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IMAI second-level learning programme for district clinicians working at hospitals in limited-resource settings Participant training manual for clinicians: Triage and Emergency Treatments: Quick Check Essentials This manual covers the training of nurses, clinical officers and medical doctors in the recognition and care of emergency patients using the Quick Check method. June 2014 Integrated Management of Adolescent and Adult Illness (IMAI) IMAI second-level learning programme for district clinicians working at hospitals in limited-resource settings Participant training manual: Triage and Emergency Treatments: Quick Check Essentials This manual covers the training of nurses, clinical officers and medical doctors in the recognition and care of emergency patients using the Quick Check method. This training course is based on guidelines in the IMAI District Clinician Manual: Hospital Care for Adolescents and Adults June 2014 Produced by IMAI-IMCI Alliance for WHO HSE/PED Comments to: [email protected] Development of the Quick Check+ training curriculum was supported by funding from the government of USA (DOD DTRA) and the Government of Japan through grants to WHO/HSE/ Pandemic and Epidemic Diseases ( PED) (project manager Nikki Shindo) , with the support of WHO regional office for Africa (Francis Kasolo, Benido Impouma) and the WHO country offices in affected countries. Produced by the IMAI-IMCI Alliance. Design and illustrations: Robert Thatcher Table of contents Introduction: Quick Check ................................................................................................ 1 Chapter 1: Quick Check: Assess emergency and priority signs ................................... 2 DRILL 1-1: Quick Check Assessment.......................................................................................... 7 Assessment questions: Triage..................................................................................................... 9 Chapter 2: Airway and Breathing ................................................................................... 10 DRILL 2-1: Manage Patient on Oxygen: What would you do next? ............................................ 24 DRILL 2-2: What is the next emergency treatment? .................................................................. 25 Assessment questions: Airway and Breathing ........................................................................... 28 Chapter 3: Circulation ..................................................................................................... 29 DRILL 3-1: What you would do next? ........................................................................................ 35 DRILL 3-2: What you would do next? ........................................................................................ 37 Assessment questions: Circulation ............................................................................................ 38 Chapter 4: Altered level Consciousness/Convulsing ................................................... 39 DRILL 4-1: AVPU Scale ............................................................................................................ 40 DRILL 4-2: First-line emergency treatment: What would you do next? ...................................... 48 Assessment questions: Altered level of Consciousness and Convulsion ................................... 50 Chapter 5: Pain from life-threatening cause .................................................................. 52 DRILL 5-1: Quick Check ............................................................................................................ 59 Assessment questions: Severe pain .......................................................................................... 61 Chapter 6: Priority signs and their immediate management ....................................... 63 Assessment questions: Priority patients .................................................................................... 70 Chapter 7: Continue with urgent management of patients with emergency signs .... 71 DRILL 7-1: Continue with urgent management .......................................................................... 77 Assessment questions: Continued urgent management of patients with emergency signs ........ 82 Chapter 8: Implementing the Quick Check and emergency treatments ..................... 83 Quick Check Implementation Exercise ...................................................................................... 88 Introduction: Quick Check This training course will teach you to triage and give first line emergency treatments for adults and adolescents using the IMAI Quick Check (QC) method. The Quick Check is the adult version of the paediatric Emergency Triage Assessment and Treatment (ETAT) and is designed to be compatible with it. Many deaths can be prevented if very sick patients are identified quickly on their arrival to the health facility and treatment is started without delay. The QC assessment is a triage system that sorts patients out into groups who need emergency or urgent treatment. With appropriate training, the QC assessment can be done in less than one minute. Effective emergency management is accomplished by a team. Teamwork therefore is emphasized and practiced throughout the course. This training course should be part of a quality improvement process which targets the whole hospital. The appropriate sections of the IMAI District Clinician Manual (DCM) should be used as a clinical reference for details on patient management. After you have completed the Quick Check training, you will be able to: • triage adolescents and adults at the health facility • provide life-saving first-line emergency treatments and stabilize the patient • plan and implement the Quick Check in your own hospital as part of a clinical team. Participant training manual: Quick Check, triage and emergency treatments Introduction – 1 Chapter 1: Quick Check: Assess emergency and priority signs Learning objectives: 1. Triage (sort) patients according to the severity of illness using the Quick Check in your facility. 2. Recognize patients with Quick Check emergency signs (E). 3. Recognize patients with Quick Check priority signs (P). 4. Recognize patients who are non-urgent (can wait their turn in the queue) (Q). Around the world, many deaths in hospitals occur within 24 hours of admission. Often, patients wait in long queues and are not checked before a senior health worker examines them. As a result, seriously ill patients with treatable conditions have died while waiting to be seen and treated. A triage system will enable you to quickly identify sick patients who require immediate attention versus patients who can wait their turn. The word “triage” means sorting. Triage is the process of rapidly screening all sick patients when they first arrive in the hospital and categorizing them according to the order in which they need to be seen based on the severity of illness. After triage occurs, assess all patients with a complete history and physical exam. How do you triage patients in your hospital? Triage is a rapid process that is conducted as soon as a patient arrives at the hospital or anytime a patient’s clinical condition changes in the hospital ward. When no emergency treatments are needed, you should be able to use the Quick Check to triage a patient in less than one minute. Do not delay triage for administrative procedures such as registration. Triage Sorting of patients into groups based on their need and the severity of their condition • All clinical staff involved in the care of sick patients should be trained to triage and give basic emergency treatments. • Other auxiliary staff in the hospital such as gatemen, record clerks, cleaners, and janitors who have early patient contact should also be trained to assess for emergency and priority signs. If a patient with a life-threatening condition is recognized, staff should immediately call for help and/or take the patient to where they can receive emergency care. A seriously ill patient should be taken to the triage nurse at the front of the queue. 2 – Chapter 1 Participant training manual: Quick Check, triage and emergency treatments During triage, you will find that some patients require immediate emergency care. Provide emergency treatments wherever there is room for a bed or trolley for the sick patient and enough space for the staff to work on the patient. Ensure that an emergency trolley with drugs and supplies is easily accessible (see DCM, QC p.38 for Emergency trolley). Always use universal precautions for infection control. Triage categories: Recognize emergency, priority, or queue Triage categories Action required EMERGENCY cases Need IMMEDIATE emergency treatment PRIORITY cases Need assessment and RAPID attention QUEUE cases Non-urgent, can wait their turn in the QUEUE EMERGENCY (E): Patients require immediate emergency treatment for a potentially lifethreatening condition. If you see any emergency signs, call for help and start first-line emergency treatments. PRIORITY (P): Patients with serious conditions that require rapid assessment and treatment. Give these patients priority in the queue so they are evaluated quickly by a healthcare worker. QUEUE (Q): Patients who do not have a life-threatening or serious condition are non-urgent. These patients can wait their turn in the queue for evaluation. Most patients will be triaged to this category. Emergency signs Check for emergency signs Emergencies of Airway, Breathing, and Circulation, Consciousness, Convulsions are life threatening. Every time you evaluate a patient immediately assess for airway, breathing, circulation, consciousness, or convulsions and treat without delay. If a patient deteriorates, reassess and manage the ABCs first. A B C Airway Breathing Circulation Consciousness Convulsing In the children's ETAT, the ABC concept is expanded to include “dehydration” in the emergency assessment and is remembered as “ABCD”. In the Quick Check, the ABC concept has been expanded to include “pain from life-threatening cause.” As in the ETAT (ABCD), pain from life threatening cause can be remembered as “Dolor.” On the Quick Check wallchart, the emergency signs are located in the white boxes on the left of the chart. Emergency signs can be assessed quickly without any equipment. If any emergency sign is identified, call for help. If you are trained, start necessary emergency treatments. In this chapter, you will learn how to conduct this Quick Check for emergency and priority signs only. In the following chapters, you will learn how to do the assessments in the arrows on the Quick Check wallchart and to provide first-line treatments. Participant training manual: Quick Check, triage and emergency treatments Chapter 1 – 3 The Quick Check assessment for emergency signs FIRST ASSESS: AIRWAY AND BREATHING Appears obstructed or Central cyanosis or Severe respiratory distress THEN ASSESS: CIRCULATION (SHOCK or heavy BLEEDING) Weak or fast pulse or Capillary refill longer than 3 seconds or Heavy bleeding from any site or Severe trauma THEN ASSESS: ALTERED LEVEL CONCIOUSNESS/CONVULSING Altered level consciousness or Convulsing THEN ASSESS: PAIN FROM LIFE-THREATENING CAUSE Severe abdominal pain and Abdomen hard on palpation Severe headache or Stiff neck or Trauma to head/neck 4 – Chapter 1 New onset chest pain Major burn Snake-bite Participant training manual: Quick Check, triage and emergency treatments Priority signs Check for priority signs If no emergency signs are found, check for priority signs. Priority signs alert you to a patient who needs urgent (but not emergency) treatment for potentially serious acute problems. Priority patients should ideally be evaluated within 30 minutes of arrival at the hospital. As with all patient care, it is important to remember infection prevention and control. If cough or other signs of respiratory illness, apply source control (use of tissues, handkerchiefs or medical masks) on the patient in the waiting room when coughing or sneezing, and perform hand hygiene. If possible, accommodate patient at least 1 meter away from other patients or in a room, and evaluate as soon as possible – see Section 6. If history of exposure or fever, bleeding or other signs during an outbreak suggest viral haemorrhagic fever: isolate the patient, use standard precautions and personal protection equipment, call for help. See Section 11.46 in IMAI District Clinician Manual and VHF guidelines. Priority signs for urgent care – these patients should not wait in queue: Any respiratory distress/complaint of difficulty breathing* Violent behaviour towards self or others or very agitated Very pale Very weak/ill Recent fainting Bleeding: Large haemoptysis GI bleeding (vomiting or in stools) External bleeding Fractures or dislocations Burns Bites from suspected venomous snake or from rabid animal Frequent diarrhoea >5 times per day Visual changes New loss of function (possible stroke) Rape/abuse (maintain a high index of suspicion) New extensive rash with peeling and mucus membrane involvement (Stevens-Johnson) Acute pain, cough or dyspnea, priapism, or fever in patient with sickle cell disease * Patients in severe distress are categorized as having an emergency sign. These are suggested priority signs that may need to be adapted to include commonly seen urgent conditions and based on local epidemiology of disease. Class activity Stand by the Quick Check wallchart. Using the Quick Check wallchart, identify the emergency and priority signs. As a group, repeat the emergency and priority signs aloud. Participant training manual: Quick Check, triage and emergency treatments Chapter 1 – 5 Class exercise 1-1 You have many patients waiting in line. You must triage these patients. Label each patient as (E)mergency, (P)riority, or (Q)ueue. Use the Quick Check wallchart to help you. 1. 33-year-old asthmatic with severe respiratory distress, unable to speak in complete sentences 2. 18-year-old male with pain and swelling to left ankle for 2 days 3. 50-year-old female with severe headache and confusion 4. 30-year-old female with severe abdominal pain who is in her first trimester of pregnancy 5. 38-year-old male who is too weak to stand 6. 26-year-old female with cough and mild respiratory distress 7. 30-year-old male with severe abdominal pain after a motorbike accident 8. 17-year-old pregnant female with convulsions 9. 54-year-old male with rash to the legs for 1 month 10. 22-year-old female with depression and suicidal ideation After initial triage Give first-line emergency treatments The assessment for emergency signs and need for first-line emergency treatment will be covered in detail throughout the rest of this course. The triage, assessment, and initial treatments should occur quickly and address immediate, life-threatening emergency signs. These steps can be critical to the care of a severely ill patient. They should be initiated even if senior health workers are not immediately available. C AU T I O N ! Patients with trauma may have injuries to their spine. Check for trauma when providing treatments to make sure that you immobilize spine when moving patient. There are special considerations for injured patients in column 3 of the Quick Check wallchart. 6 – Chapter 1 Participant training manual: Quick Check, triage and emergency treatments If emergency sign identified: • call for help • give first line emergency treatments • establish IV access • draw blood for emergency laboratory investigations • stay calm • work as a team • use infection control precautions. More than one treatment may need to be given as quickly as possible. Several people may need to work together as a team. The person in charge should assign tasks such has placing an IV or giving emergency medications. These guidelines are intended to help guide management of patients with severe illness and may not be appropriate for all patients. If the situation is complicated by other underlying co-morbidities (i.e. cardiac disease, renal failure, severe anaemia) or diseases (dengue fever, severe malaria), the district clinician can determine if the guidelines need to be modified. Protocols developed by your hospital adapted to the local epidemiology should also be followed. While these management principles may be used for most patients, they are not intended to replace the sound clinical judgement of trained clinicians. Treat for priority signs Patients with priority signs should be moved to the front of the queue. These patients have potentially serious conditions that may worsen if care is delayed. Some hospitals may choose to place priority patients in a separate room or treatment area. While waiting, supportive treatments should be provided, for example holding pressure on a bleeding wound. If the patient presents with no emergency signs or priority signs, the patient can wait in the queue. Reassess Frequent reassessment of patients is critical. Patients initially triaged as “Priority” or “Queue” can later develop emergency signs if their condition worsens. Thus, it is important to reassess patients and change their triage category to “Emergency,” when appropriate. DRILL 1-1: Quick Check Assessment Your facilitator will lead a DRILL reviewing the Quick Check aloud. Stand around the Quick Check wallchart to help you. You will soon be able to go through all the signs in order without looking. Practice this exercise throughout the course. Now try the Quick Check on each other. Divide into pairs. Do the Quick Check, saying out loud what you are doing. Participant training manual: Quick Check, triage and emergency treatments Chapter 1 – 7 Summary Triage is the process of sorting patients into priority groups based on their need and the severity of their condition. Triage all patients upon arrival into one of the following categories: E – Patients with Emergency signs P – Patients with Priority signs Q – Patients who are non-urgent and can wait in the Queue Triage steps: 1. 2. 3. 4. 5. 6. Look for emergency signs. Give first-line emergency treatments. Call a senior health worker immediately to see emergency cases. If no emergency signs are identified, look for priority signs. If a priority sign is identified, send patient to the front of the queue. Move on to the next patient. Remember to check for trauma. Pay attention to infection control. Reassess patients as appropriate. 8 – Chapter 1 Participant training manual: Quick Check, triage and emergency treatments Assessment questions: Triage Answer all the questions on this page. Write your responses in the given spaces. If you have a problem, ask a facilitator for help. 1. Define “triage”. 2. When and where should triage take place? 3. What do the letters E, P and Q stand for? 4. True/False: Trained personnel should triage patients. 5. What do the letters A, B, and C in "ABC" stand for? 6. List three priority signs: 7. Put these actions in the right chronological order. What will you do first, what next, and so on, and what last? ___ Look for any priority signs ___ Look for emergency signs ___ Move on to the next patient ___ Place priority patients at the front of the queue ___ Start treatment of any emergency signs you find Participant training manual: Quick Check, triage and emergency treatments Chapter 1 – 9 Chapter 2: Airway and Breathing Learning objectives 1. Assess patient for emergency signs of airway or breathing. 2. Give first-line emergency treatments for airway obstruction. 3. Measure oxygen saturation with a pulse oximeter. 4. Give oxygen and adjust flow. 5. Treat wheezing with salbutamol. The letters A and B in “ABC” represent “airway and breathing”. An airway or breathing problem is life-threatening and must receive attention before moving on to other systems. First check whether the airway is open to allow proper breathing. If the airway is open and the patient is breathing, assess if breathing (ventilation) and oxygenation are adequate or impaired. If there is no problem with the airway or breathing, move on and look for emergency signs of circulation, consciousness, and convulsing. A B C Airway Breathing Circulation Consciousness Convulsing Patients who are alert and having difficulty breathing will usually position themselves to optimize their breathing. Patients with breathing difficulties may prefer to sit upright rather than lying flat. Do not force a patient with respiratory distress to lie down on a stretcher. Help the patient get to a comfortable position. Supplemental oxygen Supplemental oxygen can be a life-saving treatment. Oxygen therapy is indicated as a treatment in many emergency presentations such as severe respiratory distress, myocardial infarction, stroke, sepsis, and trauma. In low resource settings, effective oxygen systems may be in limited supply. Where available, oxygen systems can be sustainable and can significantly improve patient care. Assess need for supplemental oxygen Is the patient in severe respiratory distress? Is the patient cyanotic or are their lips blue? Is the patient convulsing? Is the patient altered or confused? Is the measured oxygen saturation <90%? 10 – Chapter 2 Participant training manual: Quick Check, triage and emergency treatments How to measure oxygen saturation (SpO2): A pulse oximeter measures oxygen saturation of haemoglobin in the blood by comparing absorbance of light at different wavelengths across a translucent part of the body. Pulse oximetry is very easy to use, and is the best method available for detecting and monitoring hypoxemia (low oxygen saturation). Pulse oximetry can also ensure the most efficient use of an expensive resource in your hospital. Class demonstration Your facilitator may demonstrate how to use a pulse oximeter. When you go to the hospital you should practice using the pulse oximeter on yourself and your colleagues so that you understand how to use it in an emergency situation. How to Set Up Oxygen The oxygen source is attached to oxygen tubing. The oxygen tubing is then attached to a device that allows the delivery of oxygen to the patient. Participant training manual: Quick Check: triage and emergency treatments Chapter 2 – 11 How to deliver oxygen This section will cover three of the most common devices used to deliver oxygen in adults and adolescents. It is important to familiarize yourself with the different devices and understand how much flow can be delivered by each method. Nasal cannula or prongs • Simple, flexible tubing systems with soft prongs that rest within the nasal openings. • Deliver relatively low flow rates of oxygen (generally 2–6 litres/minute). • Nasal cannula can be more comfortable for patients than face masks, allowing the patient to eat and talk easily. Face mask • Covers both the nose and mouth of a patient. • Used to deliver higher flow rates of oxygen (>5 litres/minute). • Delivery of oxygen to the patient can be variable based on how fast and deeply the patient is breathing. Face mask with reservoir (non-rebreather) • Only use with high flow rates of oxygen (10–15 litres/minute). • Deliver very high percentages of oxygen to a patient (60–95% FIO2). • High flows are needed to inflate the reservoir bag. • Use for patients who continue to be hypoxic despite lower oxygen flow. • Oxygen given by high flow should be humidified to prevent drying of air passages. 12 – Chapter 2 Participant training manual: Quick Check, triage and emergency treatments FiO2 FiO2 FiO2 24–40% 35–55% 70–100% 1–5 litres/min 5–9 litres/min 10–15 litres/min Follow a stepwise approach when assessing and managing emergency signs of airway and breathing 1. 2. 3. 4. 5. 6. Assess airway. Open airway if airway obstructed. Insert airway device to keep airway open and give oxygen if needed. Assess ventilation and oxygenation. Assist ventilation and/or supplement oxygenation as needed. Assess need for advanced airway management. Each of these steps is discussed in more detail in the following pages . FIRST assess: Airway and Breathing: Appears obstructed or Central cyanosis or Check for obstruction (noisy breathing, wheezing, choking, not able to speak) Severe respiratory distress Give first line emergency treatments If trauma patient with possible neck or spine injury, immobilize spine. Look at the assessment box in the far left column of the Quick Check. There are three emergency signs of airway and breathing. 1. Does the airway appear obstructed? 2. Is there central cyanosis? 3. Is the patient in severe respiratory distress? Call for help and give first-line emergency treatments for airway and breathing if any of these signs are detected. Participant training manual: Quick Check: triage and emergency treatments Chapter 2 – 13 Step 1: Assess airway Talk to the patient. If the patient is speaking clearly the airway is open. Look/listen for signs of airway obstruction Snoring or gurgling Stridor or noisy breathing Foreign body or vomit in mouth Is the airway obstructed? Rapid recognition of an obstructed airway and initiation of treatment to relieve the obstruction can be life-saving. Patients can have a partial or full airway obstruction. Patients should be under constant observation until the obstruction is removed because a partial obstruction can rapidly progress to a full obstruction. Obstruction of the airway may occur in several ways: • the tongue may fall backwards and obstruct the airway in an unconscious patient • blood or vomit in the mouth may obstruct the airway particularly in cases of trauma • swelling and laryngeal oedema may obstruct the airway in anaphylaxis • infection or swelling in the throat, such as an abscess or goitre • foreign bodies, particularly poorly chewed food such as meat. Look for: • any visible obstruction (vomit in mouth, trauma, swelling, foreign body) • the universal choking sign • a patient who is unable to swallow secretions or saliva (may be spitting into a bucket). Listen for: • noisy breathing, snoring, gurgling, stridor, or wheezing • a strong or weak cough • a clear, normal voice. When asked a question, is the patient’s voice muffled, gasping, or is the patient unable to speak at all? • Is the patient in severe respiratory distress or coughing, but you do not hear any noise (unable to speak or cough, no wheezing or stridor)? Is there central cyanosis? Cyanosis indicates that the patient is not getting enough oxygen. Look: • Do you see blue discoloration around the lips and mouth? Is the patient in severe respiratory distress? Look: • Is the patient having visible difficulty breathing? • Is the patient breathing very fast? • Do you see retractions or the use of accessory muscles? • Is the breathing laboured? • Is the breathing shallow? 14 – Chapter 2 Participant training manual: Quick Check, triage and emergency treatments • • • Do you see nasal flaring? Is the patient able to lie flat or does he/she need to sit forward to help breathing? Is the patient agitated, confused, uncooperative, or unconscious? Listen: • Is the patient able to speak in full sentences without pausing to catch breath? • Do you hear abnormal breathing sounds (stridor, wheezing)? Other considerations Make a quick visual decision if the patient is breathing too fast. You will not count the respiratory rate as part of the quick check assessment, as counting the respiratory rate accurately takes 30-60 seconds. Practice counting the respiratory rate on stable patients first so you can quickly recognize the difference between normal and abnormal respiratory rates. Once you complete the Quick Check and administer first-line emergency treatments, count the respiratory rate along with the rest of the vital signs as you continue to monitor the patient. The respiratory rate increases if the patient has difficulty breathing or is not getting enough oxygen. Be aware that other conditions such as fever, pain, and anxiety may also increase the respiratory rate. Patients who are in severe respiratory distress and not getting enough oxygen may become very agitated, combative, confused, or lethargic. In any patient who is not behaving normally, first check their airway and breathing. The airway of an unconscious patient can become obstructed by the tongue at any time. Unconscious patients should be placed near the nurses’ station in the recovery position if possible, under continuous observation (see DCM-QC). If patient presents with emergency signs of Airway and Breathing, call for help and give: First-line emergency treatments If obstructed airway: Appears obstructed or Central cyanosis or Severe respiratory distress Check for obstruction (noisy breathing), wheezing, choking, not able to speak If foreign body aspiration, treat choking patient (see QC p. 11). If suspect anaphylaxis, give 1:1000 epinephrine (adrenaline) IM – 0.5 ml if 50 kg or above, 0.4 ml if 40 kg, 0.3 if 30 kg (see QC p. 11). For all patients: Manage airway (see QC p. 12). Give oxygen 5 litres (see QC pp.14–16). If inadequate breathing, assist ventilation with bag valve mask (see QC p. 13). Help patient assume position of comfort. If wheezing, give salbutamol. Participant training manual: Quick Check: triage and emergency treatments Chapter 2 – 15 Step 2: Open airway if airway obstructed If foreign body aspiration, treat choking patient If a patient appears to be choking but is still able to cough and appears to be getting adequate ventilation, allow them to continue to try to clear the object on their own. If the cough is weak and ineffective or there is evidence for increased respiratory distress and worsening ventilation, it is time to step in and assist (see DCM-QC). If suspect anaphylaxis (wheezing and facial swelling), give epinephrine Anaphylaxis is a life threatening allergic reaction that can rapidly cause swelling of the airway and obstruction. Insect bites, foods, or medications are common causes of anaphylaxis. Patients may present with swelling of the face and airway, wheezing, hives, and shock. How to give epinephrine For anaphylaxis: give 1:1000 epinephrine (adrenaline) IM. 0.5 ml if 50 kg or above, 0.4 ml if 40 kg, 0.3 ml if 30 kg. Give IM in anterior lateral thigh. Repeat in five minutes if no response. See Section 3.1.3 for further management. Treating patients with allergic reactions with hydrocortisone will help to control the allergic reaction once the epinephrine wears off. An antihistamine may help to provide symptomatic relief of itching. Observe patients given epinephrine for at least four hours prior to discharge. 16 – Chapter 2 Participant training manual: Quick Check, triage and emergency treatments Techniques to open airway In an unconscious patient, if airway obstruction occurs due to the tongue falling backward, simple positioning manoeuvres can open the airway. If there is concern for trauma, proceed with caution before attempting these manoeuvres. Improper use of these procedures can further injure a patient with neck trauma. There are two ways to open the airway that are generally recommended-the head tilt-chin lift manoeuvre and the jaw-thrust manoeuvre. Head tilt-chin lift manoeuvre If there is NO concern for cervical spine injury, use the head-tilt chin-lift to open the airway of an unresponsive patient. This manoeuvre lifts the tongue and epiglottis away from obstructing the posterior pharynx and is demonstrated in the following diagram: One hand tilts the forehead back while the other hand firmly lifts the chin upward using two fingers, relieving the obstruction. Jaw-thrust manoeuvre If there is concern for possible cervical spine injury, first stabilize the spine. The jaw-thrust manoeuvre is a safer choice for opening the airway in cases of trauma. It allows the airway to be opened without extending the neck backward. The clinician stabilizes both hands on either side of the patient’s head and uses index and long fingers to grasp and lift jaw at the angles of the mandible to displace the jaw forward (moving the tongue away from upper airway). Participant training manual: Quick Check: triage and emergency treatments Chapter 2 – 17 Step 3: Insert airway device and give oxygen if needed Once the airway is opened an airway device may be needed to keep the airway open. Airway devices maintain an opening for air to move through, bypassing blockage due to an obstructing tongue. These devices do not protect an unconscious patient from aspiration of secretions or gastric contents, nor should they be used if you suspect an obstruction due to a foreign body. Oropharyngeal airways may not be tolerated by a semiconscious patient with an intact gag response and may cause unintended vomiting or aspiration (remove device if patient begins to gag or vomit with placement). Care must be taken to choose the correct size. Obstruction by pushing the tongue further back in the oropharynx may also be caused when placing an oral device with poor technique. Once the airway device is placed, make sure to administer oxygen. Simple instructions on how to choose the correct device and insert are as follows: Inserting an oropharyngeal airway Inserting a nasopharyngeal To insert an oropharyngeal airway in an adolescent or adult, begin by inserting the device concave side up until the tip reaches the soft palate, then carefully turn concave side down while sliding tip back over curve of tongue. To insert a nasopharyngeal airway select a tube approximately the size of the nostril, and gently insert a well lubricated tube into nostril. The stopper at the tip of the tube should be up against the end of the nostril. 18 – Chapter 2 Participant training manual: Quick Check, triage and emergency treatments Step 4: Assess ventilation and oxygenation Is ventilation impaired? Ventilation refers to movement of air in and out of the lungs. This air movement is impaired in patients with a decreased drive to breathe (low respiratory rate), from altered consciousness. Common conditions include patients with drug overdose, meningitis, or head injury. Ventilation can also be impaired when breaths are shallow or ineffective such as in patients with severe pneumonia, bronchospasm, or chest trauma. In contrast, these patients are often breathing very rapidly. ASSESS VENTILATION If ventilation is inadequate, or patient is cyanotic or unconscious with respiratory distress, then assist breathing via bag valve mask ventilation (go to STEP 5). If ventilation is adequate, give oxygen and titrate flow . Look: • Is the chest wall rising? • Is the movement of the chest wall symmetric? • Is the respiratory effort adequate? Listen: • Do you hear air movement? • Do you hear breath sounds and are they equal? If ventilation is impaired, give oxygen and prepare to assist ventilation. Step 5: Assist ventilation with bag valve mask If a patient is not ventilating adequately, assistance can be given using a bag-valve-mask device. A self-inflating bag delivers air when squeezed to ventilate the patient, and then refills when released. Attach the bag to oxygen to deliver a higher concentration of oxygen than room air. The bag is connected via a valve to the face mask. The face mask should fit the face starting at the bridge of the nose, resting evenly over both cheeks, and ending in the area between the lower lip and chin (mandibular alveolar ridge). It is important to use the right size face mask to prevent air leakage. Using this device correctly can be difficult. When ventilating a patient, you have to maintain an adequate seal with the mask so that no air escapes from around the mouth. Practice is helpful. Instructions for a single-handed mask hold and a double-handed two person mask hold are described below. Note that the hand holds serve two purposes: first to produce an effective mask seal, and second to open the airway with a chin-lift or jawthrust. Participant training manual: Quick Check: triage and emergency treatments Chapter 2 – 19 Three major points must be observed during the use of a bag-valve-mask: • Is the airway still open (or does positioning need adjustment)? • Is there an adequate mask seal (or is there air escaping)? • Are you giving proper ventilation (breath volume, rate, rhythm)? ASSIST VENTILATION WITH BAG VALVE MASK Attach the bag valve mask (BVM) to highest available flow oxygen. Place mask over patient’s mouth and nose (if two people: one person squeezes bag and other holds mask on patient’s face). Create a seal so that air does not leak out. If the patient is breathing on their own, deliver breaths during inspiration. Do not attempt to deliver a breath as the patient exhales. Squeeze bag to give one breath every 6 seconds. If unable to effectively ventilate, reconsider possibility of foreign body obstruction or air leak. Insert oral or nasal airway device if not already in place (see STEP 3). If the chest does not rise, re-check to make sure the airway is still open (adjust mask hold to ensure head-tilt chin-lift or jaw-thrust position and check position of airway device if using) and that air is not leaking out of the side of the mask. One person Single-hand mask hold: The mask connector rests between the thumb and index finger pushing evenly down to seal mask against face while the three other fingers lift mandible up into mask. Listen for air leaks and adjust hold if needed. Two people Two-hand two-person mask hold: One provider uses both hands to hold mask using index fingers and thumbs on the mask to produce a good seal, and uses the other three fingers of both hands to lift mandible up (chin-lift) and into mask. The other provider holds the bag. 20 – Chapter 2 Participant training manual: Quick Check, triage and emergency treatments How to bag patient Hold the bag in one hand and depress a two-litre bag to about 1/3 of its volume. After each breath allow the patient to completely exhale before giving another breath. Watch the chest rising and falling evenly with each breath. Avoid over-aggressive bagging, as it will result in damage to lungs. Step 6: Assess need for advanced airway management Despite efforts to give maximal oxygen delivery (via non-rebreather device) and an open airway, hypoxemia (decreased oxygen in blood) may persist. Further support of ventilation and oxygenation may be accomplished if equipment for positive pressure mechanical ventilation is available. The provision of mechanical ventilation is resource-intensive, and is not readily available in many district level hospitals. If your patient fails to improve despite oxygen and basic airway treatments, consider whether transfer to a centre where mechanical ventilation can be delivered is indicated. Further information on advanced airway management is provided in the Advanced Module on Airway and Breathing. ASSESS NEED FOR ADVANCED AIRWAY MANAGEMENT Some patients with easily reversible conditions may quickly improve and be able to ventilate on their own after emergency treatments are given. Others may need continued assistance with ventilation or intubation to protect airway. Look for signs: • Is SpO2< 90, cyanosis or severe respiratory distress on high flow oxygen therapy? • Is there impending airway failure (e.g. inhalation injury, angioedema)? • Are these basic airway manoeuvres (Steps 1 to 5) failing to maintain or protect airway? • Is prolonged ventilation likely needed (e.g. suspect continued failure from drug overdose, snake-bite)? If yes, call for help from district clinician and see advanced airway management (DCM-QC) Participant training manual: Quick Check: triage and emergency treatments Chapter 2 – 21 Delivery and titration of oxygen Start all adults who need oxygen at five litres via nasal cannula. After starting a patient on oxygen recheck for signs and symptoms of respiratory distress and check SpO2. Most patients will have improvement in their symptoms and oxygen saturation within a few minutes. Once an emergency patient is stabilizing, assess whether they are getting the correct oxygen flow. If the initial flow of oxygen does not seem to be enough and the patient’s oxygen saturation is low or the patient is still in significant respiratory distress, increase the oxygen flow. 22 – Chapter 2 Participant training manual: Quick Check, triage and emergency treatments Only start to decrease the flow of oxygen once you are convinced that the patient is receiving enough oxygen with the current flow and you have completed other first-line emergency treatments. Every time you make a change to a patient’s oxygen treatment, directly observe the patient for two to three minutes to ensure that they are stable. If the patient remains stable, reassess in 15 minutes and record their clinical exam and SpO2. If the patient develops severe respiratory distress or the SpO2 is <90% when you decrease the oxygen level, then increase the oxygen flow to the initial level. The following is an example of how oxygen may be titrated in a patient who is stabilizing: • If after 15 minutes the oxygen saturation on five litres NC is >90% or the patient is no longer in respiratory distress, decrease the oxygen flow to four litres NC and observe. • Check patient. If after 15 minutes the oxygen saturation on four litres NC is >90% or the patient is no longer in respiratory distress, decrease the oxygen flow to two litres NC and observe. • Check patient. If after 15 minutes the oxygen saturation on two litres NC is >90% or the patient is no longer in respiratory distress, stop the oxygen and observe the patient on room air. • Check patient. If after 15 minutes the oxygen saturation on room air is >90% or the patient is no longer in respiratory distress, keep the patient off oxygen. You must recheck the SpO2 or for any signs or symptoms of respiratory distress in ONE hour as patients may develop delayed hypoxia. In some cultures, families may be worried about giving oxygen to their loved ones fearing that giving oxygen means that the patient is going to die. Remember to address the family’s concerns and explain that oxygen can be used like a medicine to treat disease and improve a patient’s condition. Participant training manual: Quick Check: triage and emergency treatments Chapter 2 – 23 DRILL 2-1: Manage Patient on Oxygen: What would you do next? Clinical situations 1. 23-year-old male with cyanosis, respiratory distress, oxygen saturation cannot be measured 2. 26-year-old female with complaint of difficulty breathing, but no emergency signs of airway or breathing on exam and oxygen saturation of 94% 3. 45-year-old male on five litres NC, with continued severe respiratory distress and oxygen saturation of 84% 4. 62-year-old female on a face mask at six litres, who is improving and has a saturation of 94% 5. 24-year-old male who was initially improving on three litres NC oxygen, but has suddenly deteriorated with severe respiratory distress and oxygen saturation of 82% 6. 36-year-old female with an oxygen saturation of 93%, who had her oxygen flow rate decreased to four litres/min 15 minutes ago Managing the patient with wheezing If wheezing, give salbutamol Bronchospasm usually has audible wheezing. If the bronchospasm is extremely severe, you may hear no wheezing at all. Bronchospasm or wheezing is an important and treatable cause of severe respiratory distress. It is common in patients with asthma and chronic obstructive lung disease (COPD), but can also complicate pneumonia in patients without these chronic conditions. Salbutamol is medication which opens the airways. Give salbutamol via a metered dose inhaler with a spacer or using a nebulizer. The mist form via a nebulizer may be the most effective method of delivery when there is severe respiratory distress. Patients should be reassessed within a few minutes after receiving a salbutamol treatment. Many patients may need more than one treatment to treat their wheezing. If wheezing is severe, patients can continuously be administered salbutamol via nebulizer. Salbutamol should always be delivered by a nebulizer or metered dose inhaler with a spacer when available. Avoid giving salbutamol tablets or liquid by mouth as they are ineffective for bronchospasm. 24 – Chapter 2 Participant training manual: Quick Check, triage and emergency treatments Salbutamol administered via metered dose inhaler should always be given with a spacer. A spacer is easily made from a plastic soda bottle (see DCM-QC). DRILL 2-2: What is the next emergency treatment? Clinical situations 1. 18-year-old male with rash, facial swelling, impending airway obstruction 2. 42-year-old male who is unconscious and cyanotic, gurgling noise heard when breathing 3. Patient who is unable to speak, and began grabbing at neck after coughing while eating a piece of meat 4. Patient who is on five litres via nasal cannula for a pneumonia and oxygen saturation is 96% Participant training manual: Quick Check: triage and emergency treatments Chapter 2 – 25 Group exercise: Count respiratory rate After the Quick Check and first line emergency treatments always check a complete set of vital signs, which includes the respiratory rate. Monitoring the respiratory rate frequently in seriously ill patients will help to follow the patient’s progress and determine the need for additional treatments. The respiratory rate is a critical vital sign to check on every patient. In the Quick Check determine the respiratory rate by quickly looking at a patient to see if he/she is breathing fast or normally. Once you have instituted emergency treatments, go back and count the respiratory rate and record it. Arrange yourselves in pairs and practice counting respiratory rate. You should become familiar with what a patient looks like who is breathing normally or fast. What is a normal respiratory rate? *******************************START HOME STUDY*************************** Management of trauma-related respiratory emergencies During the initial evaluation for airway and breathing, the provider should be aware of special considerations if trauma is suspected, particularly if there is a risk of head, neck, or spinal injury. Treat tension pneumothorax with urgent needle decompression A small hole in the lung surface, known as the pleura or along the tracheobronchial tree, can result in collapse of the lung, called a pneumothorax. A tension pneumothorax is a life- threatening emergency that must be treated immediately. It may occur as a result of trauma (blunt or penetrating), a medical procedure such as placement of a central venous catheter, or spontaneously. Suspect a tension pneumothorax if: 1. Severe, rapidly progressive respiratory distress. 2. Absent lung sounds. 3. Shift of the trachea, visible directly above the sternum, away from the side of the pneumothorax. 4. Low blood pressure or shock. If these signs are present, the provider must act immediately and treat the pneumothroax with needle decompression. Do not wait to contact senior health officers (if they are not in the immediate area) or for an X-ray confirmation. 26 – Chapter 2 Participant training manual: Quick Check, triage and emergency treatments A hiss of air may be heard once the needle is in place and the blood pressure stabilizes and improves. Needle decompression is an immediate life-saving intervention that should be followed-up with the placement of a chest tube. Massive haemothorax Significant chest trauma (penetrating or blunt) may also result in bleeding into the pleural space of the lungs (haemothorax). Insertion of a chest tube to drain the fluid is necessary to treat a massive haemothorax. Suspect a haemothorax if: 1. 2. 3. 4. Trauma to the chest wall Shock Respiratory distress Loss of breath sounds and dullness to percussion on side of the injury. If haemothorax is suspected, give oxygen and call for district clinician. Ensure the patient has at least two large bore IV lines. Send blood for type and cross match. ***********************************END HOME STUDY**************************** Summary Assess airway and breathing: Give oxygen and titrate Does the airway appear obstructed? If patient is wheezing, treat with inhaled salbutamol Is there central cyanosis? Is there severe respiratory distress? If the patient has an airway/breathing emergency: If suspected anaphylaxis, treat with epinephrine. Observe frequently Remove any obstruction and open the airway If trauma with possible neck or spine injury: Place an oral or nasal airway if indicated If chest trauma suspect tension pneumothorax or haemothorax. Assist ventilation with bag valve mask if not breathing or ventilating adequately Manage airway and protect spine Participant training manual: Quick Check: triage and emergency treatments Chapter 2 – 27 Assessment questions: Airway and Breathing Answer all the questions on this page. Write your responses in the given spaces. If you have a problem, ask a facilitator for help. 1. List the airway and breathing emergency signs. 2. List five signs of severe respiratory distress. 3. For patients with emergency airway and breathing signs, what is the recommended initial oxygen flow rate? 4. What is the recommended technique to open the airway in a patient with suspected head or neck trauma? 5. Describe three steps that you would take to manage a patient who is unconscious and whose tongue you suspect is obstructing the airway? 6. List the first-line emergency treatments for patients with emergency signs of airway and breathing. 7. True/False: As part of the Quick Check, you should check all vital signs and oxygen saturation for any patient with airway/breathing signs before you provide first-line treatment. 8. True/False: Inhaled salbutamol can be a life-saving treatment for a patient who is in severe respiratory distress and is wheezing. 28 – Chapter 2 Participant training manual: Quick Check, triage and emergency treatments Chapter 3: Circulation Learning objectives 1. Assess the patient for emergency signs of circulation (shock). 2. Give first-line emergency treatments for shock or heavy bleeding. 3. Place IV and give fluids rapidly. A B C Airway Breathing The letter C in “ABC” stands for three key areas, the first of which is: Circulation (assessment and management of shock) After you assess a patient for emergency signs of airway and breathing, and give them Consciousness first-line emergency treatments, assess for emergency signs of circulation. If you detect Convulsing an emergency sign of circulation, measure the blood pressure (BP) and heart rate. If BP <90 OR pulse (P) >110 with an emergency sign of circulation, initiate first-line emergency treatments and call for help. If a patient does not present with emergency signs of circulation, move onto the rest of the Quick Check and triage the patient into the appropriate category. Circulation Class discussion Think about some common causes of shock in patients. What have these patients looked or acted like? Then assess: Circulation (shock or heavy bleeding) Weak or fast pulse or Capillary refill longer than three seconds Check SBP, pulse or Is she pregnant? Heavy bleeding from any site Give first-line emergency treatments or Severe trauma Participant training manual: Quick Check, triage and emergency treatments Chapter 3 – 29 The Quick Check is designed to rapidly screen patients during triage for the presence of poor perfusion to vital organs (i.e., shock). This rapid assessment includes the items in the first column of the Quick Check (the first column of the table above). If any of these emergency signs are present, you must check the blood pressure and pulse and determine the need for first-line emergency treatments. Other signs of poor perfusion commonly seen in severely ill hospitalized patients include decreased urinary output and confusion. If you identify emergency sign of circulation in patient: • check SBP (systolic blood pressure) • check pulse If patient is a woman of child bearing age: • Is she pregnant? Adjust the BP cuff size according to the patient’s arm size. Make sure the inflatable part of the blood pressure cuff goes all around the arm. Using a blood pressure cuff that is too small will result in a falsely high (and falsely reassuring) blood pressure and one that is too large can result in a falsely low blood pressure. Is the pulse weak or fast? Feel the radial pulse (the pulse at the wrist). If strong and not obviously fast, the pulse is adequate. Move on to the next step in assessing circulation. A strong radial pulse means that the systolic blood pressure is at least 80 mmHg. If the radial pulse is difficult to find, weak or very fast, this is an emergency sign of circulation and you should suspect shock. A patient, who is not in shock, should have an easily palpable radial pulse. If the radial pulse cannot be felt, check for a more central pulse. In an adult, adolescent or older child, feel for the carotid pulse in the neck or for the femoral pulse in the groin. To find the carotid pulse, place two or three fingers on the Adam’s apple then slide into the groove between the Adam’s apple and the muscle. To find the femoral pulse, feel along the line that runs from the groin to the hip. It should be at 2/3 the distance, closer to the groin. If pulse palpable Then systolic BP is at least Radial pulse 80 mmHg Femoral pulse 70 mmHg Carotid pulse 60 mmHg Do not spend too much time trying to find a carotid or femoral pulse. If unable to easily detect a pulse, assume that the patient has an emergency sign of circulation and move on to the next step to treat the patient. 30 – Chapter 3 Participant training manual: Quick Check, triage and emergency treatments Is the capillary refill time longer than three seconds? Capillary refill is a simple test that assesses how quickly blood returns to the skin after pressure is applied. Check capillary refill by applying pressure to the pink part of the nail bed of the thumb or big toe. The capillary refill is the time it takes from release of pressure to complete return of the pink colour in the nail bed. A normal capillary refill is 3 seconds or less. Capillary refill is generally a reliable sign except when the room temperature is low. A cold environment causes vasoconstriction and thus causes a delayed capillary refill. How to check capillary refill: • Grasp the patient’s thumb or big toe between your finger and thumb. • Apply minimal pressure for 3 seconds to produce blanching (a change in colour from pink to white) of the nail bed and then release. • Time the capillary refill from the moment of release until total return of the pink colour. • If the refill time is longer than 3 seconds, the patient may be in shock. • To confirm shock, check the pulses and blood pressure. Checking capillary refill A. Applying pressure to the nail bed for 3 seconds B. Check the time to the return of the pink colour after releasing the pressure Class activity Arrange yourselves in groups of two or three and practice checking pulses and capillary refill. It is important to know what is normal and practice often so that you can quickly recognize what is abnormal. Is there any heavy bleeding from any site? • Look for obvious heavy bleeding such as bleeding from the nose, vaginal bleeding, rectal bleeding, or vomiting blood. • Look for a tender, distended abdomen that may be a sign of internal bleeding such as from a ruptured ectopic pregnancy. Is there any severe trauma? • Always suspect internal bleeding if a patient presents with severe trauma and shock. • Look for visible bleeding from the wound. • Look for a tender, distended abdomen which may be a sign of internal bleeding. Patients who are subjected to trauma (road traffic accidents, falls, and violence) may have significant blood loss and can quickly go into shock. Life-threatening internal bleeding may not be apparent until a large amount of blood has been lost. If your assessment of a trauma patient shows an emergency sign of circulation with an SBP< 90 mmHg or heart rate greater than 110 bpm, always suspect that the patient has internal bleeding. Participant training manual: Quick Check, triage and emergency treatments Chapter 3 – 31 If patient has emergency signs of Circulation, call for help and begin first-line emergency treatments: If systolic BP<90 mmHg or pulse >110 per minute or heavy bleeding: Give oxygen 5 litres if respiratory distress or SpO2<90. Weak or fast pulse or Insert IV, give 1 litre bolus crystalloid (LR or NS) then reassess (see give fluids rapidly p. 18) Capillary refill longer than three seconds or Heavy bleeding from any site or Severe trauma Check SBP, pulse Keep warm (cover) Is she pregnant? If in second half of pregnancy, place on her side (preferably on the left), not on back If anaphylaxis (rash, wheezing, facial swelling, low SBP) give 1:1000 epinephrine (adrenaline) IM – 0.5 ml if 50 kg or above, 0.4 ml if 40 kg, 0.3 ml if 30 kg (p. 11). If you detect an emergency sign of circulation, call for help and begin emergency treatments if you are trained. Remember to always use universal precautions, particularly if there is any active bleeding. Document the SBP and pulse and respond to any abnormal vital signs. Note: There are different types of shock including septic shock, haemorrhagic shock, cardiogenic shock, and neurogenic shock. The management of different types of shock will be addressed in other chapters. Give oxygen at five litres if respiratory distress or SpO2<90 Patients who are in shock have decreased perfusion to their tissues. These patients may have a primary respiratory problem or may need oxygen because of decreased oxygenation to their tissues. Refer to the previous section (Chapter 2) to review the proper administration of oxygen. Insert IV, give one litre bolus crystalloid (LR or NS) rapidly, then reassess. How to insert IV and give fluids rapidly If heavy bleeding or shock, insert two large bore cannulae – at least 16 or 18 gauge. Attach LR or NS. Give one litre as rapidly with infusion wide open. Assess response of pulse, SBP and signs of perfusion (urine output, mental status). If still in shock and no evidence of fluid overload, give another bolus. If still in shock after 2 litres and suspect ongoing blood loss, start blood transfusion and search again for source of bleeding. 32 – Chapter 3 Participant training manual: Quick Check, triage and emergency treatments If still in shock after 2 litres, call for help from district clinician. Insert urinary catheter (see Section 7.3.2 and 7.3.6) and monitor hourly urine output. A urine output of at least 30 ml/hour suggests adequate hydration. See sections 3.1 (Shock) and 4 (Trauma) for further information on fluid management. If not able to insert peripheral IV, use alternative: Call for more experienced help, consider: External jugular vein cannulation Femoral vein cannulation (or internal jugular or subclavian vein cannulation if trained). Venous cut-down –see 7.3.10. A large bore IV (at least 16 or 18 gauge) will allow you to give IV fluids rapidly. These large IVs should always be used for resuscitations. Place the IV in a large vein, such as in the antecubital fossa. If a patient is very unstable, give rapid fluids through two different IV sites at the same time. If you are unable to insert an IV quickly, call for help. Consider alternate sites (femoral vein, external jugular vein) or venous cut down (see Surgical Care at the District Hospital for further information). In addition, some hospitals may have access to intraosseous cannulation for adults. Only crystalloid fluid (Lactated Ringer’s (LR) or normal saline (NS)) should be used in resuscitation. Give fluids fast and warm if possible. Gravity will help make the fluid run faster. Hang the bag as high as possible. Patients in shock should have the first litre of fluid infused as fast as possible, and at least over 30 minutes. Immediately assess patient after first bolus. If SBP<90, pulse >110 or any signs of poor perfusion (poor urine output, mental status) persists, give a second one litre bolus of crystalloid rapidly. If patient remains in shock after two litre bolus of crystalloid, and you suspect patient suffers from trauma or hemorrhagic shock, transfuse blood. Search for and treat source of bleeding. Patients with severe anaemia may also require blood transfusion. For further details regarding blood transfusion in the patient with traumatic injury see Section 4 of the DCM. Urine output should be used to help guide fluid resuscitation in severely ill patients with shock. Ideally, a urinary catheter should be placed for any patient in shock, and urine output monitored hourly. In the average size adult urine output should be at least 30 ml/hour. If a patient has a history of congestive heart failure, renal failure, severe anaemia, or clinical signs of pulmonary oedema, assess for cardiogenic shock and give fluids more cautiously. Give a 250 ml bolus and reassess for respiratory distress, increased jugular venous pressure, or crackles (rales) on pulmonary exam. Further details on management of patients in congestive heart failure are discussed in the module on severe respiratory distress. Participant training manual: Quick Check, triage and emergency treatments Chapter 3 – 33 Keep warm (cover) Keep a patient in shock warm. Ensure that the patient is dry and covered with blankets or warm clothing. If pregnant, place on left side If pregnant, place the woman on her side, preferably in the left lateral decubitus position (left side down). The enlarging uterus in the second half of pregnancy may compress the inferior vena cava (the largest vein which brings blood back to the heart) when she is lying on her back. Placing the woman on her left side if possible helps to prevent this situation and increases blood flow to the heart. If anaphylaxis (rash, wheezing, facial swelling, low BP), give epinephrine (adrenaline) IM If the patient has low blood pressure and is wheezing, has facial swelling, or a rash such as hives suspect anaphylactic shock. Anaphylaxis is a severe allergic reaction that is a result of exposure to an allergen, such as medication, food, or insect bites. It is caused by a massive release of histamine in the body resulting in shock or airway swelling. How to give epinephrine For anaphylaxis: give 1:1000 epinephrine (adrenaline) IM. 0.5 ml if 50 kg or above, 0.4 ml if 40 kg, 0.3 ml if 30 kg. Give IM in anterior lateral thigh. Repeat in five minutes if no response. See Section 3.1.3 for further management. Treat anaphylactic shock immediately with epinephrine. This is an emergency and the epinephrine should be given right away. Also give IV fluids to treat low blood pressure. After giving epinephrine, also treat the patient with hydrocortisone to help to control the allergic reaction. An antihistamine may also help to provide symptomatic relief of itching. Observe patients given epinephrine for at least four hours prior to discharge. Monitoring the patient Patients with emergency signs of circulation require frequent reassessment and monitoring to see if further treatment is needed. After any intervention, reassess vital signs. Has the blood pressure improved? Has the pulse slowed? If a patient presents with shock, assess with the Quick Check, and then look for and treat the underlying problem. Other modules cover in detail the management and monitoring of patients in shock. Also see DCM, Section 3.1. 34 – Chapter 3 Participant training manual: Quick Check, triage and emergency treatments DRILL 3-1: What you would do next? Clinical situations 1. 40-year-old male presents to the hospital with fever and generalized weakness. You assess this patient for emergency signs and find that their airway and breathing is intact. You note that their pulse is weak and the measured blood pressure is 80/40. You decide to place an IV and start IVF. What IVF would you give and how fast should they be given? 2. 45-year-old male is waiting in the queue to be registered. You see that the patient is able to talk to you in full sentences, is not cyanotic, and is not in any respiratory distress. What is the next step in your assessment? 3. 28-year-old female who is 8 ½ months pregnant presents with dizziness and a weak pulse. How should you position the patient? How will this affect her blood pressure? 4. 19-year-old male presents with acute onset of an itchy rash and weakness after starting an antibiotic. His pulse is weak and fast. You then check his blood pressure which is 70/30. What would you do next? ******************************START HOME STUDY**************************** If trauma administer first-line emergency treatments for Circulation If a patient presents with emergency signs of circulation and trauma, assume that the patient is bleeding. Initial management of trauma is similar to all patients with shock. Systematically examine the patient for possible sources of bleeding. Send blood immediately for haemoglobin and type (grouping) and cross match, and stop any active bleeding. If you suspect the patient has internal bleeding call for help and arrange for transport to the operating theatre as soon as possible. Give oxygen five litres if SpO2<90 or respiratory distress Trauma patients often have injuries also leading to respiratory problems. Treat these patients initially with oxygen. Preventing hypoxia is also critical in patients with head injury, to prevent secondary injury to the brain. Once the patient is stabilizing, reassess to determine if the oxygen is still needed and titrate flow (see Chapter two: titrate oxygen). Participant training manual: Quick Check, triage and emergency treatments Chapter 3 – 35 Give rapid IV fluids As in other patients with shock, trauma patients with shock should be treated with rapid IVF. Only use crystalloid (LR or NS) fluid and infuse warm if possible. Keep warm As with all patients in shock, keep trauma patients covered and warm after they have been completely assessed. Urgently send blood for type and cross-match. Trauma patients suffering from ongoing hemorrhage may require rapid blood transfusion. If pregnant, position the patient left side down If you are unable to roll the patient because of concern for spinal trauma, manually displace the uterus to the left side. If external bleeding Haemorrhage control is the first priority in anyone who is actively bleeding. Always try to control bleeding with direct pressure. • Apply firm, direct compression. • Reinforce dressings as needed. Only use a tourniquet if other bleeding control measures have failed and bleeding is lifethreatening. Infection control! The person applying the pressure should be wearing personal protective equipment such as gloves, gowns and eye protection. If suspect internal bleeding Uncontrolled, non-compressible haemorrhage (abdomen, chest, pelvic, and around long bone fractures) requires emergency surgical intervention • • If possible femur fracture → splint If possible pelvic fracture → apply a pelvic binder or sheet. If patient remains in shock after two litres of IVF and you suspect ongoing blood loss, arrange for transport to the operating theatre to look for and control internal bleeding and consider blood transfusion. Call for help and plan emergency surgical intervention or arrange transport to a referral facility as soon as possible. ******************************END HOME STUDY**************************** 36 – Chapter 3 Participant training manual: Quick Check, triage and emergency treatments Summary To assess circulation Is the pulse fast and weak? Is the capillary refill time longer than 3 seconds? Is there any heavy bleeding? Is there a history of significant trauma? If any emergency sign of circulation is present, then check if blood pressure < 90 mmHg OR pulse > 110 bpm and give first-line emergency treatments: Give oxygen if needed. If the patient has any external bleeding, apply pressure to stop bleeding. Quickly establish IV access and begin giving fluids for shock. Make sure the patient is warm. If pregnant and with vaginal bleeding, position left side down. Take blood samples for emergency laboratory tests. If ongoing bleeding, arrange blood transfusion and transport to the operating theatre. Always use universal precautions for infection control. Participant training manual: Quick Check, triage and emergency treatments Chapter 3 – 37 Assessment questions: Circulation Answer all the questions on this page. Write in the given spaces. If you have a problem, ask a facilitator for help. 1. True/False: A patient with a capillary refill of 4 seconds has an emergency sign of circulation. 2. What is the minimum blood pressure if you can feel a strong radial pulse? 3. Name types of fluid you can give to treat shock. What amount do you initially give? How quickly do you administer the fluid? 4. A 40-year-old man was rushed to the hospital after collapsing at home. You find his hands are cold and the capillary refill time is longer than three seconds. List four things that you would do as part of the Quick Check assessment? 5. A 25-year-old woman is brought to hospital with fever and rapid breathing. She has had five episodes of vomiting and watery diarrhoea for one day. She weighs 50 kg. The capillary refill is greater than three seconds. The radial pulse is not palpable, but the femoral pulse is fast and weak. There is no respiratory distress or cyanosis and no abnormal respiratory noises. How do you triage this patient? What initial emergency treatments would you give? 38 – Chapter 3 Participant training manual: Quick Check, triage and emergency treatments Chapter 4: Altered level Consciousness/Convulsing Learning objectives 1. Recognize altered level of consciousness. 2. Recognize and treat convulsions. 3. Assess using AVPU scale. 4. Give first-line emergency treatment for altered consciousness. 5. Give first-line emergency treatment for convulsions. In addition to circulation, C represents the need to assess consciousness and convulsing. A B C An alteration in consciousness means that Airway the patient is not behaving normally. There Breathing are many reasons your patient may Circulation experience an altered state of consciousness. These include severe Consciousness infection, a metabolic problem such as low Convulsing blood sugar or low sodium, severe head injury, acute psychosis from a psychiatric problem, or alcohol or drug intoxication. Patients with shock or severe respiratory distress can also present with altered levels of consciousness. If a patient is awake, alert, not confused, talking and coherent, consciousness is not altered. Class discussion Think about some common causes of altered level of consciousness that you have seen in patients before. What have these patients looked or acted like? Then assess: Altered level consciousness/convulsing Altered level consciousness or Is she pregnant? Give first-line emergency treatments Convulsing Participant training manual: Quick Check, triage and emergency treatments Chapter 4 – 39 Is there altered level of consciousness? First, look to see if the patient is conscious (awake or alert). A simple scale known as AVPU is used to do this assessment. A V P U Is the patient Alert? If not, Is the patient responding to Voice? If not, Is the patient responding to Pain? The patient who is Unresponsive to voice (or being shaken) AND to pain is Unconscious. Alert • Is the person awake? Make sure the patient is not just sleeping. Voice If the patient is not awake and alert, try to rouse the patient. If the patient is not alert but responds to voice, you can describe patient as being lethargic. • Call his/her name loudly. • If the patient does not respond to this, gently shake the arm. Pain If the patient does not respond to voice or gentle shaking of the arm, see if the patient will respond to pain. If the patient is not alert and responds only to pain, you can describe the patient as unconscious. • Apply a firm squeeze to the nail bed of a fingernail, enough to cause some pain. • If the patient does not respond, briefly use your knuckles to grind firmly on the sternum (sternal rub). Unresponsive/unconscious If the patient does not respond to voice (or being shaken) and to pain, the patient is unconscious. DRILL 4-1: AVPU Scale How would you classify these patients on the AVPU scale? 1. Patient is found with eyes closed in waiting room slumped in a chair. You call out her name loudly, and she slowly opens her eyes but then closes them again. 2. Patient is brought in to you by his family who says that he passed out at home. When you see him, he looks weak and tired but is talking. 3. Patient is brought in after a car accident. He is not awake. You call his name. No response. You shake his arm. No response. You then try a sternal rub. He moves his left arm and grimaces. 4. Patient was found on the floor at home and brought in by family. You call his name and shake his arm. No response. You then try squeezing his fingernail. No response. You also try sternal rub. No response. 5. Patient is waiting in queue at district hospital because she has been feeling dizzy. Suddenly she falls to the ground. You run over to see if she is okay but she is not moving. You say “madam!” loudly and she mumbles while her eyes open. 40 – Chapter 4 Participant training manual: Quick Check, triage and emergency treatments If patient is Alert, then assess for confusion • Does the patient know his/her name, where they are and why they have come to the hospital? • Is the patient answering questions appropriately? • Is the patient agitated, screaming, uncooperative, or slurring words? If a patient has an alteration of consciousness (V, P or U) or is alert and confused, then give first-line emergency treatments. Protect yourself and hospital staff if a patient is agitated. Then assess: For Convulsing A convulsion or generalized seizure results in the sudden loss of consciousness. When associated with stiffening and uncontrolled jerky movements of the limbs, it is called a generalized tonic clonic seizure (also known as a fit). Sometimes patients may have subtle convulsions that do not result in obvious movement of their arms and legs. These patients may have rhythmic eye movements to one side or you may just see one limb moving rhythmically. A patient who is alert, following commands, or purposeful in their movements is not convulsing. To determine if a patient is suffering from a convulsion, ask yourself the following questions: • Is your patient unconscious? • Is there rhythmic or uncontrolled jerking movement of the arms or legs? • Is there rhythmic eye movement? • Is the tongue lacerated? • Is there bowel and bladder incontinence? • Is there a history of trauma? During a convulsion, a patient may bite their tongue or cheek or have bowel and bladder incontinence. If your patient has an altered level of consciousness and has these findings, suspect that the patient may have had a convulsion. If you suspect a convulsion in a woman of child bearing age, determine whether she is pregnant. A convulsion in a pregnant patient can be a sign of a life-threatening condition known as eclampsia. After a convulsion, a patient is normally sleepy for up to several hours (post-ictal period). They should gradually become more alert during that time. If the patient is not waking up at all, the patient may be having continuous seizures known as “status epilepticus”. A patient may arrive at the hospital alert, but with a history of having had a convulsion several days ago. This patient does not require first-line emergency treatment. Make sure that a family member or caregiver remains with this patient until they are evaluated. Ask the caregiver to alert a healthcare worker if the patient has a second convulsion. Participant training manual: Quick Check, triage and emergency treatments Chapter 4 – 41 Then give: First-line emergency treatments for altered level of Consciousness or Convulsing Do not move neck if cervical spine injury possible. For all: Altered level consciousness or Is she pregnant? Convulsing Protect from fall or injury. Manage airway and assist into recovery position (see QC p. 19). Give oxygen five litres. Call for help but do not leave patient alone. Give glucose (if blood glucose is low or unknown) (see QC p. 19). Check (then monitor and record) level of consciousness on AVPU scale. If convulsing: Give diazepam IV or rectally (see QC p. 19). If convulsing in second half of pregnancy or post-partum up to one week, give magnesium sulphate rather than diazepam (see QC p. 28). Then check SBP, pulse, RR, temperature. If convulsions continue after 10 minutes: Continue to monitor airway, breathing, circulation. Recheck glucose. Give second dose diazepam (unless pregnant/post-partum). Consult district clinician to start phenytoin (Section 3.5). Protect patient from fall or injury Patients who are unconscious or convulsing are not aware of what they are doing. It is important to prevent further injury. • Make sure someone is with the patient at all times. If necessary, engage family members to help watch the patient with your instruction. • Place patient on a stretcher and raise railings when available. • If the patient is convulsing, pad the side of the railings with blankets. • Place patient where he/she can be continuously observed by the staff and as close to the nursing station as possible. • If there is concern for trauma or an injury to the spine, protect the patient’s cervical spine at all times. Manage the airway and assist into the recovery position Patients who are altered or convulsing are particularly at risk for airway obstruction because of their tongue. Secretions or vomit may also cause obstruction or aspiration. For altered patient who is not convulsing: • manage airway • suction secretions or vomit if present • if the patient vomits, turn on his/her side to avoid aspiration. 42 – Chapter 4 Participant training manual: Quick Check, triage and emergency treatments If neck trauma is not suspected place patient in recovery position: • Turn the patient on the side to reduce risk of aspiration. • Keep the neck slightly extended and stabilize by placing the cheek on one hand. • Bend one leg to stabilize the body position. For a convulsing patient: • Do not attempt to hold patient down. • Do not put anything in mouth. Tongue depressors can become easily dislodged and cause airway obstruction. • Turn patient on his/her side to avoid aspiration. • Once convulsion has stopped and the airway is clear, place the patient in the recovery position. Give oxygen five litres Initially administer five litres of oxygen to patients with altered level of consciousness or convulsions. If the patient is suffering from hypoxemia, the patient’s mental status may improve after treatment. After stabilization, assess if additional oxygen is needed and titrate as appropriate. Call for help but do not leave patient alone Give glucose (if blood glucose is low or unknown) Low blood glucose can cause confusion, agitation, unconsciousness, and convulsions. If a patient is in an altered state because of low blood glucose, they will often rapidly return to a normal level of consciousness after glucose is administered. If glucose testing is unavailable or a delay in obtaining results is expected, assume that the unconscious or convulsing patient has hypoglycaemia and treat with glucose. How to give glucose if symptoms of hypoglycaemia or if glucose low (< 3 mmol/l (54 mg/dl)) Give IV glucose: make sure IV is running well for adolescent or adult, give D50 25 to 50 ml; if D10 available, give 125 to 250 ml rapidly (D50 is the same as dextrose 50% and glucose 50%). If no IV glucose is available, give sugar water by mouth (if conscious) or nasogastric tube. dissolve four level teaspoons of sugar (20 grams) in a 200 ml cup of clean water. Repeat if necessary. Checking blood glucose Where blood glucose results can be obtained quickly, measure the glucose level immediately. Remember, hypoglycaemia is present if the measured blood glucose level is low <3 mmol/litre (54 mg/dl). Finger-prick testing is one way to get blood glucose levels rapidly. Participant training manual: Quick Check, triage and emergency treatments Chapter 4 – 43 Check (then monitor and record) consciousness level on AVPU scale. It is important to monitor and record the patients consciousness level so that you can rapidly detect any change and communicate with other health care providers who may be caring for the patient. If convulsing: Give diazepam IV or rectally Diazepam is the first line medication to treat convulsions (anticonvulsant). Give diazepam intravenously or rectally. If the convulsion has stopped on its own, do not automatically give diazepam. Call for help, and discuss further management with the district clinician. Rectal diazepam acts within 2 to 4 minutes. If IV is in place, give diazepam slowly over 1 minute. How to give diazepam rectally: • Base dose on the weight of the patient. • Draw up the dose from an ampoule of diazepam into a syringe. • Remove the needle. • Insert the syringe 4 to 5 cm (about the length of your little finger) into the rectum and inject the diazepam solution. • Hold the buttocks together for a few minutes. If convulsions continue after 10 minutes: • Monitor airway, breathing, and circulation. • Recheck glucose and treat if low. • Give second dose of diazepam. The maximum dose of IV diazepam is 30 mg. Diazepam can affect the patient’s breathing by causing ventilatory depression. • Consult district clinician to add second antiepileptic drug (phenobarbital or phenytoin). These patients need to be continuously monitored and have vital signs assessed frequently. If the patient develops a very low respiratory rate, call for help from a senior clinician and assist with bag valve mask ventilation. 44 – Chapter 4 Participant training manual: Quick Check, triage and emergency treatments If convulsing and in second half of pregnancy or post-partum up to one week, suspect eclampsia and give magnesium sulfate. Pre-eclampsia in pregnant women is associated with hypertension, visual changes, headache and protein in the urine. This situation can progress to a life-threatening condition that causes seizures in pregnant women known as eclampsia. Along with giving first-line therapy, call for help from a senior clinician. Medications can be used temporarily to control the seizures but delivery of the baby is the definitive treatment for eclampsia. After giving first-line emergency treatments, check vital signs • Measure BP, pulse, RR, SpO2, and temperature • Respond to abnormal vital signs • Continue with the urgent management of patients with emergency signs. Participant training manual: Quick Check, triage and emergency treatments Chapter 4 – 45 ******************************START HOME STUDY**************************** Management of trauma-related neurologic emergencies Patients with altered level of consciousness or convulsions following trauma may have intracranial bleeding or brain swelling and serious spinal injury. • Protect the spine if spinal injury is suspected. • Look/feel for deformity of skull. Does it feel even? Is there a laceration or open skull fracture? • Do the pupils react to light? • Is there bloody fluid coming from ear or nose? In an unconscious trauma patient, one pupil larger than the other is a sign of a severe brain injury and impending brain herniation. If there is fluid coming from ear or nose, suspect a fracture at the base of the skull. Call for help immediately. Protect the spine To determine that there is no injury to the spine, the patient must be conscious, cooperative, not intoxicated, and able to concentrate on the exam (no other major injuries). If the patient is conscious, check for: • posterior neck pain at rest • tenderness with palpation of posterior cervical spine • sensory or motor deficit. If the patient has none of these symptoms, ask them to move their neck. If there is no pain or neurological signs when the patient moves the neck, the spine is clear. If the patient cannot be cleared clinically, he or she should remain immobilized until X-ray rules out damage to the cervical spine. Three X-ray views are needed to clear the cervical spine (lateral, AP, open mouth odontoid). The most important view is the lateral X-ray. An adequate lateral X-ray must view to C7/T1. If the patient is unconscious, then the cervical spine needs to be immobilized until an X-ray rules out damage. 46 – Chapter 4 Participant training manual: Quick Check, triage and emergency treatments Give oxygen five litres It is important to make sure patients with head injuries have enough oxygen to prevent further brain damage. After the patient is stabilized, reassess the need for supplemental oxygen and titrate as needed. Expose the patient fully The patient should be completely undressed including undergarments to look for any additional injuries. Be sure to roll the patient using spinal precautions and look at the back. Look for traumatic injuries to chest, abdomen or pelvis Look for any bruising, abrasions, lacerations, visible bone or tissue, or other wounds. Palpate the chest for any crepitus (feeling of bubbles under the skin) or rib fractures. Listen to the chest to check for equal breath sounds. Check if the abdomen is distended and palpate the abdomen to check for tenderness, rebound, or guarding. Palpate the pelvis to check for tenderness and compress the pelvis to check for any instability. Participant training manual: Quick Check, triage and emergency treatments Chapter 4 – 47 Log roll technique: Try this as an exercise Objective: Move head and body as one unit to keep the spine in line. Need three to four people for the exercise. 1. First person kneels at the patient’s head facing the patient and places his/her hands on each side of the patient’s head and jaw. 2. Two to three more people should kneel at the patient’s side at the level of the shoulder, hip, and knee. 3. These three persons reach across the patient and grasp the patient’s shoulder and waist (one person), hip and thigh (one person), and knee and ankle (one person). 4. Three persons then roll the patient toward them slightly as the first person turns the patient’s head slightly to keep in line with the spine. The first person holding the head should count to three, and the patient should be turned on his/her count at three. ******************************END HOME STUDY**************************** DRILL 4-2: First-line emergency treatment: What would you do next? Clinical situations 1. A 22-year-old female presents four days after giving birth with alteration of consciousness. Her family states she has been having “fits” at home. While assessing the patient she begins to have a convulsion. What actions would you initially take? What is the best medication to stop the convulsion? 2. A 34-year-old male presents with stumbling, slurred speech, and inability to answer questions appropriately. His friend states he was drinking alcohol. What would you do for this patient? 3. A 42-year-old male presents unresponsive. His family states he has had fever for several days. You check for emergency signs of airway, breathing, and circulation and the patient has none. What would you do next? 4. A 27-year-old male with a history of epilepsy presents after having a seizure. He is lethargic, but responding to pain. His family states he ran out of his medication. What would you do next? 48 – Chapter 4 Participant training manual: Quick Check, triage and emergency treatments Summary Assess for altered level of consciousness or convulsions: Use AVPU scale for consciousness Look for signs of convulsions Give first line emergency treatments for altered consciousness: Position the patient/protect from fall or injury Manage the airway If no trauma, recovery position Give oxygen if oxygen saturation is low. Call for help Give glucose if low or unknown Assess pregnancy status Give first line emergency treatments for convulsions (in addition to treatment for consciousness): Do not put anything in the mouth Give diazepam IV or rectally Give magnesium sulfate if in second half of pregnancy or if one week post-partum If trauma: Do not move neck if injury to spine is suspected Look for signs of serious head injury Log roll when moving patient Expose patient fully Look for other traumatic injuries Participant training manual: Quick Check, triage and emergency treatments Chapter 4 – 49 Assessment questions: Altered level of Consciousness and Convulsing Answer all the questions on this page. Write in the given spaces. If you have a problem, ask a facilitator for help. 1. Write out the AVPU scale. A V P U 2. A 50-year-old man is brought to you at the district hospital by his brother who found him on the floor of their house. He is not awake nor is he responding to his name. You shake his arm but he does not respond. You then rub his sternum firmly, but he still does not move. What stage of AVPU do you assign him? 3. A 39-year-old woman was brought to the hospital family for fever and weakness. While triaging patients in the queue. You notice that she is slumped over. You assess her quickly and note that she does not have Airway/Breathing or Circulation signs. She is not awake and does not respond to her name. When you push firmly on her fingernail bed, she pulls her hand away. What stage of AVPU do you assign her? 4. A patient who is unconscious, with no history or trauma, should be placed in what position to protect the airway? 5. What technique can you use to move an unconscious patient with signs of serious trauma? 6. At what blood sugar level is a patient considered hypoglycaemic? 7. A 25-year-old pregnant woman is waiting to see the doctor for a headache when she loses consciousness and starts seizing. You are working in the triage area and see her. You run over to help her. What are the first steps in managing this patient? 50 – Chapter 4 Participant training manual: Quick Check, triage and emergency treatments 8. A patient is brought to the district hospital after falling off a ladder right outside the hospital where he had been repairing the building. You determine that he is lethargic but does respond to voice. His airway is clear, and he is breathing adequately. You would like to check his blood sugar and are told that the machine is not working. What should you do next? 9. How much rectal diazepam (from a 10 mg/2 ml solution) should you give to a 50 kg woman who is having a convulsion? How long should you wait before giving a second dose if the convulsion does not stop? What are the side effects of diazepam? 10. A 28-year-old woman who is 8 months pregnant and weighs approximately 65 kg is rushed in by family because she started seizing. What would you do to manage this patient? Calculate the dosage of any medication you would give her. Participant training manual: Quick Check, triage and emergency treatments Chapter 4 – 51 ******************************START HOME STUDY**************************** Chapter 5: Pain from life-threatening cause A B C D Airway Breathing Circulation Consciousness Convulsing “Dolor” – pain from life-threatening cause Learning objectives 1. Distinguish characteristics of pain from life-threatening causes versus pain from nonlife-threatening causes. 2. Recognize signs of specific life-threatening conditions presenting with pain. 3. Give first-line emergency treatments for life-threatening causes of pain. In the first four chapters, you learned about triage and giving emergency treatments for patients with emergency signs of airway, breathing, circulation, consciousness or convulsions. Pain can also be a prominent symptom of many of these life-threatening problems. For example, a pregnant female with severe abdominal pain may have a ruptured ectopic pregnancy that can rapidly haemorrhage and lead to death. Many of these patients can be saved if these life-threatening conditions are recognized early and treated. These patients should also be managed as patients with “emergency signs”. However, pain is also a very common complaint in health facilities and may be caused by different conditions. Some conditions may be life-threatening (e.g. myocardial infarction) while others are not. Patients also have different levels of pain tolerance and different patients may behave differently with the same problem. It is important to be able to recognize patients with life-threatening causes of pain. In this chapter, you will learn how to recognize and manage patients with life threatening causes of pain. 52 – Chapter 5 Participant training manual: Quick Check, triage and emergency treatments Recognize To recognize a patient with pain from an immediately life-threatening illness, look for the following: • Is the patient able to walk? Was the patient carried in by their family? o A patient who has peritoneal signs indicating an abdominal catastrophe, such as • rebound or guarding, or severe abdominal pain may not be able to walk because every movement irritates the peritoneum. These are warning signs for a perforated viscous (perforated appendix or perforated ulcer). Is the patient sweating? Are there beads of sweat on their face? o Sweating can be a physiological response to severe pain o A patient presenting with severe chest pain, sweating and pallor should raise your • suspicion for an acute myocardial infarction. Is the patient guarding against certain movements or positions? o A patient with severe pain in the neck and head who feels resistance to any • movements or positions of the neck or head should raise the suspicion for acute meningitis. o A patient who takes only small, shallow breaths and presents with severe chest pain that worsens with inspiration may be suffering from a pneumothorax, pneumonia or infected pleural effusion. o A patient with severe abdominal pain and peritoneal signs may avoid sudden movements and resist examination of the abdomen with deep palpation. Is the patient silent or moaning? o A patient in severe pain may either be making very little noise or making a lot of noise because any movement makes the pain worse. If you determine that a patient has pain from a life threatening cause then call for help, check vital signs and if trained, give emergency treatments. Always check for pregnancy in women of child-bearing age. Group activity Discuss some life-threatening causes of pain that you have seen before in patients. What signs and symptoms did these patients have? Participant training manual: Quick Check, triage and emergency treatments Chapter 5 – 53 Then assess for pain from a life-threatening cause 54 – Chapter 5 Participant training manual: Quick Check, triage and emergency treatments Severe abdominal pain and abdomen hard on palpation There are a number of causes for abdominal pain. An abdomen that is painful and also hard on palpation however, can be a sign of a life-threatening illness. This can include a perforated viscous, internal haemorrhage, or a severe intra-abdominal infection. These conditions need emergency treatment to prevent progression to severe sepsis, shock (haemorrhagic or septic) or the development of acute lung injury. What should you do when faced with these conditions? • Call the district clinician for help. • Call for surgical help. Acute onset of severe abdominal pain will often be caused by a surgical emergency. The patient may need surgery urgently. • All patients with abdominal pain should be NPO (nothing by mouth). Some conditions that cause abdominal pain such as pancreatitis are treated by withholding food. • Insert IV and give fluids slowly as instructed in Quick Check. These fluids keep the patient hydrated. If patient goes into shock, then give fluids rapidly. Insert IV and give fluids slowly Infuse at 30 drops/minute (to keep open) = 1.5 ml/min = 90 ml/hr. • • • • Give oxygen if respiratory distress or SpO2 <90% Give emergency IV/IM antibiotics: o If you suspect an intra-abdominal infection or ruptured viscous, empirical antibiotics should be started with broad spectrum activity against potential abdominal pathogens. o Use national or institutional guidance in choosing the antibiotic. Treat pain: o Morphine IV is usually preferred for patients with acute abdominal pain. Start with 2–5 mg IV. o Reassess the patient shortly after getting the pain medication to see if the pain is controlled. o Monitor BP and HR, as morphine can lower both. Send blood for type and cross-match: o If a patient is going to surgery or you suspect internal bleeding send blood immediately for a type and cross-match. Abdominal pain in a woman of childbearing age • • • Perform a rapid pregnancy test to confirm pregnancy as some patients with an early pregnancy may not know if they are pregnant. In early pregnancy, suspect an ectopic pregnancy. In late pregnancy, suspect placental abruption or a ruptured uterus. Participant training manual: Quick Check, triage and emergency treatments Chapter 5 – 55 Severe headache AND stiff neck or trauma to head/neck A number of reasons can cause severe headache, but when a patient presents with associated stiff neck or a history of trauma, consider life-threatening causes such as acute bacterial meningitis. If the patient is responsive, ask them the following questions about their headache. The presence of any of the following should make you suspect a life-threatening cause. • Is this headache the most severe headache of your life? • Does this headache seem different from headaches you have experienced in the past? • Do you also have a stiff neck, fever, vomiting, head injury or visual changes? Consider stroke with focal neurologic changes. If severe headache with stiff neck and fever, consider acute bacterial meningitis: (See the DCM Section 10.10b for how to treat patients with possible meningitis.) • Give IV empirical antibiotics within one hour o A common choice is two grams of ceftriaxone. o Use national or institutional guidance in choosing the antibiotic. • Call clinician to do a lumbar puncture. If the lumbar puncture can be done within 15 minutes of patient’s arrival, then wait to give antibiotics until the procedure is done. However, it is important to avoid delaying antibiotic treatment. If a lumbar puncture cannot be performed within 15 minutes, give antibiotics immediately and do lumbar puncture as soon as possible. If malaria suspected, give antimalarials. Cerebral malaria from P. falciparum infection usually presents with severe headache and altered level of consciousness. • If current or recent pregnancy, elevated BP, and headache, consider pre-eclampsia or eclampsia In a pregnant or recently pregnant woman who presents with a headache and elevated blood pressure, consider pre-eclampsia or eclampsia. This patient should be treated with magnesium sulfate as described in the Quick Check. New onset chest pain A number of reasons can cause chest pain. However, there are some characteristics, such as chest pain with nausea or dizziness, or crushing pain, that should make you suspect a life-threatening cause, such as myocardial infarction. Other life-threatening causes of chest pain include pulmonary embolism, aortic dissection, and a tension pneumothorax. If the patient is responsive, ask the following questions: • Do you have crushing pain in your chest? Does it radiate to the left jaw or arm? Are you experiencing nausea, dizziness, dyspnoea (shortness of breath), or diaphoresis (sweating)? • Is the chest pain located in the centre of the chest behind the sternum (breastbone)? What were you doing before it happened? Where you very active? • Do you have risk factors for heart disease, such as hypertension, diabetes, high cholesterol, family history or tobacco use? • Do you have a history of trauma? 56 – Chapter 5 Participant training manual: Quick Check, triage and emergency treatments If suspect acute myocardial infarction: • • • • • • Give aspirin (300 mg, chewed). Give oxygen if SpO2 less than 90%. Insert IV, give fluids slowly if no signs of shock. Give morphine for pain (see DCM, Section 20). Perform ECG. Call district clinician for help. Refer to national guidelines for management of the patient with acute myocardial infarction. Major burn Burns are a severe form of trauma that can cause significant soft tissue injury as well as metabolic changes affecting fluid balance. Major burns are a life-threatening emergency. How well a patient recovers from a major burn depends on the extent of the burn, age of the patient, other co-morbidities, and the circumstances surrounding the injury. Patients with major burns have one or more of the following: • Burns involving ≥ 15% of the total body surface area • Any circumferential burn • Inhalation injury • Significant associated trauma OR • Any burn in the elderly, or in patients with significant pre-burn illness (e.g. diabetes, HIV, malnutrition) Patients with major burns can develop respiratory problems from smoke inhalation. Warning signs for inhalation injury include face and neck burns, black sputum, wheezing, hoarse voice, and burned nasal hair. Airway oedema (swelling) may progress rapidly in the first hours after injury. Any patient with suspected inhalation injury and should be seen immediately by the senior clinician. Carbon monoxide poisoning should be suspected in anyone who loses consciousness during a fire. These patients should be started on high flow oxygen immediately. Patients with burns can rapidly go into shock from rapid loss of fluid. They will require aggressive and closely monitored fluid resuscitation. • • Give oxygen if SpO2<90% or respiratory distress Insert IV x 2 into non-burned skin and give fluids (Lactated Ringer’s or normal saline) rapidly • Monitor urine output, if possible • Manage associated trauma • Treat pain • Apply clean sterile bandages Other major burns requiring emergency evaluation and treatment include electrical conduction burns (burns resulting from high-voltage electricity through the body) and chemical burns. Chemical burns can be hazardous so staff should wear gloves at all times when caring for these patients. Depending on the severity of the burns the patient may need to be decontaminated in a shower prior to a full examination or evaluation. See Section 3.10 in DCM for further details on management of burn patients. Participant training manual: Quick Check, triage and emergency treatments Chapter 5 – 57 Pain and snake-bite Snake-bites from some venomous snakes can cause rapid cardiovascular collapse and death. Other snake-bites can cause paralysis in respiratory muscles. Managing these patients emergently can be life-saving. If possible, it is important to identify the type of snake-bite to see if antivenom is available. See DCM Section 3.9.2 for details on management. • Give oxygen if SpO2<90% or respiratory distress. • Insert IV and give fluids rapidly. • Treat pain. • Treat with antivenom if available. Pain from life-threatening cause in the trauma patient Abdominal pain and history of trauma In a patient with history of trauma, severe abdominal pain that is hard on palpation should raise the suspicion of internal bleeding from injury to liver, spleen, or vasculature. This can result from either penetrating or blunt trauma. Monitor closely for development of shock. • Place 16 or 18 gauge IV (at least 2). Give rapid IV fluids if signs of shock. • Obtain urgent surgical consult. o If a patient has a blunt or penetrating trauma and peritoneal signs, send patient to surgery for an exploratory laparotomy to manage internal bleeding and repair injuries. • Check Hb; send blood for type and cross-match. • If the diagnosis is not clear, consider performing a deep peritoneal lavage or abdominal ultrasound (if you are trained and equipment is available) to look for internal bleeding. Headache or neck pain associated with trauma If the patient has a headache or neck pain associated with trauma, suspect head or spinal injury. • Immobilize the cervical spine as described in the Quick Check. • Manage head trauma as indicated in DCM, Section 4. Chest pain associated with trauma In patients with a history of trauma, chest pain may be caused by rib fractures or more lifethreatening conditions such as a pneumothorax or haemothorax. These conditions require immediate treatment to prevent development of shock or severe respiratory distress. 58 – Chapter 5 Participant training manual: Quick Check, triage and emergency treatments DRILL 5-1: Quick Check Read the following scenarios of patients with possible life- threatening causes of pain. Say aloud what you would do to manage the patient. We will go around the room. 1. 60-year-old male presents to the ED. The patient has a history of hypertension and high cholesterol and is complaining of severe crushing chest pain. What actions would you take? 2. A 22-year-old male presents with severe headache, stiff neck, and fever. The patient is awake and alert and has no emergency signs of airway, breathing, or circulation. What actions would you take? 3. A 34-year-old female presents with a severe burn affecting 30% of the lower half of her body. Her skirt caught on fire while she was cooking dinner. She is awake and alert and has no emergency signs of ABC at this time. What actions would you take? 4. A 27-year-old male presents 30 minutes after being bitten by a venomous snake? He has no emergency signs of ABC. What actions would you take? 5. A 45-year-old male with a history of ulcers presents with a painful abdomen which started hurting suddenly 30 minutes prior to arrival. The patient is sweating and guarding against pain. His abdomen is tender and hard on palpation. What actions would you take? 6. A 22-year-old female approximately seven weeks pregnant presents with acute onset of severe Participant training manual: Quick Check, triage and emergency treatments Chapter 5 – 59 abdominal pain. She is pale and moaning. Her abdomen is hard and tender on palpation. What actions would you take? 7. -Send blood for type and cross 25-year-old man was brought in by family after a car accident. The patient was in the front seat without a seat belt and has a hard abdomen on palpation. What action do you take? Summary Patients with pain from life-threatening causes usually present with one of the following: Unable to walk, sweating, guarding against pain, or are very silent or moaning. Identify location of pain and look for other symptom(s) or sign(s) of life threatening conditions, such as: Severe abdominal pain AND hard abdomen on palpation Severe headache AND neck stiffness or head trauma Severe chest pain AND symptoms or signs of myocardial infarction Severe pain and major burns Severe pain and snake-bites Initial management steps include: Give oxygen five litres/minute if respiratory distress or SpO2 <90%. Insert IV. Give fluids if indicated. Call for help. Look for and treat underlying etiology. 60 – Chapter 5 Participant training manual: Quick Check, triage and emergency treatments Assessment questions: Severe pain Answer all the questions on this page. Write in the given spaces. If you have a problem, ask a facilitator for help. 1. A 20-year-old woman who is six weeks pregnant arrives at your triage desk looking pale with complaints of severe abdominal pain. a. Does this patient have a quick check emergency sign? b. What would you do to assess the patient? c. During your evaluation, you discover that her systolic blood pressure is 80 and her abdomen is hard and very tender to palpation. What will you do next? 2. A 66-year-old male is brought to the emergency department after being hit by a car. He complains of shortness of breath with severe left-sided chest pain a. Does this patient have a quick check emergency sign? b. What would you do to assess the patient? c. The patient is in severe respiratory distress with high respiratory rate, tachycardic, and falling blood pressure. List a possible complication from his chest injury that may be causing his respiratory distress? Participant training manual: Quick Check, triage and emergency treatments Chapter 5 – 61 3. A patient presents with fever, headache, and stiff neck. a. What diagnosis do you suspect? b. This patient has no emergency signs of airway, breathing, circulation, or altered consciousness/convulsions. What first line emergency treatments would you begin? c. You are informed that the district clinician will be there in 2 hours to perform a lumbar puncture. Should you wait before initiating treatment? 4. A 55-year-old man who is on medication for hypertension and is a heavy smoker presents with complaints of intermittent crushing chest pain in the centre of his chest that worsens with exertion. All of the following are appropriate initial steps EXCEPT: a. b. c. d. e. Give chewable aspirin 160 mg or 325 mg Give oxygen if respiratory distress or SpO2<90 Triage the patient to wait in the queue. Perform an EKG and call the district health clinician Place an IV line 5. A 31-year-old man is brought from a factory after an explosion with burns to his right upper and lower extremity and torso. He is awake, alert, speaking clearly, in no respiratory distress and with no emergent signs of this ABCs. What initial steps would you take to manage this patient? 6. A woman in her 28th week of pregnancy comes to the hospital with a headache. Her blood pressure is 170/105. What is the most appropriate medication to use to treat her condition? a. Morphine b. Magnesium sulfate (IV) c. Antivenom d. Chewable aspirin e. Valium 7. What are some of the major life-threatening complications you see from a venomous snake-bite? ******************************END HOME STUDY********************************* 62 – Chapter 5 Participant training manual: Quick Check, triage and emergency treatments ******************************START HOME STUDY******************************* Chapter 6: Priority signs and their immediate management Learning objectives 1. Assess for priority signs. 2. Manage specific priority signs. 3. Calm, protect and restrain violent or agitated patients. After screening for emergency signs, screen all patients for priority signs Patients who do not present with emergency signs should still be screened for priority signs as soon as possible. Priority patients may also have potentially life-threatening conditions which require timely treatment. Patients who are an infection control risk or a danger to themselves or others should also be triaged as a priority. Priority patients should be brought to the front of the queue (or isolated when appropriate) and assessed and treated as soon as possible. Depending on how your facility is arranged, it may be necessary to triage the priority patients to a different room or location instead of just moving these patients to the front of the line. Other patients already waiting in the queue may get upset if they think that certain patients are getting preferential treatment. Having a consistent system in place can help avoid any conflict while triaging patients. Priority signs may need to be adapted to local diseases and conditions. If a priority sign is identified, check vital signs. The Quick Check triage system is designed to rapidly screen patients. We do not check the vital signs on all patients in triage, as that process would take too long to make the Quick Check screening rapid. However, if a priority sign is detected, prioritize the patient for evaluation, check vital signs and respond. Priority conditions requiring infection control It is important at triage to start infection control and limit the exposure to patients with highly infectious conditions. For patients with cough, institute respiratory precautions to prevent transmission of respiratory diseases. For example, patients with suspected TB or influenza-like illness during a pandemic should be given a mask to wear or moved to a separate location. While these patients do not necessarily need to be seen before others, it is a priority to start infection control procedures as soon as possible after the patient arrives at the hospital. You should be familiar with the different approaches to infection control and respiratory precautions at your health facility. Participant training manual: Quick Check, triage and emergency treatments Chapter 6 – 63 Priority signs for urgent care – these patients should not wait in queue: Any respiratory distress/complaint of difficulty breathing* Violent behaviour towards self or others or very agitated Very pale Very weak/ill Recent fainting Bleeding: Large haemoptysis GI bleeding (vomiting or in stools) External bleeding Fractures or dislocations Burns Bites from suspected venomous snake or from rabid animal Frequent diarrhoea >5 times per day Visual changes New loss of function (possible stroke) Rape/abuse (maintain a high index of suspicion) New extensive rash with peeling and mucus membrane involvement (Stevens-Johnson) Acute pain, cough or dyspnea, priapism, or fever in patient with sickle cell disease Group exercise Break into groups of two or three. Refer to the list of priority signs above. Your facilitator will ask your group to discuss three or four of the priority signs. Why do these patients take priority over other patients waiting in the queue? What conditions might these patients have? Afterwards, your facilitator will go through the whole list with the class. Identify and manage priority signs Patients with priority signs are at risk for rapidly deteriorating. Once a patient is triaged as priority, he/she should be placed at the front of the queue for urgent evaluation. If the patient is in the queue for more than 20 minutes, repeat the Quick Check and look for new emergency signs which may have developed. Respond to any abnormal vital signs. Start any necessary urgent treatments. If the patient has no emergency or priority signs, the patient is non-urgent and should be triaged to wait in the queue. Identify respiratory distress or complaint of difficulty breathing These patients may have signs or symptoms of dyspnea but do not have Quick Check emergency signs of Airway or Breathing (e.g., mild/moderate asthma exacerbation). • Measure SpO2; give oxygen 5 litres if SpO2 <90 • If wheezing, give salbutamol (see QC, p. 17) • Appropriate infection control measures 64 – Chapter 6 Participant training manual: Quick Check, triage and emergency treatments Violent behaviour toward self or others or very agitated If the patient is violent or very agitated, protect, calm and sedate the patient as appropriate (see QC, p. 29). The goal of managing violent or agitated patients is to prevent them from harming themselves, you, or others. It is always wise to get help from others. Do not try to manage them alone. • First check for and treat reversible causes of altered consciousness. Check glucose and SpO2 and consider causes including infection (see DCM, Section 3.4) • Attempt to calm the agitated patient who is cooperative and non-aggressive • Take any threats of violence seriously o Make sure other providers are within earshot o Remove any objects that are unsafe or could be used as weapons; consider if the patient might be armed • For the patient who is non-cooperative, aggressive and uncontrollable, consider restraining the patient. o Always enlist the help of others and use a coordinated, safe approach. o Physical restraints should only be considered to ensure the safety of the patient and staff in the most uncontrollable situations. Patients should not be physically restrained for long periods. While restraining a patient take care to avoid putting pressure on the neck or chest If you must use restraints, be sure to protect the wrists and ankles with soft padding and have the patient lying face up – never lying face down. If the patient vomits, position them lying down on one side. Do not leave the patient unattended and frequently monitor vital signs. o Two medications, diazepam and haloperidol are commonly used to sedate very agitated patients. Patients receiving these medications should not be left alone and airway and breathing should be frequently monitored. Diazepam (see QC, p. 29; DCM, Sections 3.6 and 3.7): Use for agitated patients with suspected cocaine, amphetamine, or alcohol use or who are suffering from sedative withdrawal. o Avoid sedatives such as diazepam in elderly patients as they are much more sensitive to them. Haloperidol: o Recommended for other agitated patients and acute psychosis o For severe agitation, give haloperidol 5 mg IM every hour up to three injections, for a maximum of 15 mg o Participant training manual: Quick Check, triage and emergency treatments Chapter 6 – 65 Some notes and cautions on haloperidol: Haloperidol will usually calm the person immediately after the first dose, but psychotic symptoms such as delusions or hallucinations may take some time (a few weeks) to disappear completely. Haloperidol can be administered through po, IM, or IV routes but when the patient needs immediate sedation, administer parenterally (usual initial dose is 5 to 10 mg). It is important to monitor pulse, blood pressure and respiration. These patients can develop life-threatening side effects including neuroleptic malignant syndrome, arrhythmias and acute dystonia. If these conditions are suspected: • maintain an airway • stop the haloperidol • give biperiden 5 mg IM or IV if it is available • if not available, give diazepam 5 mg rectally • call for help from district clinician Other less severe nervous system manifestations can also occur in patients with long term anti-psychotic use. Very pale, weak/ill-appearing, recent fainting and bleeding (without emergency signs of Circulation) These patients may not present with Quick Check emergency signs but may have serious conditions requiring urgent evaluation. Vital signs should be checked as soon as possible to determine the need for emergency evaluation and treatment. Examples include a patient with severe malaria, diabetic ketoacidosis, haemoptysis or GI bleeding. If a clinician is not immediately available, monitor airway, place IV, send blood for haemoglobin, type and cross-match and check pregnancy status. • If blood pressure is low or patient presents with very heavy bleeding, treat as emergency sign of circulation. Otherwise, triage the patient as a priority patient. • Patients with a gastrointestinal (GI) bleed may lose blood very quickly. Though they may initially have stable vital signs, they should be assessed rapidly to determine if they are actively bleeding. A patient is actively bleeding if they are vomiting bright red blood, have tarry black stool, have maroon coloured stool, or are passing bright red blood rectally. • Place a mask on the patient if there is an infectious disease concern. • Institute infection control precautions for viral hemorrhagic fever if a patient with acute onset of fever (<3 weeks) is from a known endemic area or is seen during a known outbreak, and has 2 of the following: o haemorrhagic or purpuric rash o epistaxis o haematemesis o haemoptysis o blood in stool o other haemorrhagic symptoms and no known predisposing factors for haemorrhagic manifestations (e.g., gingival bleeding, vaginal bleeding) If patient has not been evaluated within 30 minutes, reassess patient for any emergency signs and repeat HR and BP. • 66 – Chapter 6 Participant training manual: Quick Check, triage and emergency treatments Fractures, dislocations, and non-major burns These patients do not fulfill any Quick Check emergency signs criteria and should be triaged as priority for urgent assessment of complications from trauma and burns. If visible deformity, assess and treat possible fractures or dislocations (see DCM, Section 4.6). • Assess for serious traumatic injuries resulting in emergency signs. • Treat pain. • Check neurovascular status distal to injury – look to see if the extremity is warm and well-perfused and that neurological function is intact. • If the patient has neurovascular compromise, reduce fracture/dislocation immediately to prevent permanent neurovascular damage. Do not wait for X-rays prior to reduction. • Recheck neurovascular status immediately after reduction and document. Manage burns (see DCM, Section 3.10). • Monitor for emergency signs of airway, breathing and circulation. • Treat pain as soon as possible. Bites from suspected rabid animal These patients require supportive therapy, urgent evaluation to determine if rabies prophylaxis and infection control are needed (see DCM, Section 11.30). Frequent diarrhoea >5 times per day These patients may rapidly develop dehydration, electrolyte abnormalities and shock. Assess vital signs and determine need for emergency treatment and infection control (see DCM, section 10.7d). Visual changes or new loss of function (possible stroke) Patients with new visual changes or loss of function (e.g., focal weakness, difficulty speaking, difficulty walking) may be having a stroke. 1. Check for and treat reversible causes such as hypoglycemia or hypoxia. 2. Determine time of onset and if indicated and possible, refer patient for brain imaging. 3. Do not leave the patient unattended and regularly monitor for airway and breathing complications. Rape or abuse • • • A patient who has been raped or abused will often be experiencing emotional trauma as well. It is important to make sure that the patient feels safe and is cared for as soon as possible. Assure confidentiality. If possible, triage the patient in a private area. Manage injuries (see DCM, Section 4.4). Participant training manual: Quick Check, triage and emergency treatments Chapter 6 – 67 New extensive rash with peeling and mucous membrane involvement (Stevens-Johnson syndrome) Stevens-Johnson syndrome is a severe drug reaction resulting in extensive peeling and sloughing of skin and mucosa in greater than 10% of total body surface area and more than one mucosal surface (oral, conjunctival, genital). Constitutional symptoms and systemic involvement can occur. As with major burn patients, these patients can also exhibit emergency signs for circulation when their condition deteriorates into profound dehydration and shock. • Vital signs should be checked as soon as possible to determine the need for emergency evaluation and treatment (see DCM, Section 10.2.3). • Treat pain and local wound care. Acute pain, cough or dyspnea, priapism or fever in patient with sicklecell disease Patients with sickle cell disease can develop acute vaso-occlusive crises. Complications can include acute bone pain, joint swelling and priapism. Life-threatening complications include: • Acute chest syndrome, which can rapidly progress to emergency signs of Airway or Breathing • Neurologic emergencies such as stroke or seizure • Thrombotic events including pulmonary embolism • Haematologic crises such as splenic sequestration, aplastic crisis due to infection, and haemolytic crisis • Sepsis Vital signs should be checked as soon as possible to determine the need for emergency evaluation and treatment (see DCM, Section 10.18.3). • Rehydrate with oral fluids and, if necessary, intravenous fluids • Give oxygen if SpO2 < 90% • Treat pain – strong analgesics including opiates are likely to be needed 68 – Chapter 6 Participant training manual: Quick Check, triage and emergency treatments Group exercise Management of patients with priority signs Your facilitator will give you a clinical scenario. Discuss these cases as a group. Discuss what you would do next for the patient. Use the Quick Check wallchart to help you. 1. 22-year-old female with a history of asthma presents with difficulty breathing. Patient is speaking in full sentences and has no emergency signs of airway or breathing. How would you triage this patient? What actions would you take? 2. 47-year-old male with a history of ulcers presents after vomiting bright red blood at home. Patient is awake and alert, and has no emergency signs. How would you triage this patient? What actions would you take? 3. 26-year-old male with a history of schizophrenia presents with acute agitation. The patient is spitting and biting at staff members. How would you triage this patient? What actions would you take? 4. 22-year-old female in her second trimester of pregnancy presents complaining of fever. On examination she appears very weak and is leaning on a family member to help her stand up. She has no emergency signs of ABC. How would you triage this patient? What actions would you take? 5. A 55-year-old female presents with over 12 episodes of watery, non-bloody diarrhoea in one day. She appears weak. How would you triage this patient? What actions would you take? Participant training manual: Quick Check, triage and emergency treatments Chapter 6 – 69 Assessment questions: Priority patients Answer all the questions on this page. Write your responses in the given spaces. If you have a problem, ask a facilitator for help. 1. What is the major side-effect of haloperidol administration for sedation? How would you manage a patient with this complication? 2. Once a patient is determined to be a priority, what is your next step in the patient’s assessment? 3. Which of the following patients would you classify as priority? a. A 40-year-old male with a history of alcohol abuse who vomited a large amount of bright red blood while waiting and has a HR of 130. b. A female in her ninth week of pregnancy with right lower abdominal pain, abdominal tenderness and rigidity on examination, and a BP of 85/55. c. A 20-year-old male who is actively seizing. d. A 35-year-old female with complaint of difficulty breathing with a RR of 16 and an O2 saturation of 97%. e. A 60-year-old man who is confused with a history of increasing headache and stiff neck, and a temperature on presentation of 39.5°C. 4. You are seeing an agitated, but non-violent and cooperative patient. What steps would you initially take to calm this person down? If the patient becomes violent what steps will you take? 5. List 3 life-threatening complications of sickle-cell disease. ********************************END HOME STUDY********************************* 70 – Chapter 6 Participant training manual: Quick Check, triage and emergency treatments Chapter 7: Continue with urgent management of patients with emergency signs Learning objectives 1. Reassess the patient with emergency signs. 2. Give urgent treatments for suspected diagnosis. 3. Monitor your patient. 4. Prepare patient for disposition and transport. In the earlier chapters you learned how to triage patients and administer first-line emergency treatments to patients presenting with emergency signs. After the Quick Check and administration of first-line emergency treatment, reassess the patient for response to treatment and give additional treatment as needed. At this point, you can complete taking the patient’s history and conduct a physical examination. Give urgent treatments for suspected diagnosis as needed. These urgent treatments are critical to prevent morbidity and mortality in patients and should not be delayed once life-threatening emergencies have been managed. For example, in a patient with severe malaria or septic shock, antibiotics and antimalarials need to be provided immediately. The last column in the Quick Check describes some of the urgent treatments for common conditions and refers you to relevant sections of the IMAI DCM for detailed management. Case Scenario The following case scenario is an example of how to use the Quick Check, and continue with the urgent management of patients with emergency signs. Use the wallchart to follow along as you review this case out loud. A 23-year-old female presents with fever, cough, and shortness of breath. At triage the patient is noted to be in severe respiratory distress with fast breathing, cyanosis, and wheezing. The triage nurse recognizes that the patient has Quick Check emergency signs of airway and breathing. The nurse gives first-line emergency treatments giving oxygen five litres via nasal cannula and salbutamol via Metre Dose Inhaler (MDI) with spacer. The nurse finishes the Quick Check and does not detect any emergency signs of circulation, altered consciousness, or convulsions. Next, the nurse proceeds to the Quick Check column “continue with urgent management of patients with emergency signs”. Accordingly, she does the following: • Counts pulse, RR; measure SBP, temperature, SpO2 • Titrates oxygen to SpO2 90. • Gives antibiotics if fever and RR >30. • Gives antiviral if suspect influenza. • Inserts IV and start fluids at 1 ml/kg/hour. Go to Section 3.2 of the DCM to manage the severely ill patient with difficulty breathing. Participant training manual: Quick Check, triage and emergency treatments Chapter 7 – 71 After giving first-line emergency treatments do the following: Step 1: Call for help Make sure help is on the way. In some hospitals, the district clinician may not be immediately available and urgent treatments may need to be started by the nurse. Step 2: Reassess the patient for the response to treatment and document response Patients with emergency signs are severely ill and require frequent reassessment and monitoring. Check immediate response after every emergency treatment. Record the treatment given and your findings. • Check vital signs (HR, RR, BP, temperature, oxygen saturation, AVPU). • Check that all emergency medications have been given. • Check that emergency laboratory tests have been sent. • Check the patient response to treatment. Step 3: Complete history and physical examination The Quick Check is a fast, screening history and physical exam to identify life-threatening conditions. After giving first-line emergency treatments, the treating clinician must complete a thorough history and physical examination (see relevant sections of the DCM). Step 4: Give urgent treatments for suspected diagnosis After completing the history and physical examination, you will start to develop a differential diagnosis. Always consider life-threatening conditions first. Always reconsider the diagnosis if the patient’s condition is worsening. In caring for patients with immediately life-threatening illnesses, clinical reasoning must be part of a systematic approach to patient management – appropriate, empirical treatments are given without delay while clinical information is being integrated. Clinical reasoning is an art, and an important skill that helps in clinical decision-making. At any time, if the patient fails to respond to a treatment, the differential diagnosis list should be reviewed and alternate causes reconsidered Once you take the patient’s history and conduct the physical exam, create a problem list for the patient, including the main problem or problems. You can use the list to develop a differential diagnosis (list of possible diagnosis). At first, this differential diagnosis list is usually very broad in scope, arranged by categories with most immediately life-threatening illnesses on the top. Sometimes at this stage little information may be known. This is especially true if the patient cannot give a history and the initial exam was cursory. The IMAI DCM provides broad differential diagnosis lists for these problems. As needed, gather more information from family members or friends. Perform a more thorough physical examination and consider further investigations such as laboratory and radiological tests to help support or refute the diagnosis. In resource-constrained settings, clinical decisions are often made with limited diagnostic support services. Prioritizing the differential diagnosis involves integrating the information gathered and weighing the likelihood of one diagnosis over other possible diagnoses. When little information is available, it may be necessary to treat for several different conditions at the 72 – Chapter 7 Participant training manual: Quick Check, triage and emergency treatments same time. Be cautious not to remove a diagnosis too early from the list. As additional information is gathered, conditions which were initially categorized as low priority may become more likely. If the patient fails to improve with empirical treatments, reconsider the prioritization of your differential diagnosis list. For example, if during the Quick Check you find a patient is in shock, the five types of shock should be on your initial differential diagnosis. First-line emergency treatments such as inserting an IV and giving a fluid bolus should be started without delay. If the patient also has a fever, then septic shock should rise to the top of the differential diagnosis and empirical antibiotics should be administered. The initial physical examination and laboratory investigations should aim to make sure there is no alternate cause of shock, such as active bleeding, in addition to recognizing the source of infection. It may be obvious that the patient has pneumonia based on a lung exam or it may be unclear that the patient has a kidney infection until the urine results are back. Even though it takes time to find the cause of the infection, it is imperative that empirical treatments for all potential sources of infections are administered without delay. Once the infection is recognized, appropriate treatment can be targeted for this infection. The symptom-based sections of the IMAI District Clinician Manual all follow this systematic approach to the diagnosis and management of patients, with minor variations between sections: 1. 2. 3. 4. 5. 6. 7. Perform Quick Check (QC) and give first-line emergency treatments. Complete history and physical exam. Assess HIV status. Classify illness and consider differential using differential diagnosis (DDx) tables. Give urgent treatments. Perform investigations. Initiate definitive management and monitor response. Urgent management of emergency signs of airway and breathing During the Quick Check patients with emergency signs of airway or breathing should have had first-line emergency treatments including airway management, administration of oxygen and administration of bronchodilators if wheezing. • After starting a patient on oxygen for an emergency sign of airway or breathing, titrate the oxygen flow to SpO2 ≥ 90%. • In severely ill patients with emergency signs of airway or breathing and fever, suspect severe pneumonia or other infectious process. If patient with emergency sign of airway or breathing, fever, and RR>30, give empirical antibiotics for suspected pneumonia (see DCM, Section 3.2). Early administration of antibiotics within one hour saves lives. • If influenza is suspected, early treatment with antivirals can help decrease morbidity and mortality in severely ill patients. Treatment with antivirals should be based on local epidemiology of disease and local or national guidelines. • All severely ill patients should have IV access. Insert IV (16 or 18 gauge) and start fluids at 1 ml/kg/hour. If the patient has emergency signs of circulation or volume overload is suspected, adjust the rate of fluid administration accordingly. Participant training manual: Quick Check, triage and emergency treatments Chapter 7 – 73 • Additional urgent management of emergency signs of airway and breathing: o o o o o o difficulty breathing (see DCM, Section 3.2) continued moderate to severe wheezing (see QC p.17; DCM, Section 3.2) pinpoint pupils – suspect organophosphate intoxication (DCM, Section 3.8) pinpoint pupils – suspect opioid intoxication (see QC p. 18; DCM, Section 3.6) suspect other poisoning or snake-bite (DCM, Sections 3.8, 3.9) inhalation burn (DCM, Sections 3.2, 3.10) Urgent management of emergency signs of circulation In addition to the first-line general treatment of shock described in the Quick Check (oxygen, fluids, temperature and haemorrhage control), look for the cause of shock and give urgent treatment. If bleeding, use universal precautions including mask and eye protection. If during an outbreak or in an endemic region for viral hemorrhagic fevers, ensure appropriate infection control procedures are in place. There are different etiologies of shock. Septic shock occurs from an overwhelming infection. Hypovolaemic shock occurs from severe dehydration or fluid loss (diarrhoea). Cardiogenic shock occurs from cardiac failure. Anaphylactic shock occurs from a severe allergic reaction. Haemorrhagic shock occurs from severe blood loss. Neurogenic shock occurs from acute spinal injury. • If fever, strongly consider septic shock and severe malaria. o One of the most important treatments when caring for patients with septic shock is administration of anti-infective therapy as soon as possible. Within the first hour, give empirical antibiotics or antimalarials if P. falciparum is suspected; give antivirals if influenza is suspected. If the first-line treatment is unavailable, do not delay and use an alternative medication. o If feasible, send blood culture before starting antibiotics. If malaria is a consideration, give antimalarials based on local guidelines. Dose artemether and quinine based upon the patient’s weight (see DCM-QC). If the patient’s glucose level is low or unknown, give glucose along with quinine as quinine can cause hypoglycaemia. See DCM, Section 8.4 for more details on dosing, side-effects, and contraindications. The second part of this course will review in more detail the management of patients with septic shock. 74 – Chapter 7 Participant training manual: Quick Check, triage and emergency treatments • In patients complaining of chest pain or with a history of cardiomyopathy, valvular heart disease, congestive heart failure or ischemic heart disease, suspect cardiogenic shock. o Patients with heart failure, cardiogenic shock, or severe anaemia can rapidly become volume overloaded when receiving intravenous fluids. Small IV fluid boluses (200 ml), or oral hydration if tolerated, are recommended with frequent evaluation to determine need for additional hydration. Look for signs of pulmonary oedema such as respiratory distress with increasing RR, crackles on lung auscultation, elevated jugular venous pressure and lower extremity oedema (see DCM, Section 3.2). • If history of diarrhoea or dehydration, suspect hypovolaemic shock. o A patient with severe diarrhoea can rapidly become dehydrated and go into shock. Immediately begin IV and oral fluids using the approach outlined below (Plan C in DCM 5.7.4). IV Rehydration (Plan C) Start IV fluid immediately. If the patient can drink, give ORS by mouth while the drip is set up. Give 100 ml/kg Ringer’s Lactate Solution (or, if not available, normal saline), divided as follows: Age First give 30 ml/kg in Then give 70 ml/kg: Infants (under 12 months) 1 hour* 5 hours Older (12 months or older, including adults) 30 minutes* 2 ½ hours * Repeat once if radial pulse is very weak or not detectable. Reassess the patient every 1–2 hours. If hydration status is not improving, give the IV drip more rapidly. Also give ORS (about 5 ml/kg/hour) as soon as the patient can drink, usually after 3–4 hours (infants) or 1–2 hours for children, adolescents and adults. Reassess patient after 3 hours. Classify dehydration. Then choose the appropriate plan (A, B, or C) to continue treatment. ******************************START HOME STUDY****************************** Vaginal bleeding can lead to shock in both pregnant and non-pregnant women o If the patient has vaginal bleeding, assess pregnancy status and amount of bleeding. Insert IV line, give rapid IV fluids and send haemoglobin, type and cross. o If early pregnancy with light bleeding, consider ectopic pregnancy. With heavy bleeding (pad or cloth soaked in < 5 minutes), consider spontaneous or complicated abortion. Initiate empirical antibiotics if fever or foul-smelling vaginal discharge. o If bleeding in late pregnancy or during labour, consider placenta previa, abruptio placenta, or ruptured uterus. Avoid performing vaginal exam as it my increase risk for infection and worsen bleeding. Call for help from senior clinician. o If postpartum with heavy bleeding (pad or cloth soaked in < 5 minutes, constant trickling of blood, bleeding > 250 ml or delivered outside hospital and still bleeding), massage uterus and give oxytocin. • Large nosebleed (epistaxis) can lead to shock, particularly in patients with poor clotting or bleeding from the posterior part of their nose. Hold pressure by pinching nostrils tightly between fingers and thumb. Manage airway. Participant training manual: Quick Check, triage and emergency treatments Chapter 7 – 75 Send blood for type and cross-match and haemoglobin if major bleeding and anticipate a blood transfusion. o Follow emergency treatment for management of epistaxis (see DCM-QC) • If a patient presents with large amounts of bloody vomiting, they are most likely having upper gastrointestinal bleeding and can quickly develop haemorrhagic shock. Patients can vomit blood as a result of an ulcer, severe gastritis, a tear in their oesophagus caused by vomiting or oesophageal varices. Manage heavy upper gastrointestinal bleeding Call for help Insert nasogastric tube to decompress (do not lavage – see Section 7.2). Insert IV and give fluids rapidly (see QC p. 18). Send blood specimen for type and cross match then transfuse as needed. Repeat Quick Check and monitor pulse, SBP and haemoglobin. If endoscope and trained provider: locate site and cauterize. Give proton pump inhibitor in high dose (e.g. omeprazole 80 mg). Check whole blood clotting time if available. ******************************END HOME STUDY******************************* Urgent management of emergency signs altered consciousness/ convulsions Patients with altered consciousness require frequent reassessment and monitoring of airway and breathing until patient is fully alert. If consciousness improves after first-line emergency treatment, obtain further history. If unable to obtain further history from the patient, try to obtain information from friends and family members. Patients with certain conditions such as alcohol intoxication or recent seizure should gradually become more alert. If the mental status does not improve as expected, reconsider your diagnosis. For example, in the alcoholic patient reassess for occult head trauma that may have been missed in the initial evaluation. • Use the appropriate Section of the IMAI manual to help form a differential diagnosis and determine the appropriate treatment plan. o Altered consciousness (DCM, Section 3.4); convulsions (DCM, Section 3.5). o If fever with altered consciousness or convulsions, suspect meningitis or cerebral malaria, if in endemic malaria area. If suspect meningitis and no focal neurological deficits or papilloedema on fundoscopic examination, perform lumbar puncture. Do not delay giving antibiotics if cannot be done within 15 minutes (see QC p. 19). o Pinpoint pupils – suspect organophosphate intoxication (DCM, Section 3.8). o Pinpoint pupils – suspect opioid intoxication (see QC p. 18; DCM, Section 3.6). o Alcohol intoxication or withdrawal (DCM, Section 3.7). o Other poisoning or snake-bite (DCM, Sections 3.8, 3.9). Step 5: Monitor your patient Monitor patients treated with first-line emergency treatments and urgent treatments carefully and frequently. In advanced learning units, we will discuss the use of a patient monitoring form for the severely ill patient to record the patient information and treatments. 76 – Chapter 7 Participant training manual: Quick Check, triage and emergency treatments Step 6: Prepare your patient for transport After receiving urgent treatment, prepare patient for transport to where they will receive definitive treatment (ward, intensive care unit, operating theatre, or higher level of care). If patient requires transfer to a higher level of care, do not delay transport for additional diagnostic testing if testing can be performed at the receiving facility. The transport period is one of the most hazardous phases in caring for patients. Ensuring patient safety during transfer requires resources and monitoring. Prior to transport: • If possible, stabilize emergency signs. • Give urgent treatments. • Communicate with receiving hospital or ward. • Document vital signs. • Document all treatment given. • Assign staff or family member to accompany patient. • Keep patient comfortable. Treat anxiety and pain. Cover patient and keep warm. DRILL 7-1: Continue with urgent management Discuss the following patient scenarios. What would be the next steps? Refer to appropriate section in DCM for further management guidance. 1. 19-year-old female patient with severe respiratory distress, cough and bronchospasm. - First line emergency treatments given: oxygen and salbutamol. Reassessment vital signs: T 38C, BP 120/70, HR 100, RR 35, SpO2 92%. What urgent treatments would you give next (if any)? 2. 26-year-old male patient is brought in to hospital unconscious with alcohol on his breath. - First line emergency treatments given: airway management, oxygen, IV fluids and glucose. Reassessment: T 36 C, BP 120/70, HR 100, RR 20, SpO2 98% and patient is starting to wake up. What urgent treatments would you give next (if any)? 3. 37-year-old male presents with fever and lethargy and has weak, fast pulse. Initial BP was 70/30 and HR was 120. - First line emergency treatments: oxygen and 1 litre IV fluids bolus of NS. Reassessment: T 38.5 C, BP 75/40, HR 110, RR 25 and SpO2 98%. What urgent treatments would you give next (if any)? Participant training manual: Quick Check, triage and emergency treatments Chapter 7 – 77 4. 23-year-old pregnant female 8 months gravida presents with hypertension and convulsion. - - First line emergency treatments: oxygen, patient placed in recovery position, IV glucose, and IV magnesium sulfate. Reassessment: T 36 BP 150/80, HR 100, RR 25, SpO2 95%. Patient begins to have another convulsion. What urgent treatments would you give next (if any)? • 16-year-old male presents confused with fever and meningismus. His family states he had a headache earlier in the day. - - First line emergency treatments: oxygen, patient placed in recovery position, IV glucose, IV fluid bolus of NS. Reassessment: T 40 BP90/50 HR 125 RR 27 SpO2 98%. The patient’s condition is unchanged. What urgent treatments would you give next (if any)? Clinical scenarios The cases below are designed to allow you to practice this approach, especially the application of the differential diagnosis tables, in realistic clinical situations. The following approach will guide you in using the differential diagnosis tables. Complete case 7-1 now, and the remainder at home. 1. 2. 3. 4. 5. Use the differential diagnosis tables to establish links between clinical features and possible underlying diagnoses Prioritize the list of possible diagnoses from the table based on what conditions are most likely in the setting and/or life threatening Request and perform specific diagnostic tests in order to support or refute diagnoses from the initial differential list Do clinical findings and/or diagnostic test results support a condition from the initial differential diagnosis list? If yes, treat accordingly. If treatment is successful, follow patient as indicated. If treatment is unsuccessful, re-evaluate patient, modify differential diagnosis, and return to step 1. If no, re-evaluate patient, modify differential diagnosis, and return to step 1. If diagnosis is uncertain • consider initiating empirical therapy for serious or life threatening conditions; • consider initiating empirical therapy for non-severe conditions when a diagnosis is likely and treatment is accessible and likely to be effective Review the first case as a group, and then practice the remaining cases on your own or with a partner. Use the relevant sections of your district clinician manual to help guide you. 78 – Chapter 7 Participant training manual: Quick Check, triage and emergency treatments CASE 7-1 History of presenting complaint A 32-year-old woman has been transferred from a health centre associated with your district hospital due to severe shortness of breath. The woman gave birth to her third child two months ago. Her shortness of breath began soon after delivery and has been gradually worsening. She has also developed a cough that is productive of clear sputum. She finally decided to walk to the health centre for help. What should you do next? Initial findings She has no signs of airway obstruction but does appear to be in severe respiratory distress. She is unable to speak in full sentences due to her shortness of breath. Oxygen saturation is 85%. Pulses and capillary refill are normal, and her husband tells you she has not been complaining of any vaginal bleeding and has not had any major trauma. She does not appear to be in any pain. The triage nurse administers oxygen. DDx In favour Physical examination Her temperature is 37°C, respirations 27, heart rate 90, blood pressure 120/65, and oxygen saturation remains in the upper 80s. She prefers to stay seated and refuses to lay flat. Veins on her neck appear prominent. Heart exam is otherwise unremarkable. On lung exam, she has crackles in both lower lung fields extending half-way up. Abdominal exam is unremarkable. Her legs appear very swollen, and she has 2+ oedema bilaterally to just below the knee. DDx In favour Investigations Blood glucose, malaria smear, and haemoglobin are all normal. PA chest radiography shows cardiomegaly with bilateral infiltrates. Fortunately, your facility has ultrasound equipment, and you see that the left ventricular function appears severely depressed; there is no obvious mitral stenosis. Likely diagnosis Management plan Participant training manual: Quick Check, triage and emergency treatments Chapter 7 – 79 CASE 7-2 History of presenting complaint A 54-year-old man presents to the emergency ward with chest pain. The nurses have seen him many times when he has come in for being very drunk and losing consciousness. Today he appears alert and is complaining loudly of chest and abdominal pain. What should you do next? Initial findings There are no emergency signs of airway/breathing signs. His pulse is fast and the nurse notes that his heart rate is 110. His capillary refill is normal and his blood pressure is 110/50. An IV is inserted and he is given a bag of normal saline. He has never had this pain before. He has no history of high blood pressure, smoking, or diabetes. He has been told his father died while very young. He has no idea why he died, but thinking about it too much makes him sad. DDx In favour Physical examination His temperature is 39°C. His oxygen saturation is 88%. He is holding the right side of his chest and keeps telling you that it hurts. He talks to you while you examine him. Apparently the pain began last week, a day after he was found on the roadside after losing consciousness. He had vomited all over himself. He is tachycardic, but heart exam is otherwise normal. On lung exam he has pronounced crackles on the right side. His abdominal examination is normal. DDx In favour Investigations Blood glucose, malaria smear, and haemoglobin are all normal. PA chest radiography shows right middle lobe infiltrate. Likely diagnosis Management plan 80 – Chapter 7 Participant training manual: Quick Check, triage and emergency treatments CASE 7-3 History of presenting complaint A 31-year-old woman presents with a decreased level of consciousness. She opens her eyes on command but her speech is confused and incoherent. What should you do next? Initial findings She has no emergency signs of airway/breathing or circulation. She is given oxygen and glucose by the triage nurse. Her blood pressure, heart rate, and respiratory rate are all normal. Her temperature is 38.6°C. DDx In favour Physical examination Your initial examination reveals a temperature of 38.6°C, heart rate of 78, blood pressure 120/65, respirations 16. Her chest is clear and the abdomen is soft and nontender. Her reflexes are normal and plantar reflex are down-going. While you are examining her, a woman claiming to be her mother-in-law arrives and is able to give additional information. The patient has had a severe headache with fever and neck pain for a week. At times over the course of the last few days she has been complaining of double vision. She was recently widowed and has three children who are all well. She does not drink alcohol. DDx In favour Investigations Blood glucose, malaria smear, and haemoglobin are all normal. Rapid HIV testing is positive. A lumbar puncture is done and the India ink stain is positive. Likely diagnosis Management plan Participant training manual: Quick Check, triage and emergency treatments Chapter 7 – 81 Assessment questions: Continued urgent management of patients with emergency signs Answer all the questions on this page. Write your responses in the given spaces. If you have a problem, ask a facilitator for help. 1. After completion of the Quick Check and administration of first-line emergency treatments, what is the next step? 2. Continued urgent management of a patient with airway and breathing emergency signs would include everything EXCEPT: a. b. c. d. e. Count HR, RR, measure oxygen saturation Place the patient back in the queue Titrate oxygen to SpO2>90% Give antibiotics if fever and RR >30 Insert IV 3. True/False: Antibiotics should be given within one hour for patients with septic shock. 4. List three conditions which can lead to hypovolaemic or haemorrhagic shock? 5. A patient has been in your emergency ward for several hours with decreased level of consciousness and alcohol intoxication. On reassessment the patient’s mental status is not improving. What other condition(s) should you check for? 6. True/False: A patient presents to the emergency ward immediately after a convulsion and is not waking up. If the patient had a simple convulsion, you expect the patient would gradually wake up over the next several hours. 82 – Chapter 8 Participant training manual: Quick Check, triage and emergency treatments Chapter 8: Implementing the Quick Check and emergency treatments Learning objectives 1. Understand the system changes (process improvement) needed to successfully implement the Quick Check. 2. Create a plan to train key staff in the Quick Check in your hospital. 3. Develop action plans to initiate the system changes (improvement process) needed to implement the Quick Check in your hospital. 4. Monitor the implementation of the Quick Check in your hospital. Now that you have been trained in the Quick Check (QC), you will be able to use the QC process to improve the triage and emergency care of patients in your hospital. However, training is only the first step. Successful implementation is a multi-step process that requires a system-wide change and commitment from both clinical and managerial staff. Discuss the following case scenario and then fill in the table as a group. 1. Case scenario. A 26-year old male who has had fever and headache for 2 days comes to your health facility. He waits for his card and registration in the queue for 1 hour, and then waits to see the primary care nurse. While waiting to see the primary care nurse, he becomes too weak to sit up and lies down on the floor. Two hours later his family members are unable to arouse him, and he is noted to have shallow respirations. He is then put onto a trolley and taken to the consulting room to wait to see the doctor. Several minutes later he stops breathing. The nurse finds a breathing bag that she had seen others use to assist patients with breathing; however, she does not know how to use it. The nurse knows to give oxygen therapy, but the one oxygen cylinder in the hospital is being used in the operating theatre. The patient becomes blue, his heart stops beating, and he dies. Answer the following questions. Identify some of the problems encountered in this case scenario that may have contributed to the death of this patient, using the following categories. Problems with health worker skills Problems with health system Participant training manual: Quick Check, triage and emergency treatments Problems with monitoring and evaluation Chapter 8 – 83 Now identify solutions that may have improved the care of this patient, using the same categories. Improving health worker skills Improving the health system Improving monitoring and evaluation The QC is the first component in the WHO referral care manual entitled IMAI District Clinician Manual: Hospital Care for Adolescents and Adults in Limited Resource Settings. Thus, depending upon your position, you may choose to implement the QC as a single initiative or as the first component of an overall effort to improve the quality of care of seriously ill patients in your hospital. Likewise, your hospital may choose to implement the QC on its own, or it may become part of a multiple-hospital quality improvement collaboration to implement the QC. Implementing the IMAI strategy to improve care at the district hospital requires: • improvements in case management skills of health staff through the provision of locally adapted guidelines on integrated management of adolescent and adult illness and activities to promote their use; • improvements in the health system and cultural change required for effective case management of adolescent and adult illness; • a system that enables the collection of relevant data to inform programme assessment and modification. 84 – Chapter 8 Participant training manual: Quick Check, triage and emergency treatments IMAI strategy planning and management activities Improving health worker skills Improving the health system to deliver IMAI Monitoring and evaluation • • • • • • • Develop/adapt case management guidelines and standards. Train all cadres of hospital staff, including non-clinical staff with patient contact, in the recognition of patients’ with severe illness. Train clinical staff in clinical management of the severely ill patient. Improve and maintain health worker performance through clinical mentoring, supportive supervision, performance evaluation, and other on-going learning opportunities. Teach quality improvement techniques to health workers to assist them in identifying problems and creating innovative solutions in order to provide quality, efficient, and safe care. • • • • • • • • • Improve consistent availability of necessary drugs, supplies, and equipment. Develop a sustainable system for essential equipment maintenance. Optimize the physical environment to improve flow of the severely ill patient through the hospital and patient monitoring. Optimize staff organization to be able to deliver timely care to severely ill patients. Improve referral systems between and within health centres to optimize continuity and patient safety. Create a culture of teamwork that promotes effective, professional, and respectful communication. Identify/develop methods for sustainable finance. Promote efficient use of scarce resources. Promote patient safety at all times. Ensure equity of access. Participant training manual: Quick Check, triage and emergency treatments • • • • Use patient monitoring systems to more effectively care for severely ill patients. Evaluate performance through monitoring key process and outcome indicators and then comparing them to standards of best practice (benchmarks). Create a quality assurance system that provides timely and accurate performance evaluation. Create a multidisciplinary quality improvement team responsible for evaluating trends in performance to determine if changes are successful and should be expanded, or if they need to be adjusted. Provide feedback to health workers about performance to keep up morale and to continue to inspire their drive for improvement. Chapter 8 – 85 Implementing QC in your hospital Reflect on your current emergency department or casualty ward. Answer the following questions. 1. Does you casualty ward currently have a triage system that effectively identifies emergency patients in a timely fashion? If yes, please explain the system. 2. Does your casualty ward currently have all the necessary staff and supplies to provide emergency treatments? If no, what is missing? 3. Do your casualty and hospital wards have a monitoring system to follow severely ill patients? Planning for implementation When preparing to implement the QC, the following questions will first need to be answered. Why? What arguments can you give to decision-makers to implement the QC in your work place? (advocacy) Who? What staff categories should be involved in QC? Where? Where should the QC be implemented? When? When should it be done? (patient flow and tasks) What? What extra staff, training, equipment, supplies, and medications are needed that are not yet available now? 86 – Chapter 8 Participant training manual: Quick Check, triage and emergency treatments Planning is a key component to successful implementation. Below is a table with general descriptions of key resources necessary for effective implementation. Category of key resource Non-clinical staff General description Clinical staff Sufficient staff members adequately trained in triage and the delivery of emergency treatments and management of patients with severe pneumonia and septic shock Readily available and functioning (see more detail below) Supplies and equipment Monitoring system Infrastructure and organization Communication system Coordination with other health care sectors Quality Assurance System Sufficient staff members adequately trained in triage An easy-to-use and easily accessible monitoring form should be available in the OPD and on the wards An OPD area that is well organized to triage all patients upon arrival and to deliver appropriate and timely emergency care and infection preventions and control interventions. Physical space that allows safe patient transfer between the OPD and hospital wards. Hospital wards that are well organized to closely monitor severely ill patients and deliver on-going treatments. Effective and respectful communication to promote team work and ensure continuity of care Coordination with the ministry of health, referral hospitals, health centres, non-governmental organizations, academic institutions, and research enterprises to optimize resource procurement and allocation A system that monitors patient outcomes, observes trends (good and bad), identifies areas for improvement, and then supports the implementation, monitoring and sustainability of quality improvement projects. Create a multidisciplinary Quality Team with project leaders and methods of dissemination of performance evaluations to staff. Case scenario Read the following case description. As a group discuss what resources are necessary to care for this patient. A 28-year old HIV-positive woman presents to the OPD with difficulty breathing, cough, malaise, and fever for 4 days. She is confused and appears to be in severe respiratory distress. Fill in the table below. Category Human resources Necessary resources Supplies and equipment Medications Laboratory and diagnostic test Infrastructure/organization Participant training manual: Quick Check, triage and emergency treatments Chapter 8 – 87 Quick Check Implementation Exercise Now that we have discussed some of the general concepts regarding implementation of the Quick Check, we will work on developing individualized action plans that can be used when you return to your hospital. In groups you will develop action plans as a way forward, and then present them to the larger group and share ideas and solutions. Directions: Develop an action plan to implement the QC in your hospital. Work as a hospital group and use the table to guide your presentation to the clinical team and your hospital management. Consider the following needs when preparing your action plan: • Advocacy (including identification of any major stakeholders who need to be involved in the process of accepting new standards into hospital care) • Human resources and training needs • Material resources and management (supplies, equipment, medications) • Infrastructure • Patient flow • Monitoring and evaluation Prepare a summary of your findings in the form of recommendations to the hospital superintendent or the hospital management board. 88 – Chapter 8 Participant training manual: Quick Check, triage and emergency treatments Developing individual plans of actions Planning framework Goals Activities Time frame J F M Requirements A M J J Participant training manual: Quick Check, triage and emergency treatments A S O N Cost Responsible persons Source of funds D Chapter 8 – 89 Planning framework Goals Activities Time frame J F M Requirements A M Participant training manual: Quick Check, triage and emergency treatments J J A S O N Cost Responsible persons Source of funds D Chapter 8 – 90