Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Advanced Resuscitation Techniques [AID] Season 2015/16 Learner Guide This document doesn’t require submission Candidate Name: ____________________________________________________ Acknowledgments________________________________________ This resource has been developed by Surf Life Saving Australia (SLSA). SLSA wishes to thank the editorial team who developed the resources for this course: Judy Spicer, Steve Allan, Marcia Fife, Anne-Marie Widermanski, Shane Daw, Gareth Morgan, Ashlee Biddle, Carly Hogg, Dr Natalie Hood, SLSA National Medical Advisor © 2014 Surf Life Saving Australia Ltd. This work is copyright, but permission is given to SLSA trainers and assessors to make copies for use within their own training environment. This permission does not extend to making copies for use outside the immediate training environment for which they are made, or the making of copies for hire or resale to third parties. For permission outside these guidelines, apply in writing to: Surf Life Saving Australia Locked Bag 1010, Roseberry NSW 2018 Ph: (02) 9215 8000 Fax: (02) 9215 8180 Web: www.sls.com.au All resources developed by Surf Life Saving Australia are reviewed at least annually and updated as required. Feedback can be supplied through writing to the address above. ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 2 of 40 Contents__________________________________________________ Acknowledgments Course Summary Course outcomes Prerequisites What you need to complete this course Currency of the Advanced Resuscitation Techniques Certificate (AID) award Topic 1: First aid and resuscitation First aid Legalities of first aid First aid safety Chain of Survival Emergency action plan Primary assessment Secondary assessment Management of injuries Ongoing management 2 5 5 5 5 5 6 6 6 8 9 9 11 13 13 16 Topic 2: Advanced Resuscitation & Oxygen Administration 17 Why use oxygen? Respiratory noises/Abnormal breathing First aid conditions which require additional oxygen Oxygen resuscitation equipment Administering oxygen therapy – for casualties that are breathing Resuscitation with oxygen – for causalities that are NOT breathing Using oxygen and bag-valve-mask device during resuscitation Equipment maintenance Oropharyngeal airways 17 18 19 20 24 25 26 27 28 Topic 3: Suction Suction device components Length of time to apply suction Suction checks Administering suction Post-use maintenance of suction unit Trouble shooting suctioning Topic 4: Defibrillation Circulatory/Cardiovascular systems The heart Heart rhythms and arrhythmias Automated external defibrillators (AED) Public access defibrillation Use of defibrillators on children AED operator responsibilities Defibrillator components Preoperational checks Major faults ARTC Learner Guide 2015/16 (Version 3.1) October 2014 30 30 30 31 31 32 32 33 33 34 35 37 37 37 37 37 38 38 Life Saving Victoria RTO 21799 Page 3 of 40 Defibrillation pads Operating the AED Post-defibrillation causality care Post-defibrillation equipment maintenance ARTC Learner Guide 2015/16 (Version 3.1) October 2014 38 39 40 40 Life Saving Victoria RTO 21799 Page 4 of 40 Course Summary____________________________________________ The aim of the Advanced Resuscitation Techniques Certificate course is to develop your skills and knowledge to use oxygen, airway management devices, and automated external defibrillators during resuscitation, and to administer oxygen to conscious or unconscious breathing casualties. Course outcomes By the end of this course, you should be able to: • Respond to an emergency situation • Perform primary (DRSABCD) and secondary (vital signs) assessment of the patient • Perform advanced resuscitation, including use of oxygen equipment, oropharyngeal airways and suction • Communicate details of the incident • Complete documentation • Evaluate the incident and own performance • Restore equipment ready for us You will also develop knowledge and skills to enable you to demonstrate competency in the nationally recognised unit of competency: • HLTAID007 Provide advanced resuscitation Prerequisites To commence training for the Advanced Resuscitation Techniques Certificate you must meet the following course prerequisites: • be at least 15 years of age on the date of final assessment What you need to complete this course • • • • • • • • • a trainer/facilitator a copy of this Learner Guide access to a CPR resuscitation manikin (Adult or Child AND Infant) access to oxygen equipment access to a suction device for training access to an airway training manikin and oropharyngeal airways access to a training defibrillator (AED) selection of oxygen masks with tubing, nasal cannula, therapy mask, resuscitation mask with oxygen port, thermometer to be part of a training squad of at least four people or have additional personnel to participate in training scenarios with you Currency of the Advanced Resuscitation Techniques Certificate (AID) award For the SLSA Advanced Resuscitation Techniques (AID) award to remain current, you must maintain your skills in the ARTC award annually. ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 5 of 40 Topic 1: First Aid and Resuscitation____________________________ The prerequisites of this course are that participants already have an understanding of resuscitation and basic first aid. This topic is a review of relevant first aid and resuscitation principles to assist participants with understanding where the use of advanced resuscitation techniques, such as defibrillation, oxygen and advanced airway management techniques, will support and improve the care they can provide to a casualty. First aid What is first aid? First aid is the initial care of the suddenly sick or injured until medical aid arrives or the casualty recovers. Medical aid,on the other hand, is professional medical treatment by a doctor, registered nurse, or ambulance paramedic. Aims of first aid The aims of first aid are to: • preserve life • protect the unconscious • prevent the condition from worsening and to relieve pain • promote recovery As a first aider you also aim to prevent: • • • • further damage to yourself, others and the casualty the casualty’s condition from becoming worse delay in the casualty’s recovery any harmful intervention Legalities of first aid Duty of care Australian law does not impose a duty of care on any person to give assistance unless that person already owes a duty of care to the sick or injured person. A first aider at a work site has an implied duty of care, as does someone caring for children. There is no such clear duty for a volunteer, but once a person starts to act, that person becomes the caregiver and should stay with the sick or injured person until professional help arrives. Negligence The legal concept of duty of care arises from the laws relating to negligence. Negligence is when someone who owes a duty of care has failed to provide a reasonable standard of care, which results in further injury. For someone to be considered negligent under the law, four (4) conditions need to exist or to have been breached (not adhered to). These are: 1. That a duty of care actually exists between one person and another a. in the eyes of the law, a duty of care exists in a situation where it is reasonable for one person to be relying on another to look out for their best interests b. in a first aid situation it is reasonable for the person receiving first aid to be relying on the person providing the first aid. When a decision to provide first aid has been made, a duty of care exists 2. That a person owing another a duty of care only acts towards that person in the same way that any other reasonable person (in the same situation) would do, and in such a way that they are competent to do so (‘standard of care’) a. the legal concept of a ‘reasonable’ person behaving ‘reasonably’ is based on the values and expectations held by the general public (the average man/ woman on the street) and society in general at that point in time ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 6 of 40 b. to determine what is ‘reasonable’ action, a court would make a decision based on what they thought an average person (of similar knowledge and skill) would currently do in exactly the same type of situation c. for someone to be competent in doing a certain thing, they must be properly or sufficiently qualified, or else capable of carrying out that task or role safely and efficiently d. a person administering first aid SHOULD NOT do anything that they are not sure about. The person should act responsibly, within their level of competence and follow established policies and guidelines e. if a first aider is not sure of something, advice should be sought (emergency services or medical personnel). The first aider should never be afraid to refer to or hand the casualty over to someone who has more knowledge 3. That an actual duty of care and standard of care has not been met a. a court of law actually decides this based on evidence presented in court 4. E ven if it can be shown that duty of care has not been met, for someone to be found negligent it must be proven that someone actually suffered some type of harm as a direct result A court will look at all of the circumstances to determine what is reasonable in any given situation. Upon rendering assistance, a person is under the duty of care to do everything reasonable in the circumstances. A duty of care cannot be evaded by abandoning assistance halfway through. In the general community, the law does not impose a requirement on people to go to the assistance of anyone if they do not want to. The exception is the Northern Territory, where under Statute Law people are required to offer assistance to anyone in need. Always work within yur training, following organizational procedures and manufacturers’ instructions for equipment where required Assisting with medication A first aider is permitted to help a casualty requiring assistance to take their own medication. Examples of this Include: • someone suffering an episode of asthma. The asthmatic person should have their own reliever medication, which the first aider can then assist to retrieve and/or assist to administer • the same situation exists for someone who has angina. The person should have their own sublingual (taken under the tongue) medication, which the first aider can assist the person to retrieve and selfadminister • someone suffering from anaphylactic shock. The first aider can assist the affected person to retrieve and administer their auto-injector If someone requires medication for something such as pain due to a non-acute reason, they should see a medical professional to determine the actual cause of the pain and subsequent appropriate treatment/response. Food is not medication; giving something sweet to someone thought to be diabetic and hypoglycaemic is acceptable There may be additional regulations in your state or territory governing storage and supply of medications in the work environment. Ask your Trainer for more information. Documentation (record keeping) Documentation serves the following purposes: • to assist the first aider in managing their casualty’s injuries or illnesses and being able to perform an accurate handover t o ambulance personnel • to be a legal record and statistical information Organisations providing a first aid service will have first aid forms to assist in information gathering and reporting. (SLSA members should fill out an Incident Report form for all major first aid and resuscitation cases). ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 7 of 40 Confidentiality All information relating to a casualty’s injury or condition must be kept confidential. However, you must give all relevant information to medical personnel when they arrive. Currency of knowledge The Australian Resuscitation Council (ARC) recommends that CPR skills be updated at least annually. This is covered by the SLSA requirement to underake an annual skills maintenance (proficiency) test. First aid safety Your own skills and limitations You should take care to only undertake first aid or resuscitation activities that are within your limits and the limits of what you have been trained for. Infection control First aiders should always follow standard precautions when performing first aid. These include using the following barrier devices during first aid and resuscitation: • • • gloves resuscitation mask safety glasses Airway obstructions An airway obstruction (blockage) can be either partial or total. The more the airway is blocked, the more the casualty is in danger of losing consciousness. Causes of airway obstructions include swelling of the throat tissues, choking and body position (e.g. if the head is slumped) Manual handling You should always be mindful of handling casualties with care and in accordance with any safe work procedures. At minimum this includes: • • • Not carrying things beyond you capacity Using your knees and keeping your back straight when you lift Not twisting to the side when you lift. Contaminated waste disposal First aid supplies and tools or other items that have come in contact with bodily fluids such as vomit or blood should be disposed of in clinical waste bags. Debriefing It is important to consider having a debrief after any first aid incident. Debriefing gives you a chance to look at what you did at the incident. It is not a blaming exercise, it is to identify what worked well, to improve future performance and to reduce post incident stress. Rescue teams and many workplaces have standard debriefing procedures. A member of the public can have their own debriefing simply by talking to someone about what happened – this could include family and friends, or their general practitioner. Post-traumatic stress An unsuccessful resuscitation, not knowing the ultimate outcome, or even a successful resuscitation or emergency response can all take an emotional toll on the first aider. This is known as post traumatic stress. If you, or a colleague, are experiencing stress after an incident, it is important to seek out support. Surf Life Saving provides support to its members. Further information regarding stress management after a critical incident can be found in Volume One of the Guidelines for Safer Surf Clubs. ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 8 of 40 Chain of survival In 1990, the American Heart Association introduced a treatment model for casualties of sudden cardiac arrest called the chain of survival. It outlines the specific sequence of events that needs to happen for a casualty to survive and recover from sudden cardiac arrest. Figure 1.1 Chain of survival Early access This first step occurs when someone suspects or determines that the casualty is in sudden cardiac arrest and calls for help. Early CPR This second step is about buying time for the casualty. Cardiopulmonary resuscitation (CPR) keeps the casualty’s blood flowing until defibrillation can begin. At this stage any attempt at CPR is better than no attempt. While a person with current training in CPR is ideal, any attempt by a bystander whether trained or not will contribute to this stage in the chain. Early defibrillation This third step is about resetting the heart’s rhythm by shocking the casualty as quickly as possible with a defibrillator. Studies show that this is the most critical link in the chain of survival. Early advanced life support This fourth step occurs when medical personnel provide advanced care that can include airway support, medications and hospital. Emergency action plan Many variables exist when dealing with emergencies. Knowing when to do what in a first aid situation, despite the number of possible variables, is the key to giving the casualty or casualties the best chance of a full recovery. In any first aid situation the first aider must have an action plan. The plan of action for first aiders is known as the emergency action plan (EAP). The steps in the EAP are listed below: • • • pause and plan call for emergency assistance primary assessment Before conducting a primary assessment, if possible: • • • • introduce yourself to the casualty and ask their name explain your intentions to the casualty seek consent to treat the casualty consider and respect the casualty’s privacy Secondary assessment: o management of injuries o vital signs survey o history o body check o treatment o Ongoing management ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 9 of 40 Pause and plan The aim of pause and plan is to remind the first aider to remain calm, and to stop and think. Any time you are called to an incident, consider the following questions: • is the area safe? • do you have the appropriate first aid kit and equipment to manage the incident? - As a first aider trained in advanced resuscitation techniques, you should also consider bringing oxygen equipment and a defibrillator with you when responding to an incident. • how long could you be out in the elements? • do you have a radio or mobile phone? • are you likely to need assistance? • do you need to call 000 before you attend the incident? Through an understanding of your environment and the injuries you are likely to encounter you should already have answered most of these questions. The couple of seconds it takes to pause and plan will save you minutes down the track. Hazard and incident management The safety of rescuers is the first priority in any emergency situation – so care in approaching the scene is critical. Be alert to the hazards which are obvious, e.g. fire, smoke, fallen power line; hazards which are hidden, e.g. a needle under a casualty; hazards which may develop, e.g. a change in the weather, movement of a vehicle or a structure, a fire which is out of control.It is important to confirm that emergency services have been notified. First responders may not be able to approach casualties if the hazards present a risk to their safety. You will need to assess the emergency site and implement the following steps: 1. 2. 3. 4. 5. identify hazards (always be on the alert for any potential danger) assess risks identify potential causes of injuries identify likely type and severity of injuries choose the most appropriate responses and resources Safety concerns: • remain well clear of any hazards until it is safe to enter/approach • check for any indication of dangerous substances, either liquid or gas; approach from upwind • allow no one to smoke near any emergency/incident site • ask bystanders to help maintain a perimeter around the incident/ emergency site and to stay back themselves Hazards/dangers that may be present include: • biohazards, chemicals, corrosive agents • fire, flammable liquids or gases, smoke or dangerous fumes • electricity, power lines • rising or fast flowing water, submersion in water • vehicle traffic • falling objects, unstable structures • slippery surfaces • sharp edges • explosion, bombs, bullets • confined spaces • heights • glass/sharps • people – aggressive, armed with a weapon, uncontrollable, extreme anxiety/stress ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 10 of 40 Call for emergency assistance It is essential that emergency services are contacted as soon as possible. This should not be delayed until the primary assessment has been completed, but can happen at any stage during the primary assessment. The four Ps, Position, Problem, People and Progress can be used to remember the information that will need to be supplied to an emergency services operator or, when working as part of a first responder organisation such as surf lifesaving, via radio to your communications centre. Primary assessment ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 11 of 40 Danger Make sure that there is no danger to yourself and no further danger to bystanders or the casualty. Response Assess the consciousness of the casualty. Send for Help resuscitation will provide the casualty with approximately 16% oxygen in each breath. Using an oxygen resuscitation device such as an airbag resuscitator with a reservoir attached will provide up to 95% oxygen with each compression of the airbag. The benefit of this additional oxygen during CPR is invaluable and should be used during CPR whenever equipment and a trained operator are available. Call for emergency assistance. Compressions Airway Ensuring a clear airway is a key aspect of successfully resuscitating a casualty. The use of suction devices to clear foreign matter from the mouth and the use of oropharyngeal airways to assist in ensuring that the tongue does not block the airway, can assist in maintaining the casualty’s airway. These devices are an addition to good airway management, first aiders should continue to manage the airway ensuring head tilt and chin lift. When using an airbag during resuscitation, the jaw thrust method should be used to apply head tilt and chin lift and ensure a good seal between the resuscitation mask and the casualty’s face. CPR should be commenced if the unconscious casualty is unresponsive and not breathing normally. Basic CPR skills are essential to ensure the best outcome for a casualty; these skills should not be neglected in favour of using other resuscitation devices. As an experienced first aider, other first aiders in your team may look to you for guidance. You will need to be confident in your resuscitation skills to be able to provide direction to your team. You may also be required to instruct bystanders in assisting with CPR to allow you to access and use the additional equipment in which you have been trained Defibrillation If you have not previously learned jaw thrust, ask your trainer to explain how this is done now. A full explanation of how t o perform jaw thrust can be found in chapter four of the SLSA, Public Safety th and Aquatic Rescue 34 Edition manual. Breathing Defibrillation should be administered as soon as possible. When working in a team, a first aider who is trained in the use of a defibrillator should be the operator. The operator of the defibrillator must take control of the team performing resuscitation as they will be responsible for the delivery of the shock and ensuring the safety of the team. Performing rescue breaths using expired air during Group Activity 1.1: Jaw Thrust You should have learned how to perform jaw thrust in your previous first aid training. This technique is essential when using an airbag during CPR. Refresh your skills in jaw thrust by practising on a partner or a resuscitation manikin ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 12 of 40 Secondary assessment The secondary assessment is a systematic means of finding other conditions that were not apparent during the primary assessment. The secondary assessment should not be undertaken if life-threatening conditions are still present. Before conducting a secondary assessment, always: • introduce yourself to the casualty and ask their name • explain your intentions to the casualty • seek consent to treat the casualty • consider and respect the casualty’s privacy Management of injuries After completing the primary assessment and having identified that the casualty is responsive and is breathing, the first aid er can begin managing other injuries. It is important to remember that CPR must not be interrupted to treat other injuries. Order of treatment The control of major bleeding is the first priority after the completion of the primary assessment. Then manage any major burns, treat the casualty for shock, stabilise any fractures and treat any other injuries. Note: A key issue in managing a casualty is treating shock. Beyond treating the cause of shock (e.g. a major bleed), the introduction of oxygen to provide therapy at this stage is the single most effective treatment available to a first aider. Casualty position The casualty should be moved or assisted into the most comfortable position for their condition. Does the casualty require protection from the sun, wind or rain? Call for further assistance if required The first aider should now consider what further assistance or equipment may be needed to treat the casualty, and call 000 if necessary and not already done. Vital signs Vital signs are essential for not only establishing how well or sick the casualty is, but for monitoring trends in their cond ition and assessing the effectiveness of the treatment. There are four vital observations that should be, if possible, written down against time and the name of the casualty. These observations are: • • • • Skin appearance / temperature Conscious state Pulse Respiration The first set of these, once taken and recorded, becomes the ‘baseline observation’. Changes in the casualty’s condition are measured against this baseline. ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 13 of 40 Skin appearance Check: • Colour - Check the colour of the skin in the mouth and lips. Red, pink, pale or blue. (Checking the lining of the mouth and lips allows a quick assessment of casualties from all ethnic backgrounds). Temperature - is the skin warm or cool to the touch? Condition - is the skin dry or wet? • • Conscious state Note the following: • • • Is the casualty alert and aware of time and place? Is the casualty confused, violent, agitated? Is the casualty roused by touch or pain? There are 4 levels of consciousness (AVPU): 1. 2. 3. 4. Alert - the casualty is responsive and alert Responsive to Verbal stimulus - the casualty is not aware of time and place The casualty responds only to Painful stimuli Unresponsive - the casualty does not respond to stimuli Pulse • • DO NOT use a pulse to determine if resuscitation is required. DO NOT use your own thumb to check pulse (there is a pulse in your thumb) Carotid pulse - located in the neck, the carotid is the strongest and most easily accessible of pulse points. The Radial pulse (wrist) is often the easiest to find. Brachial pulse - It can be quite hard to feel a baby's pulse but the best place is the brachial artery which is located on the inside of the arm just above the elbow Rate: How many beats per minute? Taken over one minute • • • Adults - 60 to 100 beats per minute Children - 90 to 130 beats per minute Infants - 120 to 160 beats per minute Rhythm: Is the pulse regular or irregular? Carotid pulse Strength/Volume: Is the pulse strong or weak? Respiration Rate: How many breaths per minute? Radial pulse Rhythm: Is the breathing regular or irregular? Sounds: Is there gasping, gurgling, wheezing or snoring? Brachial pulse Note DO NOT tell the casualty you are checking their breathing. This may unconsciously alter their breathing. ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 14 of 40 Adult Normal Abnormal Pulse - rate, rhythm, volume 60-100 beats per minute <60 or >100 beats per minute Breathing - normal, abnormal 12-20 breaths per minute <8 or>20 breaths per minute Skin (colour and Warm and pink Cool or hot, pale, moist, flushed/red, Conscious state Alert and orientated Drowsy or unconscious Group Activity 1.2: Vital Signs In pairs, assess your partner’s vital signs - pulse, breathing and temperature. History A history is relevant information about a casualty’s current injury/illness, their present symptoms and relevant previous illnesses. You can obtain a history by: • • • observing the scene listening to what is said by the casualty and bystanders asking questions. Appropriate questions can be remembered by the acronym SAMPLE: • • • • • • Signs and symptoms Allergies Medication Previous medical history (look for a MedicAlert bracelet or necklace) Last oral intake Event If the casualty is unconscious or has an altered level of consciousness, there may be companions or bystanders who have witnessed the incident and who can be asked for information about what happened. You can make the casualty feel less anxious by remaining calm, speaking clearly and simply, reassuring the casualty and referring to them by name. Body check The body check is a systematic check of the casualty which may be done in the following order: 1. 2. 3. 4. 5. neck, up over the head and down across the face shoulders and front of the chest, abdomen and pelvis including ribs front and back of upper limbs front and back of lower limbs back ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 15 of 40 Ongoing management After completing treatment of injuries and illnesses identified during the primary and secondary assessments, the first aider will need to decide if referral to hospital or other medical aid is required, and call 000 for an ambulance if necessary. Once the decision has been made to refer the casualty to medical aid, ongoing monitoring and management of the casualty’s condition is important. Using oxygen to provide therapy to a casualty with other illnesses and injuries is also useful. It c an be given safely to any casualty that the first aider is concerned about. • • • • • Ongoing monitoring and management while waiting for medical assistance should include: reassessing the casualty’s vital signs at regular intervals continuing to identify actual or potential problems and plan appropriate care notifying the ambulance service of any change to the casualty’s status as appropriate handing over the casualty to ambulance personnel Who should be sent to hospital? Anyone to whom any of the following applies should be sent to hospital: • • • • • has lost consciousness, even for a brief period has required either initial rescue breathing or CPR may have a secondary condition, such as a heart attack or a neck injury has a persistent cough or an abnormal skin colour may have inhaled any amount of fluid or gas If none of the previous conditions applies, but if the first aider has any doubt about the casualty’s state of health, the casualty should be advised to seek medical advice as soon as possible. Hand over If an ambulance has been called, the first aider should remain with the casualty until they can hand over to the ambulance paramedics. You should be aware of the standard ambulance response times to your club/area of operation. Capabilities of emergency management services Key requirements to understand when liaising with emergency agencies include: • the capability and capacity of the first responder agencies • response time for arrival at site • on-site resources to support response • communication of worksite emergency response plan to emergency agencies • how you can help them optimise the effectiveness of their services when responding to emergencies ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 16 of 40 Topic 2 – Advanced Resuscitation & Oxygen Administration________ Why use oxygen? Perfusion is the body’s ability to deliver oxygen and nutrients to the cells and remove waste products. Oxygen administration is useful for any casualty who does not appear to be adequately perfused or is not maintaining sufficient oxygen levels. Qualified personnel may safely administer oxygen to any casualty who is not adequately perfused. Casualties likely to benefi t from oxygen include those with the following conditions, signs or symptoms: • • • • • • • • • • unconsciousness shock blood loss chest pain shortness of breath, including asthma severe pain injuries after resuscitation circulatory distress no response Respiratory system The respiratory system supplies the body with a constant supply of oxygen. Figure 2.1 The respiratory system ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 17 of 40 Upper respiratory tract The upper respiratory tract includes the nostrils, nasal cavity, mouth, pharynx (throat) and larynx (voice box). The throat i s a common passageway for both food and air. It starts from the cavity at the back of the mouth and nose and extends down to where it divides into two separate tubes, the trachea and the oesophagus. The trachea allows the passage of air to and from the lungs. It sits in front of the oesophagus and is closest to the skin. The oesophagus carries food and liquid to the stoma ch from the mouth and in reverse during vomiting or regurgitation. The upper respiratory tract is the most common location for an airway obstruction. Lower respiratory tract The lower respiratory tract consists of the trachea and the bronchi which divide into two, going into the left and the right lung. The bronchi then progressively divide into smaller bronchioles and eventually end up as alveoli and alveolar sacs. The lungs fill most of the chest cavity, which is separated from the abdomen by a large sheet of muscle known as the diaphragm. The lungs are spongy, elastic organs that move during inhalation and exhalation. The breathing process Breathing is the act of moving air in and out of the lungs. Breathing in is known as inhalation. It is a muscle action caused when the diaphragm is pulled down (contracts) and flattened. This sucks air into the body via the mouth or nose. Breathing out is known as exhalation. When muscles relax they recoil back to their original location and force the air out of the mouth or nose. The average adult takes about 12–15 breaths per minute. The average amount of air inhaled and exhaled is about 500 ml (a normal breath). In infants the normal breathing rate can be between 25-50 breaths per minute. Respiratory noises / Abnormal Breathing In a healthy person there should be no audible sound as they breathe in and out. Where a casualty has some respiratory distress, this may be accompanied by noises. Noises can include cough, inspiratory/expiratory wheeze, stridor or wet gurgling noises. A casualty in severe respiratory distress may make no sound at all. Cough --a sudden expulsion of air from the lungs (with a characteristic noise), may be associated with mild airway obstructions, or inflammation of the upper and/or lower airways Wheeze- a whistling sound when breathing in or out, most commonly encountered by first aiders treating casualties with asthma and may also be associated with other chronic obstructive airways diseases Stridor - a louder or harsher sound than a wheeze, may be associated with a partial airway obstruction Gurgling - a broken irregular sound similar to moving water may be associated with fluid or mucus in the lower airways No sound - no vocal sound, even with a casualty showing an effort to breathe. A casualty with a complete airway obstruction may make no sound, the effort to breathe may also take in the use of accessory muscles. ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 18 of 40 First aid conditions which require additional oxygen The body requires a constant supply of oxygen and when it does not receive enough, hypoxia results. It is essential to be able to recognise breathing difficulties and to provide immediate first aid including supplementary oxygen to treat the casualty. Respiratory distress or hypoxia can be caused by: • • • • • • airway obstruction, such as: - foreign material or vomit - issue swelling (allergic reaction) - incorrect head position during unconsciousness (a casualty slumped forward in the seat of their vehicle after a car crash) trauma (head injury) drugs (eg heroin, which slows down breathing to the point where a casualty may stop breathing altogether) drowning asthma impairment of nerves and/or muscles of breathing - spinal cord damage - chest injuries - some poisons and venom Hypoventilation Hypoventilation is breathing that is not adequate to meet the needs of the body (too shallow or too slow), or reduced lung function. The blood carbon dioxide level rises leading to a decreased conscious state, and the blood oxygen level falls leading to inadequate supply to vital organs. Respiratory arrest can follow if a casualty’s condition deteriorates, and is a life-threatening emergency. If the body’s other systems are not receiving oxygen they will fail to function. For example, if breathing stops, the heart will stop beating soo n after. Asthma Asthma is an inflammatory disorder of the lower respiratory system in which the lungs and air passages become sensitive and sometimes narrow, making it hard for the person to breathe. Chronic Obstructive Airways Diseases (COAD) Chronic Obstructive Airways Diseases (COAD) include emphysema, chronic bronchitis and other airways diseases. COAD is an ongoing illness, the casualty will be aware of their condition and, subject to having enough breath to speak, will be able to tell you of their condition. In healthy people, high carbon dioxide levels are a stimulus to breathe. COAD casualties, who chronically have high carbon dioxide levels, loose this reflex and instead their breathing control centre relies on low levels of oxygen in their body to stimulate them to breathe. Due to their body relying on low levels of oxygen to stimulate breathing, casualties with COAD are normally treated with low levels of oxygen (eg: two litres per minute). If the higher concentrations of oxygen commonly available in first responder oxygen equipment (eight litres per minute or more) are used to treat a COAD casualty it may cause them to under breathe. Management of COAD • • • • • • • DRSABCD reassure the casualty provide oxygen therapy, with the casualty sitting in an upright position to ensure maximum space for lung action continually monitor breathing and response and commence CPR if absent seek medical aid - call 000 for an ambulance if required do not leave the casualty unattended, especially if receiving oxygen document observations in order to identify trends ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 19 of 40 Note Any casualty presenting with breathing difficulties should be treated with oxygen. Supplemental oxygen administration must take precedence over the concern that a casualty may under breathe due to being administered high oxygen concentration levels. Hyperventilation Hyperventilation is the result of over-breathing that can be stress-related, deliberate or from medical conditions. The rate and depth of breathing are more than is necessary to maintain a normal level of carbon dioxide in the blood. As hyperventilation does not cause a lack of oxygen, the casualty should not be administered oxygen therapy in this situation. Oxygen resuscitation equipment Approval of equipment All oxygen resuscitation kits must meet Australian Standards. To check that your equipment meet s Australian Standards, look for the Australian Standards logo on your equipment or packaging. For use within surf lifesaving refer to SLSA Lifesaving Gear and Equipment specifications and/or SLSA - SLSA Approved Gear and Equipment Manual Servicing equipment Oxygen regulators and flow valves require annual servicing. The manufacturer’s recommendations for servicing should be followed. Figure 2.2: Examples of oxygen resuscitation kits Figure 2.3 Components included in an oxygen resuscitation kit It is important for those trained in the use of oxygen resuscitation units to ensure that they are familiar with the components and operation of the unit(s) in use at their location. The basic components are labeled above. ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 20 of 40 Equipment descriptions Protective case This houses all the relevant equipment. It may be a soft bag or hard plastic or metal case. In some models, it incorporates the oxygen cylinder itself. Medical oxygen cylinder Medical oxygen cylinders are all white. Previously cylinders were black with a white shoulder, and this was phased out between September 2009 and June 2011. The cylinder has two locating pin holes next to the main outlet. This is called the”Pin Index Safety System (or PISS)”. These holes mate with pins on the mounting yoke of the oxygen equipment. A fresh, full cylinder will usually have a protective wrapping of blue or white plastic around the oxygen outlet to prevent dust and dirt from entering during transportation. Before attaching the cylinder to the oxygen equipment, all wrapping must be removed and the cylinder ‘cracked’ by quickly opening and closing the outlet valve. Cylinder cradle This provides support for the oxygen cylinder. Cylinder yoke This is the connection for the oxygen cylinder. In some instances, it is part of the case; otherwise, it may be attached as p art of the regulator. Sealing washer This fits in the yoke to prevent leakage from the cylinder joint. Spare seals are kept in the oxygen equipment case. Locating pins These are positioned in the yoke, so that the operator can locate the oxygen cylinder correctly. Thumb screw This helps to secure and maintain the cylinder in position. Cylinder key wheel This is used to open or close the cylinder valve. External cylinder connection This allows larger oxygen cylinders to be attached. It is important to remember that when an external cylinder is in use, a small cylinder or the yoke plug should be firmly in place to prevent oxygen leaking. This connection is not found on all unit s. Contents gauge This indicates the amount of oxygen in the cylinder. Regulator This regulates the oxygen pressure and flow of oxygen. OP airways Oropharyngeal airways help maintain a clear airway. Bag-valve-mask device This silicone-based apparatus is used for inflating a casualty’s lungs by squeezing, which supplies oxygen from an oxygen reservoir bag. Oxygen reservoir bag Is attached to the airbag and stores oxygen to ensure that maximum oxygen is delivered to the casualty. ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 21 of 40 Tubing Depending on the unit, there will be either one or two tubes, usually clear and/or green in colour. Control valves These are turned on when using the airbag resuscitator or oxygen therapy, giving a fixed flow rate of oxygen. On some models, the control valve and flow rate are built into the regulator. Resuscitation masks Each unit should contain at least one adult and one child-sized mask. Therapy masks Each unit contains at least one adult and one child-sized mask. These masks may be the therapy type or the non-rebreather type of mask. Therapy masks are single use only. Chalk This is used to mark the volume of oxygen in the cylinder. Gloves Used for personal protection. Pens, pencils and paper Used for taking records during oxygen usage. Patient filter (optional) A patient filter is inserted between the resuscitation mask and the patient valve on the airbag. This filter stops any vomit, blood or saliva from entering and clogging the patient valve during resuscitation. The patient filter is single use only. Other equipment The equipment below may also be a part of your oxygen resuscitation kit. • Automatic oxygen-powered resuscitator o These devices deliver oxygen under high pressure to inflate the lungs of casualties who are not breathing. (These devices are not approved for use by surf lifesaving members). • Suction o This feature helps the operator to remove fluids from the casualty’s mouth. Group activity 2.1: Oxygen equipment In pairs or small groups, take turns at naming all the pieces of equipment in your kit. As some equipment may vary slightly, you may need to check with your trainer. Once you and your partner are confident that you can remember all the items, remove an item or two without your partner watching, and then have them review the kit and identify the missing item(s). • protective case • medical oxygen cylinder cylinder yoke • • sealing washer • thumb screw • cylinder key wheel contents gauge • • regulator • OP airways (Oropharyngeal airways) Airbag • • oxygen reservoir bag • tubing • control valve(s) resuscitation masks (adult and child) • • masks - therapy or non-rebreather (adult and child) ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 22 of 40 • • • chalk gloves pen/pencil and paper Routine check of oxygen cylinder • • • • • before a cylinder is fitted to the oxygen equipment, check the heat warning tag (reject any cylinders with melted or deformed tags), and remove the protective plastic wrapping ‘crack’ the cylinder by turning it on and off very briefly, keeping it as upright as possible and taking care that the outlet is not pointed at any person or potential danger (eg sand). Cracking the cylinder removes any foreign matter from its valve opening check that the sealing washer is present and is not damaged or dirty. Replace missing or damaged sealing washers, otherwise the equipment is inoperable and cannot be used the cylinder must be inserted into the yoke ensuring that the inlet and outlet holes are aligned. This is achieved by ensuring that the locating pins on the yoke are aligned to the locating pin holes on the cylinder valve. Then tighten the thumb screw check the contents of the cylinder by using the cylinder key wheel to slowly open the cylinder valve un til the gauge reaches a steady point. This slow build-up of pressure saves damage to the regulator and gauge, which can occur from a sudden rush of pressure. Open the cylinder valves fully, and then turn the key wheel back half a turn to prevent locking. The gauge should register ‘full’. This may be indicated by the word ‘full’ or a green mark on the cylinder. Where a cylinder is less than half full, reject it and fit a new cylinder. Safety precautions Oxygen must be used with care and respect at all times: • never use oxygen near an open flame • never use oxygen near cigarettes • never use grease or oil with oxygen equipment • never use oxygen when delivering a shock via a defibrillator Pullout Text Pre-use check of oxygen equipment To ensure that oxygen equipment is ready for use: • • • • • • check the oxygen tubing for cracks or other damage. Ensure that the open end will fit easily to both therapy masks, as well as the oxygen nipple of the airbag check the flow of oxygen from the cylinder through the tubing check that there is no odour from the oxygen being expelled from the tubing check the airbag close the cylinder valve, and then drain oxygen from the system by operating the delivery system (where the unit has two ensure both are operated) and check that the needle on the contents gauge falls to zero mark the cylinder with the contents, time and date of inspection Ancillary equipment To ensure that ancillary equipment is ready for use: • • • • check both therapy masks for cleanliness and serviceability check the condition of the resuscitation mask cuffs for fit, perishing or cracks ensure that a minimum of two larger (adult) size oropharyngeal airways are present and sealed in their original packaging check in the case for: - chalk, for marking the amount of oxygen in the cylinder - pens, pencils and paper for keeping records - gloves, for personal protection during emergency care - spare sealing washers, to replace defective or missing seals, as required Casing and additional equipment General care of the case and optional equipment includes: • • keeping the whole unit clean and free from sand, sea water, oil and grease checking additional equipment (eg suction, automatic oxygen-powered resuscitators) ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 23 of 40 Group activity 2.2: Routine equipment checks In pairs or small groups, take turns checking that the oxygen equipment and ancillary items are available and serviceable. Have your partner test you by following the process outlined previous. Storing oxygen equipment Oxygen equipment should be stored: • in a cool but accessible place, as heat causes rubber and plastic components to deteriorate (spare oxygen cylinders should be stored in a cool and accessible place, near the oxygen equipment) • away from busy traffic areas and sand and dust contamination • away from oil or grease – these substances can cause fire when in contact with high-pressure oxygen • in a ventilated space – any leakage in an enclosed space could cause an increased concentration of oxygen which could be dangerous in the event of a fire • uncovered – any leakage of a covered unit could cause an increased concentration of oxygen in the unit • without any pressure in the system – turn off the cylinder then drain oxygen from the system by operating the delivery system • in a location designated as a no-smoking area and not near naked flames; leaking oxygen can fuel a fire Empty oxygen cylinders should be returned for refilling without delay. Cylinders that are half full or less can be used for training. Safety Data Sheets (SDS) Your club or service should have a Safety Data Sheet for each hazardous substance stored on the premises. These may be stored in a central folder or each sheet may be stored with the hazardous substance. Safety data sheets contain information on how the substance should be stored and what to do if poisoning occurs. Administering oxygen therapy - for casualties that are breathing (conscious or unconscious) To administer oxygen therapy: • check oxygen equipment before each use • place the equipment so that the operator can reach it easily and see the contents gauge • connect the therapy mask to the tubing and turn on the oxygen to a flow rate of 8 litres per minute; you should be able to feel and hear the oxygen coming through the mask. This will deliver 45% oxygen. • reassure the casualty and tell them what you are about to do, then put the mask on the casualty’s face and ensure that it is secure by adjusting the elastic and pinching the metal noseband • place unconscious casualties in the lateral position. Note If a conscious casualty does not want to use the mask, they can hold the mask in front of their face, or remove the tubing from it and direct the oxygen flow around the mouth and nose ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Figure 2.4: Correctly fitted therapy mask Life Saving Victoria RTO 21799 Page 24 of 40 Resuscitation with oxygen – for casualties that are NOT breathing Mouth-to-mask resuscitation with oxygen Research has shown that adding oxygen during mouth to mask resuscitation can increase the oxygen received by the casualty from 16% to 50% (16% is the oxygen content of expired air). If the therapy setting of eight litres per minute is used, the concentration of oxygen in the casualty’s lungs will be almost 45%, but if the resuscitation setting of 14 –15 litres per minute is used and the seal is good, the concentration for the casualty will be greater (ie >50%). It is recommended that the higher setting be used if there is enough oxygen available for the time resuscitation is expected to lastIf not,the flow of eight litres per minute is satisfactory. A number of different facemasks are approved for use in mouth-to-mask resuscitation. Some of these have oxygen ports that allow the oxygen therapy tubing to be connected. Mouth-to-mask resuscitation with oxygen can be a one-person operation; however, it is preferable that two operators are used. One person needs to do mouth-to-mask resuscitation while a second person handles the oxygen unit. The oxygen is turned to the appropriate setting and the tubing fitted either to the oxygen port, through the opening of the mask, or between the cheek and the mask if an adequate seal is maintained. Masks with ports are highly recommended for this procedure Bag-valve-mask Patient valve Airbag Oxygen nipple Patient filter Resuscitation mask Air inlet valve Oxygen reservoir Figure 2.5 Components of an airbag resuscitation device The bag-valve-mask with oxygen reservoir is a manually operated, soft-recoil silicone bag with a secondary bag attached. This secondary bag acts as a reservoir for oxygen when connected to an external oxygen supply. Components of the bag-valve-mask vary between manufacturers, and between models from the same manufacturer. Some manufacturers supply single use only bag-valve-masks – these must be discarded appropriately following use, and replaced with a new unit. Users must become familiar with the equipment used at their location. Disposable bag-valve-mask units are contained in a sealed bag which should be visually checked for damage as part of routine inspections. The unit then needs to be checked fully when taken out of the protective bag immediately prior to use. The resuscitator with oxygen reservoir will provide the casualty with up to 95% oxygen when connected to an oxygen supply, with a flow rate of 14-15 litres per minute. Casualties who are not breathing should be treated initially using CPR, but they will always benefit from the administration of oxygen by trained personnel. ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 25 of 40 When the oxygen unit arrives and is being set up, the first operator should continue with the mouth -to-mask resuscitation method (or change to it, if a mask was not previously available) while preparing to change over to the bag. This may take some time, however, and resuscitation must continue during the change over period. It is possible to give mouth -to-mask resuscitation with oxygen briefly using the tubing before the bag is ready. Bag-valve-mask checks To ensure the bag-valve-mask is ready for use: • • • • check the bag-valve-mask for leaks and direction of airflow by: o blocking the patient valve with the thumb or hand and compressing the bag under reasonable pressure o checking that air does not leak out of the rear valve, the bag or the casualty valve o releasing the thumb or hand, when the bag should compress and refill rapidly check the function of the yellow disc membrane on the patient valve by: o placing the oxygen reservoir bag over the casualty valve and inflating it fully by squeezing the ventilation bag o squeezing the reservoir bag gently. The yellow disc membrane will lift (during resuscitation, the casualty exhales through this disc membrane) check the overflow valve of the oxygen reservoir by: o inflating the reservoir bag as described above and connecting it to the reservoir valve o compressing the reservoir bag rapidly and watching the disc in the valve lift (this membrane ensures that the reservoir bag cannot be overfilled with oxygen) check the air-intake membrane which is located in the rear valve of the airbag by: o checking its function by inflating the reservoir bag as described above and connecting it to the airbag o repeatedly compressing the airbag. The reservoir bag will empty and the airbag will draw in air through the air-intake membrane Group activity 2.3: Bag-valve-mask checks In pairs or small groups, take turns checking that the valves of the bag-valve-mask are operational and all components are serviceable. Have your partner test you by following the processes previously outlined. Using oxygen and bag-valve-mask device during resuscitation Setting up the bag-valve-mask • the operator needs to inform other first aiders about who they are and their qualifications to operate the equipment • the operator sets up the equipment clear of the casualty and first aiders, but in a position where the gauge is clearly visible • immediately on opening the case, a suitably sized resuscitation mask is passed to the rescue breathing operator to change to the mouth-to-mask resuscitation method. If mouth-to-mask resuscitation is in progress, however, the bag-valve-mask can be fitted directly to the mask (after an operational check) • the operator should quickly check: o the correct operation of the patient valve o the valve to the oxygen reservoir bag o the connection to the oxygen supply • the oxygen is then turned on to 14-15 litres per minute to allow inflation of the airbag reservoir • when the reservoir bag is inflated, compress the airbag to expel any air from the unit. This should then leave the airbag with 100% oxygen Operating the bag-valve-mask (BVM) device To apply the bag-valve-mask device during resuscitation: • tell the other operator that the BVM device is ready for use, when the oxygen reservoir is inflated again • position the casualty valve in the resuscitation mask and compress the airbag so that there is no change at all in the timing of resuscitation, which is important if CPR is being performed • compress the airbag with two hands (for an adult) using a gentle squeezing motion, taking at least 1.5-2 seconds for the • chest to rise. The amount of oxygen to be forced into the casualty’s chest is the amount required to make the chest rise • release the airbag and allow it to refill ready for the next ventilation. ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 26 of 40 • the rescue breathing operator controls the backward head tilt and ensures a proper seal between the mask and the casualty’s face ensure that the casualty’s chest rises with each inflation and falls as air exits the lungs: - both the airbag rescue breathing operators are responsible for this - if at any time, either operator is not happy with the functioning of the oxygen equipment, the equipment must be removed immediately and rescue breathing must continue by the mouth-to-mask, mouth-to-mouth or mouth-to-nose method. • • If the bag-valve-mask is being used during CPR, at least two first aiders must be present, although it is highly recommended that there are three. One controls the casualty’s airway and ensures the seal of the resuscitation mask; the second activate s the oxygen equipment; and the third performs chest compressions. If only two operators are present, one should control the airway, ensure the mask seal and activate the oxygen equipment while the second operator performs chest compressions. If oxygen equipment is being used on a child, the paediatric bag-valve-mask device (if available) should be used and compressed with one hand. When the child’s chest is seen to rise, stop compression of the bag. Bag-valvemask devices not specifically manufactured for the exclusive use on infants should not be used on infants. If the oxygen bottle is depleted during resuscitation, continue to use the bag-valve-mask and remove the reservoir bag. Complications with the use of a bag-valve-mask device and suitable strategies to minimize Manual resuscitators have no built in tidal volume control - the amount of air used to force-inflate the lungs during each breath depends entirely on how much the operator squeezes the bag. This may lead to the risk of various complications, many of which depend entirely on whether the manual resuscitator is being used with a face mask or ET (Endotracheal) tube. Complications are related to over-inflating or over-pressurising the casualty, which can cause: 1. air to inflate the stomach (called gastric insufflation); 2. lung injury from over stretching (called volutrauma); and/or 3. lung injury from over-pressurisation (called barotrauma). Always strictly follow instructions and guidelines, concentrate and control what you are doing. Group activity 2.4: CPR with oxygen In teams of three, practice performing CPR using the bag-valve-mask device. Operational time A full ‘C’ cylinder (440–490 litres) will have the following approximate operational times: • • 50 minutes, with continuous use of oxygen therapy at 8 litres per minute 30 minutes, with continuous use of airbag (and oxygen) at 14-15 litres per minute Equipment maintenance General care • • • • the machine should be kept clean and free of sand and foreign materials to ensure its correct operation, equipment must be checked before starting operational duties (eg patrol) each day and after any use (including training sessions) whenever the oxygen equipment shows defects that may cause it to operate incorrectly, the machine must be taken out of service immediately and repaired by the manufacturer the oxygen equipment should be serviced at least every 12 months, or according to the manufacturer’s recommendations. ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 27 of 40 Care after use After use, disposable items should be discarded of appropriately. Any equipment that is to be reused should be cleaned as per the manufacturer’s guidelines . Equipment used in training should be cleaned as per SLSA Guideline 3.1: Disinfection of equipment Major faults A major fault is any fault that cannot be repaired through basic maintenance (eg cleaning and replacement of spare or missing parts that are routinely stocked in the first aid room) and that affects the safety or ability to use the equipment properly. All major faults should be logged in the appropriate organisational logs (eg SLSA Patrol log for SLSA members) and reported to the Club/Service First Aid Officer. Oropharyngeal airways Oropharyngeal (OP) airways are curved plastic devices that help keep the airway clear in the unconscious casualty by depressing the tongue and keeping the teeth and lips apart. The OP airway by itself does not replace correct airway management practices and should be considered only as a tool to assist in the management of a casualty’s airway. A correctly inserted OP airway will greatly facilitate the maintenance of a clear airway. An OP airway is a plastic device consisting of a rigid flange and a hollow curved tube. The flange, when properly fitted, rests against the casualty’s lips. This flange does not prevent an adequate seal from a facemask being achieved. OP airways come in various sizes for different-sized casualties. The smallest OP airways are approximately 5 cm long and the largest are more than 10cm. OP airways are inserted using the ‘rotation’ method which is explained in the following pages. This method is not recommended for infants or children under the age of eight because the roof of their mouth is still soft and easily damaged. SLSA does not teach members the methods for OP airway insertion into infants and children, therefore members should not attempt to insert an OP airway into children under the age of eight years. Personal protection: For first aiders’ own safety, it is strongly recommended that they wear protective gloves and use a resuscitation mask for every first aid or resuscitation case Figure 2.8 An airway blocked by the tongue (top) and using an OP airway to assist with a clear airway (bottom) Care of OP airways OP airways must be kept in their original packaging. They should be easily accessible in the first aid kit, oxygen unit and first aid rooms. OP airways packaging should be checked to ensure that it has not been opened and is still intact. After use on a casualty, the contaminated OP airway should be disposed of in a safe manner, preferably in a clinical-waste bag provided by attending ambulance or medical personnel. If this is not possible, the contaminated OP airway should be placed in a clinical-waste bag and stored in a safe place until proper disposal can be organised Note: OP airways must only be inserted into the mouth of a deeply unconscious casualty To choose an OP airway of the correct size, place the airway against the side of the casualty’s face. The flange (top flattened end) of the airway will extend just past the centre of the casualty’s lips. The curve of the airway is then run sideways along the casualty’s jaw. The correct sized airway is the one that reaches the angle of the casualty’s jaw. Figure 2.9 Measuring an airway from the centre of the lips to the corner of the jaw ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 28 of 40 When to insert an OP airway The use of an OP airway is optional. First aiders should take less than 15 seconds to correctly size and insert an OP airway into a casualty’s mouth. Whether an OP airway is used or not, the management principles of DRSABCD do not change The OP airway can be inserted while the casualty is on their back, or when on their side if they have been rolled over to drain fluids. If insertion is occurring. during CPR there is no need to stop compressions for the airway to be inserted Important: OP airways should not be used: • if the casualty is conscious or semi-conscious - insertion of an OP airway into a conscious casualty may induce vomiting or gagging • if an airway adjunct of the correct size is not available • if there is a large amount of vomit or fluid in the casualty’s mouth Inserting an OP airway Once you have selected the correct size airway: • tilt the casualty’s head backwards; open the casualty’s mouth with one hand using jaw support or jaw thrust, if necessary • visually check the casualty’s airway, and manually clear it, if necessary • measure and choose an OP airway of the correct size • remove the OP airway from the packet and lubricate it, using moisture from the lips of the casualty, or water • hold the OP airway by the flange. With the tip pointing towards the roof of the casualty’s mouth, insert the airway to approximately onethird of its length • when one-third of the airway is inside the mouth, rotate it 180° until the tip points downwards, at the same time sliding it over the casualty’s tongue in one smooth movement into the back of the pharynx until the flange is touching the lips • it should slip easily into place. If it is difficult, stop and reposition the casualty’s lower jaw and tongue before trying again. • Never force it into position. Care is needed to avoid damage to the mouth and throat. Figure 2.10 Inserting an OP Airway Group activity 2.5: Inserting OP airways In pairs, practise choosing the correct size OP airway for your partner. Practise inserting the OP airway into the airway training manikin. Precautions when inserting an OP airway: • ensure that the lower lip is not pinched between the casualty’s teeth and the OP airway • ensure that the OP airway does not push the tongue backwards and block the casualty’s airway • ensure that you have adequate head tilt before inserting the OP airway • don’t force the OP airway into the mouth - it should slide in easily. Removing the OP airway If the casualty shows any signs of rejecting the OP airway, remove it immediately. In many cases, the casualty may spit it o ut. The OP airway can be removed easily by sliding it out of the mouth following its natural curve Note: Do not attempt to rotate the airway on removal. It is unnecessary and may cause damage to the mouth and throat. ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 29 of 40 Topic 3: Suction___________________________________________ Clearing of a casualty’s airway can be achieved by using manual finger sweeps. However, if you have a unit available with suctioning capability, you may clear additional fluids from the upper airway by using the suction component of the unit. Suction devices help to safely remove secretions from the person’s mouth and upper airway. Suctioning is a skill that will require practice to become proficient. Regular checking and cleaning of the suction device will ensure that you remain familiar with the device(s) used by your club/service. Suction comes in three types: • manual • oxygen powered (vacuum bottle) • battery (or electric) powered. Figure 3.1: Using suction to clear a casualty’s airway Suction device components While there are many variations to suction devices based on the type and the manufacturer, there are four components common to most suction devices. These are: Suction catheter- A plastic tube which is inserted into the casualty’s mouth to suction out any foreign material. Suction catheters are single use only and should be disposed of in clinical-waste containers. Collection jar: Fluids and foreign material suctioned from the casualty are collected in the jar. Collection jars are usually single-use with the jar being disposed of along with the contents in clinical-waste containers. Jar cap and connection port: The jar cap and connection port keeps the contents in the collection jar and includes the fittings to connect the suction catheter and the device which provides the suction power. Suction device: The device which provides the suction power and is the suction pump handle in manual devices, oxygen equipment in oxygen powered devices or the electric pump in a battery or electric powered device. Figure 3.2: Components of manual suction device Note SLSA has currently approved the use of manual suction devices only during surf lifesaving operations. Length of time to apply suction Prolonged suction should be avoided as this can stimulate the vagus nerve in the back of the throat and cause bradycardia (slow pulse). For this reason manual suction should be on for only 15 seconds at a time with a break for at least five second s in between operations. Due to their constant suctioning action, powered suctioning devices should only be used for five seconds before a five second break. ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 30 of 40 Suction checks • • • • • ensure that the device is clean and that all components are available including: - suction catheter - collection jar - collection jar cap - suction tubing (if required) - suction device operate the manual suction device (or turn suction on for powered devices) test for suction against thumb or finger by placing it over the vacuum port (port should stick to the thumb or finger) turn off (powered devices only) return the suction device to the case in its original position. Figure 3.3: Vaccuum port Individual activity 3.1: Suction equipment Look at the suction equipment that your club/service has available for use or the equipment you have been provided to train with. Identify the following components: • suction catheter • collection jar • jar cap and connection port • suction device • vacuum port If you cannot identify all of the components check with your trainer. Your device may not have these exact components but will have something that performs the same function Test the function of your suction device by performing the checks described above. Administering suction 1. Check the suction device for correct operation. 2. Select the catheter and remove it from the sealed packaging leaving a contact point with the wrapper 3. Put on gloves if not already done so 4. Connect the suction catheter to the connection port (or tubing for powered suction devices) 5. Completely remove catheter from wrapper (turn on the suction source for powered devices) 6. Measure the maximum length of insertion by placing the tip of the catheter at the corner of the jaw and measuring to the centre of the lips. Mark this point with a finger (this will ensure that you insert the catheter no further than the back teeth). wrapper. Figure 3.4; Measuring insertion length 7. Insert the catheter into the lower cheek of the casualty (in the lateral position) ensuring that the catheter is inserted no further than the point marked by the operator’s finger 8. Do not operate manual suction during insertion (or block the vent on a powered suction device). 9. Operate suction for no longer than 15 seconds with manual suction devices before a five second break. (If using powered devices suction only for five seconds before a five second break. 10. Rotate the catheter within the casualty’s lower cheek, ensuring that the action is smooth and gentle, to prevent damage. 11. Ensure that only two thirds of the container is filled. 12. Turn off suction on the completion of the procedure (if using powered suction). 13. Dispose of the catheter in the appropriate manner. ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Figure 3.5: Inserting the catheter no further than length marked by fingers Life Saving Victoria RTO 21799 Page 31 of 40 Group activity 3.2: Administering suction In pairs or groups of three, practice assembling your suction equipment and sizing the insertion distance on your partner. If an appropriate manikin is available practise performing suction. Note To ensure infection free training, do no place the suction catheter in your own mouth of that of your partner(s) Post-use maintenance of the suction unit • • • dispose of disposable jars in a suitable manner reusable jars can be flushed with clean cold water and rinsed with antiseptic solution ensure that all unit components are disassembled and thoroughly cleaned as per ARC guidelines. Trouble shooting suctioning There are a number of reasons why suction equipment can fail or not operate correctly. If experiencing problems, check the following: • is the suction tubing blocked • is the contents bottle full or cracked • is the seal missing or perished • is the unit not turned on • is the oxygen supply exhausted (for oxygen powered units) • is the battery flat (if battery powered unit). ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 32 of 40 Topic 4 – Defibrillation_____________________________________ Defibrillation is the delivery of an electrical current to the heart to correct an ineffective irregular heartbeat. The electricity is delivered indirectly to the heart via the chest wall. Today in Australia public access defibrillators are becoming more widely available and training in their use is easily accessed. The Australian Resuscitation Council supports the implementation of public access defibrillation programs and recommends that defibrillation should preferably be undertaken by trained lay people or health professionals. Figure 4.1 Comparison of survival rates from sudden cardiac arrest showing the difference made by defibrillation Circulatory / Cardiovascular systems Despite its vital importance, the heart does not work alone. It is part of the cardiovascular (circulatory) system which also includes the kilometres of blood vessels that run through the body. Tissue cells take in nutrients and oxygen and expel waste 24 hours per day. This can happen only with the continuous beating of the heart, a muscular organ that pumps blood through a system of arteries and veins. Arteries are large blood vessels which carry oxygen-rich blood from the heart to the rest of the body. The arteries subdivide into smaller blood vessels and ultimately become capillaries. The capillaries transport blood to all the cells of the body. After the oxygen is given to the cells, veins carry the blood low in oxygen back to the heart. Cardiopulmonary system Comprise of - both the organs, the heart (cardiovascular system) and the lungs (respiratory system), and their functions, including blood and blood vessels. Located in the thoracic cavity of the body. Responsible for - pumping and channelling blood and oxygen to and from the body. ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 33 of 40 Conditions which require first aid and defibrillation The delivery of oxygen to the body can be threatened by the following cardiovascular conditions: • blood loss caused by severe bleeding (internal or external) • impaired circulation • failure of the heart to pump adequately, eg heart attack, or dysrhythmia (irregular heart beat). If body tissues do not receive oxygen, they are damaged beyond repair, eg stroke. Stroke is when one of the arteries supplying the brain is blocked or ruptures, resulting in an area of the brain receiving no blood and the tissues becoming damaged. A similar effect occurs when one of the arteries supplying the heart with blood becomes blocked; the heart tissues are damaged by the lack of oxygen and a heart attack is a possible outcome. If the heart stops beating (cardiac arrest), it is inevitable that breathing will also cease. There may be some agonal respirations (intermittent gasps from a casualty who is not breathing or responsive) but these are not enough to sustain life. The Heart The relative size and weight of the heart contradicts its incredible strength and endurance. About the size of your fist, the hollow cone shape looks nothing like the heart that is traditionally shown. The heart weighs about 250–350 grams and is about 12–14 cm long. Approximately two-thirds of the heart is located just to the left of the sternum (breastbone). The heart has two actions, mechanical and electrical. Electrical stimulus causes mechanical reaction which results in a coordinated pumping action leading to effective circulation. Mechanical action The mechanical action of the heart pumps blood through its structures in the following way: • • • from the body (upper and lower) to the right atrium to the right ventricle to the lungs then from the lungs to the left atrium to the left ventricle and out to the body (upper and lower). Figure 4.2: Mechanical action of the heart Electrical action In a normal heart, electrical impulses travel a well-defined pathway: • • • • sinoatrial (SA) node atrioventricular (AV) node right and left bundle branches conduction pathways (Purkinje fibres) This electrical conduction pathway synchronises the atria and ventricles to contract and relax in a coordinated motion necessary to pump blood efficiently. ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Figure 4.3: Electrical action of heart Life Saving Victoria RTO 21799 Page 34 of 40 Heart rhythms and arrhythmias The electrical impulses passing through the heart can be mapped on a graph called an electrocardiogram (ECG). When a person’s heart becomes stressed, changes can be seen in the ECG. An automated external defibrillator (AED) measures the electrical activity in a casualty’s heart, through electrodes placed o n their chest, and recognises life-threatening abnormal rhythms (arrhythmias) such as ventricular fibrillation and pulseless ventricular tachycardia. Sinus rhythm The normal rhythm of a healthy heart is called sinus rhythm. An AED will not recommend a shock if it detects this rhythm in a casualty. A patient can have an electrical sinus rhythm but still not have a pulse. In these cases, even if no shock is recommended, if the patient is not breathing and unresponsive, continue CPR. The medical term for normal electrical rhythm but no pulse is ‘electro-mechanical dissociation’. Figure 4.4 ECG of a sinus rhythm Ventricular fibrillation Ventricular fibrillation (VF) is a life-threatening heart arrhythmia which is characterised by chaotic electrical and mechanical heart activity and which produces a quivering action rather than co-ordinated contractions. It is most commonly associated with coronary artery disease and heart attack (myocardial infarction). Electrical shock, poisoning and drowning can also cause ventricular fibrillation. Figure 4.5 ECG of ventricular fibrillation Ventricular tachycardia (VT) Ventricular tachycardia occurs when the ventricles beat faster than the rhythm generated by the SA node. The rate will vary, however it is always faster than 100 bpm and generally slower than 200 bpm. ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 35 of 40 Figure 4.6 ECG of ventricular tachycardia Ventricular tachycardia can be life-threatening as it may degenerate into pulseless ventricular tachycardia, inhibiting effective distribution of oxygenated blood throughout the body, leading to hypoxia and organ damage, which may lead to death. Signs and symptoms of VT include: • • • • • • • • • fainting difficulty breathing or shortness of breath very rapid pulse or no pulse palpitations - the casualty may feel like their heart is racing light-headedness or dizziness chest pain pale/grey skin colour sweating nausea. Management of VT • • minor cases may spontaneously revert to normal sinus rhythm without treatment pulseless VT will require treatment with an AED. Asystole Asystole refers to the absence of electrical activity in the heart. Figure 4.7 ECG showing asystole Note An AED will not recommend a shock as it can only correct the heart’s electrical activity, not create it from nothing. ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 36 of 40 Automated external defibrillators (AED) An AED is used to reverse the effect of a cardiac arrest. Cardiac arrest occurs when a casualty: • • is not responding is not breathing An AED is only to be attached to casualties who are not breathing and not responsive. However, an AED should be on standby in all first aid situations where there is a possibility the patient may go into cardiac arrest. Figure 4.8: Electrical action of heart The defibrillation process uses electricity to contract (depolarise) the entire heart at one time. Following this, resting (repolarisation) of the whole heart muscle occurs. Effectively the process stops the heart. Once repolarisation has occurred, it is hoped that the heart’s normal electrical activity will resume. Defibrillation is the definitive treatment for Ventricular Fibrillation. Public access defibrillation Defibrillation technology and training has reached a level in society where it is making an extremely positive impact in the chain of survival. AEDs are easy for members of the public to use and are widely available through public access defibrillation programs in public places such as airports, train stations, stadiums and shopping malls. While AEDs may be used by members of the public, the best outcomes for the casualty will be achieved when they are used by trained personnel. Accordingly, when working in a team situation, a team member with specific training in the use of an AED (such as this Advanced Resuscitation Techniques Certificate) should operate it. Use of defibrillators on children An AED can be used on children aged one and above. For children aged one to eight; if the AED has a setting that reduces the joules delivered this should be used. If this is not available the adult setting should be used. AED operator responsibilities It is the responsibility of the AED operator to apply and operate the AED and ensure the safety of bystanders and other first aiders. To do this, the AED operator must take control of the resuscitation team, directing team members and bystanders as required to ensure the safe operation of the AED. Defibrillator components A portable defibrillator of the type commonly used by first aiders consists of a case containing the base unit with single use, self-adhesive electrode pads. In addition to the AED, the following accessories should be kept with the unit (either in the same case if possible or in a case attached to the unit): • • • • • • • • • • resuscitation masks (adult) gloves razor shears gauze wipes (or similar) spare battery (if applicable to AED) spare electrode pads space blanket pen and paper chamois or towel. ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 37 of 40 Pre-operational checks All modern AEDs will have a self-check mechanism to ensure that they are operational. This check usuallu includes ensuring that there is a sufficient level of charge in the battery and that all electronic components are functioning correctly.You should make yourself familiar with the unit used by your club/service, including what is included in the automatic self-check and how you check that the unit has passed the self-check. At the start of a duty shift, you should check the following: • • • AED has passed the self check electrode pads are in date (this will be marked on the outside of the packaging) and that the packaging has not been damaged all additional equipment as listed above or required by your state or service is included and in an operational condition. Major faults A major fault is any fault that cannot be repaired through basic maintenance (e.g. cleaning and replacement of spare or missing parts that are routinely stocked in the first aid room) and affects the safety or ability to use the equipment proper ly. All major faults should be recorded in the relevant document and reported to the club/service First Aid Officer. Defibrillation pads Pad positioning Correct positioning of the electrode pads is essential for successful defibrillation to take place. The optimal position is usually indicated on the electrode pads or on the packaging they come in: • • • place the sternum electrode pad to the right of the sternum (breastbone) below the collarbone and above the right nipple place the apex electrode pad to the left of the sternum, with the upper edge of the pad below and to the left of the left nipple. If the casualty has an implanted pacemaker or defibrillator, make sure the pads are at least 8cm away from it. Apply the pads with a smooth rolling action to prevent air bubbles. Once applied, pads should not be repositioned or removed unless prompted by the AED. For children, (or adults if the front and back of the chest are clean and dry and readily accessible, e.g. not covered with sand), pads can be placed one in the front centre of the chest and the other between the shoulder blades Prepare the casualty • • • • • expose the casualty’s chest (including removing undergarments) it may be necessary to trim hair if the casualty is very hairy, with scissors/razor in the locations where pads will be placed in order to have good adhesion to the skin dry the casualty’s skin if necessary, due to immersion or sweat remove any metal jewellery and medication patches ensure that the casualty is not lying on metal grates, in pools of water or on other conductive material. ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 38 of 40 Safety precautions A safe working environment must be created before defibrillation occurs. There are three areas of danger directly related to the defibrillation process: • contact o no person or conductive material is to be in direct or indirect contact with the casualty at the time of defibrillation • conduction o there should be no conductive items near the casualty, such as: water/rain (ensure that you are clear of the incoming tide if in a beach environment) metal/grates moisture on the chest (eg vomit, blood or perspiration) • explosion o do not defibrillate if there is a chance of explosion due to the presence of gases, fumes or flammable substances. o oxygen masks should be moved away during defibrillation and the flow of oxygen directed away from the chest. Note • do not remove electrodes after a casualty’s breathing and response have returned. Keep them in place to allow prompt action should the casualty’s condition deteriorate • do not place electrodes over medication patches • avoid placing pads over an implanted pacemaker if the casualty has one. • do not operate in an unstable environment which may prevent the AED from performing a valid assessment of the ECG signal (eg. rapidly moving vehicle) Pullout Text Operating the AED There are three main steps for operating an AED: • turn the machine on • apply the pads • respond to the prompts Different AED machines have different protocols for shock delivery. Some have set joule settings, others have variable joule settings, and some even measure impedance and calculate the joules needed. Group activity 4.1: Applying an AED In groups of three, practise performing two-operator CPR with the third person arriving and applying the AED. Rotate the roles until each person in the group has performed the role of AED operator. Make sure that you: • take control of the situation • assess breathing and response • prepare the casualty’s chest • remove clothing • shave hair • remove metal jewellery • remove medication patches • apply pads to the casualty • in correct positions • using a rolling motion • follow the prompts of the AED • ensure that all first aiders and bystanders are clear of the casualty • deliver the shock as indicated by the AED • direct the team to continue CPR as required. ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 39 of 40 Post-defibrillation casualty care If the defibrillation has not been successful and when the standard protocol is exhausted: • • • leave the pads on the casualty continue CPR until relieved or unable to continue care for family and friends of the casualty. If the defibrillation has been successful: • • • • • • leave the pads on the casualty check for breathing if they are not breathing, continue CPR if they are breathing, check for a response if they are not responding, place them in the lateral position if they are responding, reassure and make them comfortable. Post-defibrillation equipment maintenance After every use, the defibrillator should be disassembled, cleaned of sand and debris, reassembled and tested as per the manufacturer’s instructions. Single-use items such as electrode pads and gloves should be disposed of and replaced from stores in the first aid room. All other equipment should be cleaned and disinfected and replaced in the kit. ARTC Learner Guide 2015/16 (Version 3.1) October 2014 Life Saving Victoria RTO 21799 Page 40 of 40