Rural Emergency Skills Training (REST)

258 Pages·2012·6.254 MB·English

by  Australian College of Rural and Remote Medicine

Rural Emergency
Skills Training
Emergency skills for rural doctors
taught by rural doctors
REST Edition 2.November 2012
This manual has been produced by:
Australian College of Rural and Remote Medicine
Level 2, 410 Queen Street
GPO Box 2507
Brisbane QLD 4001
Ph: 07 3105 8200 Fax: [phone]
Website: www.acrrm.org.au
Copyright
© 2012 Australian College of Rural and Remote Medicine. All rights reserved. No part of this
document may be reproduced by any means or in any form without express permission in writing
from the Australian College of Rural and Remote Medicine.
2
EDITION 2.NOVEMBER 2012
Contents
Acronyms / Abbreviations 7 Chapter 6 – Management of Breathing 42
Chapter 1 – Introduction 8 Assessment of Breathing 42
Introduction to Rural Emergency Skills Breathing Emergencies: Adult 43
Training Course 8
Breathing Emergencies – Child 43
Course Objectives 10
Approach to the Adult with
Principles of Emergency Medicine 10 Respiratory Distress 44
Chapter 2 – Pre-Hospital Care 11 Approach to the Child with
Respiratory Distress 45
Pre-hospital Care 11
Specific Considerations in
Pre-hospital Triage 12
Breathing Emergencies 46
Chapter 3 – Basic Life Support 13
1. Management of Acute Severe Asthma 46
Basic Life Support 13
2. Management of Acute
Exceptions in BLS 14 Pulmonary Oedema 48
Chapter 4 – Structured Approach 3. Management of Pulmonary Embolism 50
to the Critically Ill or Injured Patient 16
4. Management of Exacerbation of COPD 51
Introduction 16
5. Management of Pneumothorax 52
Recognition of an Unwell Patient 16
6. Management of Chest Trauma 54
Structured Approach to Emergency
7. Management of Bronchiolitis 55
Management of Medical Conditions and
Trauma 20 8. Management of Severe Croup 56
Chapter 5 – Management of the Airway 26 9. Management of Epiglottitis 57
Management of the Airway 26 Skills Required to Manage Breathing
Emergencies 58
Airway Emergencies 26
Skills 1 – Bag and Mask Ventilation 59
Skills 1 – Airway Opening Techniques 28
Skills 2 – Laryngeal Mask Airway 60
Skills 1a – Cervical Spine Protection 28
Skills 3 – Needle Thoracocentesis 61
Skills 2 – Suctioning and Foreign
Body Removal 29 Skills 4 – Chest Drain Insertion
– Open Technique 62
Skills 3 – Oropharyngeal Airway
Insertion (Guedel Airway) 30 Chapter 7 – Management of Circulation 64
Skills 4 - Nasopharyngeal Airway Assess the Circulation 64
Insertion 31
Advanced Cardiopulmonary Resuscitation
Skills 5 – Endotracheal Intubation 32 – Advanced Life Support (ALS) 65
Rapid Sequence Intubation 34 Biphasic Defibrillation 70
Skills 6 – Cricothyroidotomy 36 Drugs in Cardiac Arrest 70
Skills 7 – Laryngeal Mask Airway Calculations of Paediatric Parameters 71
Insertion 41
1. Management of Arrhythmias 72
2. Management of Acute Severe Central
Chest Pain 83
3
EDITION 2.NOVEMBER 2012
Contents
3. Management of STEMI – ST segment Chapter 10 – Management of
Elevation Myocardial Infarction 86 Metabolic/Endocrine Emergencies 134
4. Management of Fibrinolysis 1. Hypoglycaemia 134
and Protocols 87
2. Diabetic Ketoacidosis (DKA) 136
5. Management of NSTEACS:
3. Hyperosmolar Coma 138
Non-ST-Segment-Elevation
Acute Coronary Syndromes 88 Chapter 11 – Obstetric Emergencies 140
6. Management of Hypertensive Vaginal bleeding – (<20 Weeks) 140
Emergencies 91
Vaginal bleeding – Antepartum
7. Management of Drug infusions Haemorrhage (20 Weeks and Onward) 142
– Detailed Drug Schedules: 93
Trauma 144
8. Management of Shock 94
Preterm Labour 145
9. Management of Fluid Requirements
Premature Rupture of Membranes 147
in Children 101
Pre–Eclampsia/Eclampsia
10. Management of Anaphylaxis 102
(also known as Toxaemia) 149
Skills Required in Management
Delivery Complications 151
of Circulation 104
Chapter 12 – Management of
Skills 1 – A System for ECG
Envenomation and Poisoning 156
Interpretation 104
Snake Bite 156
Skills 2 – Basic Cardiopulmonary
Skills – Pressure Immobilisation 159
Resuscitation 105
Redback Spider Bite 160
Skills 3 – Intraosseous Needle Insertion 107
Funnel Web Spider Bite 162
Skills 4 – Intravenous Access Techniques 109
Australian Paralysis Tick 164
Chapter 8 – Management
of Neurological Emergencies 113 Blue Ringed Octopus 166
Management of Head Injury 113 Box Jellyfish (Chironex Fleckeri) 167
Potentially Serious Head Injury 114 Irukandji Syndrome (Carukia Barnesi) 168
Cervical Spine Injury 115 Poisoning and Overdose 169
1. Management of the Unconscious Ciguatera Syndrome 171
Patient 116
Chapter 13 – Management of Burns
2. Management of Seizure 117 and Smoke Inhalation 174
Skills 1 – Cervical Collar Application 119 Introduction 174
Chapter 9 – Psychiatric Emergencies 120 Pathophysiology 174
Acute Psychosis 120 Classification of Depth 174
Management of Acute Psychosis 123 First Aid for Minor Burns 175
The Suicidal Patient 129 1. Initial Management of More
Serious Burns 175
The Aggressive Patient 130
2. Secondary Survey and Assessment
of Burns 176
4
EDITION 2.NOVEMBER 2012
Contents
3. Secondary Survey and Management Chapter 17 – Dental Emergencies 201
of Burns 177
Facial pain with/without swelling “dry” socket
Indications for Burn Unit Referral 178 201
Wound Care 178 Herpetic Stomatitis 202
Chapter 14 – Management of Acute Necrotising Ulcerative Gingivitis
Orthopaedic Emergencies 179 (ANUG) 202
General Principles 179 Salivary Gland Pain +/- Swelling 203
1. Management of Fractures Dental Abscess 203
– Upper Limb 181
Pericoronitis 204
2. Management of Fractures
Gingivitis and Periodontitis 204
– Lower Limb 184
Post extraction haemorrhage 204
3. Management of Dislocations
– Upper Limb 187 Dental Traumatic Injury 205
4. Management of Dislocations Chipped and Fractured Teeth 205
– Lower Limb 189
Loosened Teeth (Luxation injury) 205
Chapter 15 – Management of
Avulsed Teeth 206
Eye Emergencies 191
Lip and cheek lacerations 206
Corneal Abrasion 191
Chapter 18 – Management of
Corrosive Injuries to the Eye 192
Infectious Diseases 207
Corneal Foreign Bodies 192
The Septic Child 207
Penetrating Eye Injuries 192
Meningitis 208
Hyphaema 193
Antibiotics 209
Conjunctivitis is not an emergency
Neonatal Infection 210
– Keratitis Is 195
Septic Arthritis and Osteomyelitis 211
Iritis 195
Infection Control Procedures 212
Acute Angle Closure Glaucoma 196
Chapter 19 – Management of
Sudden Visual Loss 197
Submersion Injury 213
Chapter 16 – Management of Ear,
Near Drowning 213
Nose and Throat Emergencies 198
Chapter 20 – Hypothermia 216
Epistaxis 198
Hypothermia 216
Nasal Foreign Bodies 199
Chapter 21 – Pain Management 219
Nasal Fractures 199
Pain Management in Adults 219
Foreign Bodies in the Ear 200
Pain Management in Children 226
Tympanic Membrane Perforation 200
Foreign Bodies in the Pharynx 200
5
EDITION 2.NOVEMBER 2012
Contents
Chapter 22 – Emergencies in Chapter 26 – Useful Tables
Palliative Care 231 and Calculations 248
Haemorrhage 231 Normal Range of Respiratory Rate, Heart
Rates and Blood Pressure 248
Spinal Cord Compression 231
Normal Range of Urine Output 248
Fitting 232
Calculations of Paediatric Parameters 248
Obstruction of Superior Vena Cava 232
Fluid Replacement for Dehydration
Febrile neutropenia 232
in children 249
Chapter 23 – Transport in
Fluid Requirements in Serious Burns
Emergency Situations 233
– Parkland Formula 249
Stabilisation 234
Burns – Surface Area 250
Planning and Preparation 235
GLASGOW COMA SCALE 251
Effective Communication 236
AVPU versus GCS 251
Airway and Breathing 237
TIMI Risk Score 252
Circulation 238
Index 253
Chapter 24 – Radiology in
Emergency Care 240
Chest X-Ray Interpretation 240
Acute chest trauma 241
Cervical Spine X-Ray Interpretation 242
SCIWORA 243
Pelvis X-Ray Interpretation 243
Limb X-rays 244
Radiography 244
Chapter 25 – Equipment in
Emergency Medicine 245
The Doctor’s Bag 245
Minor Accident Kit 246
Resuscitation Kit 247
6
EDITION 2.NOVEMBER 2012
Acronyms / Abbreviations
ABCD Airway, Breathing, Circulation, I/O Intraosseus
Disability I/V Intravenous
ACS Acute Coronary Syndrome IVI Intravenous Infusion
ALS Advanced Life Support J Joule
AMI Acute Myocardial Infarction LMA Laryngeal Mask Airway
AMPLE A=Allergies, M=Medications currently LVF Left Ventricular Failure
used, P=Past illnesses/Pregnancy, MCA Motor Car Accident
L=Last meal, MCQ Multiple Choice Questionnaire
E=Events/Environment related to MTS Major Trauma Service
the injury NEB Nebuliser
ANUG Acute Necrotising Ulcerative Gingivitis NETS Neonatal Emergency Transfer Service
APH Antepartum Haemorrhage NSTEACS Non-ST-segment-Elevation Acute
ARC Australian Resuscitation Council Coronary Syndromes
AVPU A = alert, V = responds to voice, NSTEMI Non ST-Elevation Myocardial
P = responds to pain, U = unresponsive Infarction
BLS Basic Life Support OD Overdose
BP Blood Pressure (SBP = systolic BP; PAT Paroxysmal Atrial Tachycardia
DBP = diastolic BP) PCI Percutaneous Coronary Intervention
BSL Blood Sugar Level PEA Pulseless Electrical Activity
BZP Benzodiazepine PEEP Positive End Expiratory Pressure
CHO Carbohydrate POC Products of conception
CNS Central Nervous System PPH Post Partum Haemorrhage
Coag Coagulation PSVT Paroxysmal supraventricular
COPD Chronic Obstructive Pulmonary tachycardia
Disease PTL Pre-term Labour
CPAP Continuous Positive Airway Pressure QRS The central and most visibly obvious
CPR Cardiopulmonary resuscitation part of the ECG tracing which is the
C-spine/CS Cervical spine combination of three of the graphical
CT-scan Computerised tomography scan deflections corresponding to the
DEFG Don’t Ever Forget Glucose depolarization of the right and left
DIC Disseminated Intravascular ventricles of the human heart.
Coagulation REST Rural Emergency Skills Training
DKA Diabetic Ketoacidosis RFs Risk Factors
DRABC Danger, Response, Airway, S.A.V.E. S=sugar, A=anaphylaxis, V=VF arrest,
Breathing, Circulation E=epilepsy/fitting – exceptions in BLS
EAR Expired Air Resuscitation SCIWORA Spinal Cord Injury With-Out
ECC External Cardiac Compression Radiological Abnormality
ECG Electrocardiogram SCM Sternocleidomastoid Muscle
ECM External Cardiac Massage STEMI ST-Elevation Myocardial Infarction
EM Emergency Medicine TCA Tricyclic Anti-depressants
EMD Electromechanical Dissociation TIMI score Thrombolysis in Myocardial
ETT Endo-tracheal Tube Infarction score
FBE Full Blood Examination TTJV Trans Tracheal Jet Ventillation
FDP Fibrin Degradation Products U&E Urea & Electrolytes
FH Foetal Heart VDK Venom Detection Kit
FHR Foetal Heart Rate VF Ventricular fibrillation
FHTs Foetal Heart Tracings VT Ventricular Tachycardia
GCS Glasgow Coma Score X-match Cross-match for transfusion
HELLP Hemolysis, Elevated Liver Enzymes
and Low Platelets
7
EDITION 2.NOVEMBER 2012
Chapter 1 – Introduction
Introduction to Rural Emergency Skills Training Course
Background
This course has arisen because of the need identified by rural doctors throughout Victoria, and rural
Australia more generally, for a comprehensive generic emergency medicine course that is applicable
to rural and remote doctors in a variety of settings. The manual and the course have been designed
to cover as many of the common emergencies in rural practice as possible.
The course is not designed to replace the established emergency medicine courses such as Early
Management of Severe Trauma, Advanced Paediatric Life Support and Emergency Life Support
courses. The REST course is designed to cover a wider range of clinical presentations than these
more specific courses, and to be relevant to the pre-hospital, small rural hospital and private rural
practice environment.
Aims of the Course
The aim of this course is to enhance skills in initial management of medical emergencies in rural areas.
It is now widely accepted in medical practice that the approach to emergency situations is significantly
different to the approach to other clinical presentations.
Principles of emergency medicine include initial resuscitation and stabilisation of the patient, following
the ABCDE paradigm, with attention to life threatening conditions as soon as they are detected.
This course is designed to be applicable to a variety of settings, to be flexible, transportable and
relevant to a spectrum of knowledge and skills amongst participants. In particular, the course is
designed to involve multi–disciplinary groups of medical, nursing and ambulance personnel.
The course will be available to be delivered on a regional basis in Australia by rural doctors who have
been trained in Emergency Medicine Teacher Training.
Use of this Manual
This manual is designed to reflect the range of emergencies arising in rural practice, to encompass
best-practice principles of emergency care, and to be readily accessible in the emergency situation.
The content of the manual is therefore presented in note form with individual pages easily accessible,
and able to be removed for copying or display in the treatment room or emergency area.
Æ Protocols for management of various emergency presentations are consistent with current
practice and approved by the academic bodies.
Æ Protocols for basic and advanced life support are consistent with Australian Resuscitation Council
Policy statements.
Æ The course is designed to include sound educational principles, incorporating principles of adult
learning with a particular focus on the modes of teaching and learning relevant to emergency
medicine skills.
Æ The emergency medicine skills included in the course are regarded as essential skills for the
majority of rural practitioners, are easily taught, and require a minimum of equipment.
Accreditation of this Course and Maintenance of Standards
The course is accredited for continuing professional development by the RACGP and ACRRM. It is also
an approved course for registrars in the Australian General Practice Training Program.
ACRRM has a REST Standards and Development (SAD) Committee that has responsibility for maintaining
the standards of the REST course, including the instructor qualifications and refresher training, the
manual, the course content, and the determination of satisfactory completion of the course.

8
EDITION 2.NOVEMBER 2012
Chapter 1 – Introduction
Satisfactory Completion of the Course
As of August 2006, there are seven (7) assessment components for REST, including some that are
essential to pass in order to satisfactorily complete the course.
The seven assessment components are:
Æ Pre MCQ
Æ Basic Life Support
Æ Basic Airway Management
Æ Defibrillation
Æ Cervical Spine Immobilization
Æ Post MCQ
Æ Final Assessment Scenario.
Those that are essential to pass in order to satisfactorily complete REST are: Basic Life Support, Basic
Airway Management, Cervical Spine Immobilisation and Defibrillation.
If a candidate’s performance is considered to be unsatisfactory, they will receive immediate feedback
on their results and assistance to formulate a learning plan.
They will be advised to repeat the course within a specified time frame, or may choose to undertake
another approved emergency medicine course. In this case it will be considered as satisfactory
completion of the REST course if it is completed successfully and within the time frame specified by
the ACRRM REST SAD Committee.
Should a candidate fail the REST course twice, the SAD Committee will compile the comments
and results of the principal instructors of both courses, advise the candidate that they have not
satisfactorily completed the course, and forward a recommended course of action to the appropriate
body e.g. the relevant regional training provider in the case of a registrar candidate.
Acknowledgements
ACRRM would like to acknowledge the rural doctors and specialists who have contributed to the
preparation of the original REST manual. These include: Dr David McConville, Dr Cathy McAdam,
Dr Pat Giddings, Dr Sean Taylor, Dr Kathryn Schultz, Dr John Banky, Dr Graham Slaney, Dr Margaret
Neimann, Dr Jane Greacen, Dr Michael Langford and Dr Debbie Langford.
Principal author and editor: Dr. David Campbell.
This course was developed initially by the Rural Workforce Agency Victoria, under the instigation of
Dr Jane Greacen, former CEO RWAV.
The course is now governed by the Australian College of Rural and Remote Medicine, and licensed
to appropriate providers for delivery to rural doctors and registrars.
ACRRM would like to acknowledge the following doctors in the review of this second edition of the
REST manual. Dr David Campbell, Dr Pat Giddings, Dr Mike Eaton, Dr Peter Keppel, Dr Jim Thurley,
Dr John Russell, Dr Antony Wong, Dr Rodney Campain and Dr Tony Skapetis. Acknowledgement
also goes to Dr Rory Howard’s PDA guidelines as the revision of various chapters drew heavily on
this material.
9
EDITION 2.NOVEMBER 2012
Chapter 1 – Introduction
Course Objectives
1. To present a consistent, standardised approach to the management of a comprehensive range
of clinical emergencies.
2. To enhance specific skills related to the initial assessment and stabilisation of emergency
presentations.
3. To generate confidence in the use of principles and skills in emergency care by use of simulation
scenarios.
4. To assess participants’ acquisition of knowledge and skills in emergency medicine by formal and
informal assessment tools throughout the course.
Principles of Emergency Medicine
1. The approach to the seriously ill or injured patient is a deviation from the traditional history/
examination/investigation paradigm of medical training.
There is very good evidence that patient outcome is markedly improved by adhering to a consistent
structured approach; this approach is taught in all emergency skills courses now available.
2. It is important to reinforce that as part of this structured approach, life-threatening
problems should be dealt with as soon as they are recognised e.g. obstructed airway, tension
pneumothorax, severe blood loss etc.
3. Initial stabilisation (primary assessment and resuscitation) involves management of the vital ABC
functions and assessment of disability (CNS function). This assessment and stabilisation occurs
before any illness-specific diagnostic assessment or treatment takes place. Once the patient’s
vital functions are stable, secondary assessment and specific treatment begins.
During the secondary assessment vital signs should be checked frequently to detect any change
in the patient’s condition. If there is deterioration then primary assessment and resuscitation
should be repeated.
10
EDITION 2.NOVEMBER 2012