening Response
- Verbal Stimuli
- Motor Response
Glasgow Coma Scale Eye Opening Response:
List the order of the scores in this scale.
- spontaneous eye opening response - 4
- eyes open to verbal stimuli - 3
- eyes open to painful stimuli - 2
- unresponsive - 1
Glasgow Coma Scale Verbal Response:
List the order of the scores in this scale.
- Speech is clear and coherent - 5
- Speech is disorientated but at least understandable - 4
- Basic simple speech, inappropriate, profanities - 3
- Speech unintelligible, incomprehensible, moaning - 2
- Unresponsive - 1
Glasgow Coma Scale Motor Response:
List in order
- Can move on verbal command - 6
- Localizes with painful stimuli - 5
- Withdrawal to painful stimuli - 4
- Decorticate response - 3
- Decerebrate response - 2
- Unresponsive - 1
The Glasgow Coma Scale was adopted, because in the past it was difficult to describe levels of consciousness with descriptive words. Terms like "drowsiness" often mean differing things to different people. The advantage of this scoring system is that its measurements are simple to use, and effective.
As part of the secondary survey vital signs, the attendant must examine the pupils, especially if a head injury is suspected. What are you looking for?
a) foreign bodies
b) hyphema (blood in eye)
c) dilated, sluggish, poorly reactive pupil
c) If one pupil is dilated and poorly responsive to light, the attendant must suspect a head injury, this is a sure sign of decreased levels in consciousness. You can do this by shining a light into one eye, or by covering one eye, and noticing if the eyes constrict like normal.
Part of the Secondary Survey History Taking, while you are obtaining more information on the pain and injury, what does the mnemonic PPQRRST stand for?
- P - Position: location of pain
- P - Provoke: what makes the pain worse? weight, breathing, movement
- Q - Quality: what does pain feel like? throbbing?
- R - Radiation: does the pain radiate from one point to another?
- R - Relief: Have you been able to relieve pain in any way? Shallow breathing?
- S - Severity: On a scale of 1 - 10, how high would you rate this pain.
- T - Timing: How long ago did pain start? Does it come and go? Is it getting better, or worse, or constant?
What is the definition of Shock?
- Shock is a state of inadequate perfusion of cells. Reduced blood flow, creating inadequate circulation.
- This results in Hypoxia (low oxygen in the blood) and a build up of acidosis (too many acids). Shock can become irreversible, and can lead to death.
What is the primary aim of in treatment of Shock?
To increase tissue perfusion.
What is the definition of Perfusion?
- Perfusion is the flow of blood to and from the body cells, carrying oxygenated blood and unoxygenated blood, in the circulatory system, of the heart (pump), and through the blood vessels (arteries, veins, capillaries), to the heart and all the cells of the body
- A functioning respiratory system is needed to supply the circulatory system with oxygen.
What is the definition of Hypovolemic Shock?
Inadequate perfusion due to decrease in circulatory blood volume, which can be caused by excessive bleeding / hemorrhage, or severe fluid loss, severe burns. Signs of shock, pale, cold, clammy skin, increased heart rate, hypotension (low blood pressure), tachnypea (increased respiratory rate) "air hunger" as a result of hypoxia. Thirst due to reduced blood volume, loss of radial pulses due to hypotension (low blood pressure).
What is the definition of Cardiogenic Shock?
Heart muscle is not pumping enough blood to peripheral tissues, most common cause is Myocardial Infarction (MI or heart attack) force of left ventricle contraction is reduced due to damage to ventricle wall. Congestive heart failure, and chest trauma can also cause Cardiogenic Shock. Signs are the same as Hypovolemic Shock.
Bacteremic (septic) shock definition:
A circulatory collapse due to bacteria invading the bloodstream. This causes vasodilation (dilation of vessels) loss of tissue perfusion. Signs are confusion due to bacterial toxins, high fever warm flushed skin, later becomes cool, pale, increased pulse rate, increased respiration
What is Neurogenic (Spinal) Shock:
Only occurs in presence of spinal cord injury with complete paralysis. It impairs the blood vessels and nerve control, which make the vessels dilate, this blood becomes pooled in dilated blood vessels resulting in reduced return to the heart. Though there is no blood loss, blood volume becomes inadequate to maintain perfusion to cells.
a) Facial Fractures, especially fractures of the mandible and maxilla, must be carefully assessed and cleared, because:
b) All patients with facial fractures must be assessed for and assumed to have:
a) patients are at continuous risk for developing airway obstruction due to bleeding or swelling.
b) brain and cervical spine injury.
The main priorities with injuries to the throat and anterior neck are:
- Stabilizing the airway, assessing continuously.
- Treating them for suspected spinal injury.
a) Hyphema is:
b) Treatment is:
a) Bleeding in the eye, over the iris or pupil.
b) keep patient still in sitting position, with both eyes covered, to allow blood to collect in the bottom of the eye.
Choose 3 answers:
What do you do with an extruded eyeball?
a) Cover both eyes with sterile moist dressings.
b) push eyeball back into socket
c) protect from pressure with rigid protection, bandage lightly
d) transport supine with head sandbagged
e) wash out the eye
- a) Cover both eyes with sterile moist dressings.
- c) protect from pressure with rigid protection, bandage lightly
- d) transport supine with head sandbagged
- Never attempt b) or e)
True or False: If there is a penetrating injury to the eye, apply direct pressure.
False. Applying direct pressure can force fluid out of the eye and cause permanent damage.
A patient walks into the first aid room and makes the statement "I hurt my wrist, i think it might be broken!" What question should you ask first?
What is the Definition of a Seizure?
Seizures are the manifestation of a massive discharge of electrical impulses from the brain cells.
The normal respiratory breathing rate is:
12 - 20 breaths per minute
With a healthy adult worker, loss of the radial pulse corresponds approximately with a low blood pressure that is less than:
90 mm Hg Systolic. This is why actual measurement of blood pressure is not an important skill for the attendant.
Anatomy of the eye. What is the adjustable muscle behind the cornea? It has a shutter opening, which regulates the amount of light entering the eye. The opening is called the pupil.
What part of the eye changes light image into electrical impulses, which are carried away to the optic nerve to the brain.
Anatomy of the eye. What is the lacrimal system composed of?
The lacrimal (tear) glands and ducts. The tear glands are located beneath the upper eyelid, and the tear ducts are on the inner side of the eye, along the upper and lower lid.
Anatomy of the eye. What is the tough tissue, the white of the eye, which makes up the outer wall of the globe in the eye, and is covered by a clear membrane called conjunctiva?
What do you do for a chemical burn in the eye?
- Irrigate the patients eyes with water or saline for a minimum of 30 minutes.
- Examine and remove particles with moist applicator.
- If burn was caused by strong acids continue to flush while en route to hospital, if available, use IV bag and tubing.
What do you do with thermal burns to the eye?
- Do not examine the eye, as this may injure burned tissue.
- Cover both eyes with sterile dressings.
- Transport to medical aid.
Management of ultraviolet (flash) burn to the eye, what do you do?
- Examine eye for foreign bodies to rule it out.
- Use cold compresses and mild pain medications.
- Patient may not be able to return to work if severe.
- Patient may need to wear dark glasses for a couple of days due to increased photosensitivity.
What do you do with superficial foreign bodies to the eye?
Obtain history, wash hands, wipe dust away from face, flush eye, lift upper lid over lower lid no more than 2 times, if these steps do not work, do an eye examination.
How do you manage penetrating foreign bodies in the eye?
- Do not attempt to wash out eye. Do not remove protruding objects. If patient cannot close eyes, lightly cover injured eye with moist sterile dressing.
- Cover with a rigid eye patch (paper cup, padding) Apply no pressure to eye.
- Transport patient laying down, head slightly elevated and sandbagged.
Inadequate perfusion is also called:
Inadequate oxygen is called:
Low blood pressure is called:
What are the two different types of strokes, and definitions?
- Ischemic Stroke: caused by blocking or narrowing of the cerebral artery. Ischemia means inadequate perfusion. There are two types of ischemic strokes. A cerebral thrombosis develops the same as coronary artery disease. The arteries of the brain narrow, and a thrombus (blood clot) blocks the perfusion to the brain tissue.
- A cerebral embolism is a stroke caused by obstruction of the cerebral artery by a clot, which is formed elsewhere in the body. An embolus is not always clotted blood, it can be other foreign material.
- Hemorrhagic Stroke is the rupture of the cerebral artery. Brain damage results from bleeding into brain tissue, and damaged circulation. An aneurysm is a hemorrhagic stroke caused by being born with an abnormal, weak dilated area in a cerebral blood vessel.
True or False Question.
A patient suffering from a Cerbrovascular Accident, cannot hear what is going on.
- False. A stroke victim may not be able to speak, but they may be able to hear what is going on, so remember to converse with them reassuringly.
- When managing a stroke follow the Priority Action Approach, during the secondary survey the neurological assessment is required.
What is Status Epilepticus?
A dangerous prolonged seizure which can happen for more than 20 minutes, or 2 or more seizures without gaining consciousness in-between, that is life threatening. This is RTC.
What are Simple Partial (Focal Motor) Seizures?
Seizures that only involve part of the brain, where only one part of the body is effected in seizure, patient is responsive, may last for several minutes, and recur frequently. Warning: This type of seizure may progress into a Generalized Tonic Clonic Seizure.
What is a Generalized Tonic Clonic (grand mal) Seizure?
The most common seizure, whereas the patient will experience an aura, may comprehend the seizure is coming on, then the patient convulses. After seizure there will be a loss of consciousness and recovery for approximately 10 to 30 minutes. Patient may be appear to having respiratory distress, assisted ventilations may need to be applied, but usually they begin breathing on their own.
What are Absence (petit mal) seizures?
They are very brief seizures (less than one minute) and usually occur in children. This type of seizure is usually unnoticed, it may appear like they are just spacing out, eyelids may flutter. These seizures usually disappear by adulthood.
How to manage a seizure?
If a cervical spine injury is suspected, try to stabilize the head and neck as best as possible. Loosen clothing around neck. Do NOT force oral airway or bite stick in mouth. Apply oxygen if you can during the convulsing. Assist ventilations until patient breathes properly after convulsions. If you can feel pulse during convulsions. Obtain history. All patients who have had a seizure should be transported to hospital for further medical evaluation.
What is Priapism?
A symptom which may occur during spinal cord injury in male patients, is a persistent erection. Try to assure patient, and protect dignity by covering with blanket.
A patient has bloodshot eyes, is complaining about chest and abdomen pain, and has tiny blue spots on his face. Upon questioning him, you find out there was an explosion but he was a far distance from it. What do you do?
Patients with blast injury are in the RTC, no matter how small the symptom, pressure waves and changes in air pressure can cause major damage to the insides. Little red or blue spots can occur, as they are tiny hemorrhages. You would follow the Priority Action Approach, and management of chest injuries.
What is Hemothorax?
Hemothorax is when blood pools up within the pleural space/thoracic cavity (chest). It may be caused by open or closed chest injuries, and usually occurs with pneumothorax. Blood can come from lacerated vessels in the chest wall, or the chest cavity, or a lacerated lung. Symptoms are the same as chest injury, most important increased respiration and shock.
What is a pulmonary contusion?
A bruise of the lung. Almost always associated with blunt injuries to the chest, it can cause blood loss into the lung tissue. Mild cases may or may not have respiratory distress. Symptoms are the same as for general chest injury. Severe cases, patients cough up blood. May develop 12 - 24 hours after chest injury.
Respiratory injury due to smoke inhalation is a major cause of death, respiratory distress may be immediate or delayed. What information do you need to pass on to medical aid? All patients with smoke inhalation are in the rapid transport criteria.
- Location of worker when exposed to smoke:
- Duration of exposure:
- Presence of toxic substances:
- Decreased level of consciousness:
- Other info that may be important:
Management of asthmatic attack?
- Calm patient, put patient at rest comfortably.
- Apply oxygen at 10 Lpm if possible.
- Help them take their medication.
- Assist ventilation if patient is sleepy or unresponsive.
What is the criteria for Assisted Ventilation?
- Absent or slow respiratory rate (lower than 10 breaths per minute)
- Presence of cyanosis
- Shallow ineffective respiration
- Severe respiratory distress
What is the most common cause of airway obstruction?
Blockage of the tongue.
What do you use on supine conscious or unconscious patients to clear an obstruction of the airway?
List the methods for opening and clearing airway?
- Get conscious patient to cough
- Finger Sweep
- Heat Tilt Chin Lift
- Jaw Thrust
- Abdominal thrusts
- Chest Compressions
- Oral Airway
- Suction Devices
Why and when is the oral airway used?
It is used on all unconscious patients (patients who cannot respond to verbal stimuli) to prevent the tongue from blocking the airway, and to keep the airway open and managed. It can also aid in drainage in lateral position due to profuse bleeding or vomiting. It can also aid in clearing the airway.
Conscious partial airway obstruction:
Scene Assessment, LOC, attempt to communicate with patient, stabilize head and neck, encourage coughing, if patient is supine, roll to lateral position to aid in drainage. Use suctioning. Give abdominal thrusts if patient cannot cough it out. If partial airway obstruction persists, assist ventilation, and get them rapid transport.
Keep giving abdominal thrusts until:
a) medical help arrives
b) the foreign body is expelled, patient starts to breathe or cough, or the patient becomes unresponsive.
c) the patient complains of sore ribs or abdominals
d) you find out the airway is bleeding
- correct answer
- b) the foreign body is expelled, patient starts to breathe or cough, or the patient becomes unresponsive.
How would you manage a complete airway obstruction on an unresponsive patient?
a) chest compressions, 2 ventilations, look in mouth, finger sweet
b) look in mouth, finger sweep, 2 ventilations, chest compressions
correct answer b)
What are the main arterial pulse points?
- Dorsalis Pedis Pulse - on dorsal surface of foot
- Posterior Tibial Artery - ankle
- Radial Pulse - wrist
- Femural Artery Pulse - both sides lateral to symphysis pubis
- Brachial Pulse - elbow
- Carotid Pulse - neck
What are the steps under the Secondary Survey for History Taking?
- Chief Complaints:
- Past Medical History:
Choose 3 answers:
What are the steps for Secondary Survey / History Taking / Chief Complaints?
a) obtain and record history of injury
b) rapid fire interrogation of symptoms
c) use PPQRRST
d) perform a head to toe examination
e) underlying illnesses and medical alert bracelets
- a) Obtain and record history of injury: ask what happened
- * Avoid rapid fire interrogation.
- c) Use PPQRRST to record information of pain.
- * Head to to examination comes after History Taking.
- e) check for underlying illnesses and medical alert bracelets.
What should you do when you are searching for medical alert tags / bracelets or information and the patient is unresponsive?
a) search their personal possessions, cell phone, purse, wallet
b) search their bodies for bracelets or necklaces
c) leave it to medical aid, the patients file will be recorded at hospital
- a) It is critical that you search their possessions for medical alerts. They may have an emergency contact # and medical alerts listed on their cell phone.
- Ask witnesses, and do everything you can to contact someone who knows about possible medical alerts.
- b) Search their body for tags, necklaces, bracelets.
Under the secondary survey/ history taking/ Allergies, what allergies are you looking for?
- Any drug / medication
- Chemicals (perfume, topical agents)
- Whether patient is taking medication for allergies at the moment
- * Information about the nature of any such reaction
For the Secondary Survey / History Taking / Medications, what are the important details of medications you are looking for?
- Name of drug
- Compliance: is patient taking medication as directed
What is the order of the Head To Toe Examination?
a) head, neck, chest, abdomen, pelvis, back, extremities
b) extremities, back, pelvis, abdomen, chest, neck, head
correct answer: a)
While examining the patients head, what are you looking for?
- open wounds, swelling, deformities
- The nose and oral cavity for blood and broken teeth
- Eyes: vision, contact lenses
- Scalp and facial bones for tenderness
- Ear canals for cerebrospinal fluid, blood, and bruising behind ear. Clear fluid, bruising behind ear (battles sign), and racoon eyes are signs of basilar skull fracture.
When you are examining the neck during Head to Toe, what are you looking for?
- Deformity, open wounds, swelling, tenderness
- Listen for hoarseness or stridor
- If tenderness is discovered cervical spine and neck must be immobilized.
True or False.
All patients with a decreased level of consciousness must be assumed to have a cervical spine injury.
The last step in Head To Toe Examination/ Neurological Examination is composed of:
- Glasgo Coma Scale (already done)
- Sensory Function - asking patient if there is numbness or tingling anywhere, if they can feel touch on fingers, toes, and other parts of body.
- Motor Function - testing muscle response in the face, upper and lower extremities, have patient smile, or note response to painful stimuli, hand grips, arm raise, wiggle toes, leg lifts.