STUDENTS SKILL LAB MANUAL BOOK EMERGENCY AND TRAUMATOLOGY SYSTEM
EMERGENCY AND TRAUMATOLOGY SYSTEM MEDICAL FACULTY HASANUDDIN UNIVERSITY MAKASSAR 2011
AIRWAY MANAGEMENT Definition: Freeing the airway to ensure the air exchanges normally both by manual or tools. Learning Goals: after learning this manual the students are expected to have the ability to: 1. Identify the airway’s disturbance 2. Free or open airway without any tools 3. Free airway by using tools 4. Clean the airway 5. Deal with the obstruction of the airway for both partial and total obstruction Media and the learning tools: 1. Student’s skill lab manual book emergency and traumatology system 2. Video and slide of the Airway Management Methods 3. Children and adult mannequin dolls 4. Oropharyng tubes in all size 5. Nasopharyng tubes in all size 6. Gloves 7. Dry Gauge 8. Suction 9. Stiff and flexible Suction tubes Indication 1. It is done to the unconscious patients in any cause 2. It is done to the patients with partial or total airway obstruction Learning Method Procedures demonstration that is performed based on the manual Airway Management Activities Description Activity
Time
Description
1. Introduction
5 minutes
1. Introduction, manage the students sitting position 2. Brief explanation of the work procedures, students role, and time allocation
2. Short demonstration of the airway management technique by the instructor
10minutes
1. All students watch the airway management technique by the instructor at the model 2. Brief discussion if there are problems that are less understood
3. Practicing Airway
10minutes
1. One student as the assistant help to prepare all tools. One student practices the airway management technique. Other students observe attentively and correct if there are any mistakes. 2. Instructor watches and guides the students if there any mistakes in the practice. 3. Instructor goes around among the students and supervises using the checklist. 1. Discussion of the students’ impression toward the airway management practice: what is easy, what is hard? 2. The students give advice or correction on the practice that day. The instructor listens and gives answers. 3. The Instructor explains the general assessment on the practice: whether it runs nicely, or whether some students need more practice. If possible, announce each of the students mark.
management technique
4. Discussion
10minutes
Total time
35minutes
LEARNING MANUAL AIRWAY MANAGEMENT SKILLS Steps/Activity
Information
Early Preparation Check all tools Instructor explains and demonstrates the techniques 1. Look of how to assess the signs of Look at the breathing movement/ chest inflation and retraction airway disturbance between the ribs 2. Listen Listen to the breathing sound 3. Feel Feel the airflow of breathing This technique is used to the Opening the airway without tools patient with airway Head-tilt obstruction because of the back fall of the tongue Technique: Put one hand on the patient’s forehead and push it so the head will be upward and the tongue support will be raised to the front Chin lift
Diagnosis on airway disturbance
Technique: Use the middle and the point fingers to hold the patient’s chin bone, then lift and push the bone to the front Jaw thrust Technique: Push the angle of the left and right jaws to the front until all the inferior teeth are in line with the superior teeth. Or enter the mother finger in to the patient’s mouth and along with the other fingers pull the chin to the front.
Airway management with tools A. Oropharynx tube Installation technique: 1. Wear the gloves 2. Open the mannequin/patient’s mouth with chin lift technique or use the mother and point fingers 3. Prepare the oropharynx tube which has the right size 4. Clean and moist the tube to make the tube is easy to be entered 5. Direct the curve facing the palatal 6. Enter half of the tube, turn the curve facing under the tongue 7. Push the tube slowly to the right position 8. Make sure the tongue is supported by the tube by looking at the breathing pattern, feel and listen to the sound of breathing after the installation. B. Nasopharynx tube 1. Wear gloves 2. Evaluate the size of the nostrils with the tube that is going to be entered.
3. Evaluate the abnormality in the nasal cave. 4. Smear the tube and the nostril that is going to be entered with gel. If it’s needed, give vasoconstrictor inside the nose. 5. Hold the tube with the position where the edge facing the ear. 6. Push the tube slowly until all of the tube enter the nose and then evaluate the airflow in the tube. 7. Fix the tube with tape/plaster.
Clearing the airway
Being done if there is any
1. Finger swab
foreign things mouth
Techniques : a. Wear gloves b. Open the patients mouth with jaw thrust technique and push the chin downward c. Use two fingers (the pointer and middle fingers) which are clean or folded by gloves or gauge to clean and pick all the foreign things inside the mouth. 2. With suction
Airway management in obstruction case by solid foreign object A. CHOKING BACK BLOW / BACK SLAPS Adult and conscious casualties 1. If the patient is totter, hold the patient from behind 2. One arm holding the body, the other arm does the BACK- BLOW/ BACK SLAPS. Hold the patient and prevent from falling 3. Give five hard blows/ slaps with your fist at the imaginary cross lines of the vertebra and the scapula. If it fails, lay the patient slowly in up position. Do the abdominal thrust.
ABDOMINAL THRUST Standing/conscious adult patient 1. Hold the totter patient with your two arms from behind 2. Do the thrust, five times by pulling your two arms footing on your two fists right at thrust point on the middle of the umbilicus and the processus xyphoideus of the patient. If it fails, lay the patient in up position slowly. Do the abdominal thrust again.
ABDOMINAL THRUST Lying/unconscious adult patient 1. If the patient is unconscious, lie the patient in up position. 2. The helper takes the position like riding horse on top of the patient’s body or beside the patient’s hip. 3. Do pushing thrust five times by using your two arms footing on the thrust point (epigastria area).
inside
the
Make sure the foreign object has moved or out by: - Look inside the patient’s mouth, if it’s visible, take it - If it’s not visible, blow air mouth to mouth while watch if the air enters the lung. If the chest inflates, it means that the airway has opened - In the contrary, if the air doesn’t enter it means that the airway is still obstructed, do ABDOMINAL THRUST AGAIN, and so on If it fails, think to prepare cricothyroidotomy followed by tracheotomy .
Cricothyroidotomy Definition Performing puncture at cricothyroid membrane with large needle as a short cut for oxygenation and ventilation on the breathing failure patient because of upper respiratory tract obstruction. Learning Goals: After this learning the students are expected to have the ability to: 1. Conduct puncture at the cricothyroid membrane 2. Prepare the equipments that are needed in cricothyroidotomy 3. Conduct the emergency airway management after the puncture of cricothyroid membrane Learning media and tools: 1. Student’s skill lab manual book emergency and traumatology system 2. Video and slide of cricothyroidotomy 3. Mannequin dolls 4. Table or the place for instruments 5. Gloves 6. Disinfectant liquid (alcohol, povidon iodine) and cotton 7. Two Syringes of 12 cc 8. Lidocain 2 % 9. Jet insufflations equipment : Y form tube, where one of the wholes is connected to the oxygen and the aqualung 10. Two IV polyurethane protective catheter sized 12 to 14 11. Sterile Gauge or sterile bandage 12. Antibiotic cream 13. Plaster or fabric tape 14. Washbasin for hand washing and antiseptic soap Indications 1. If there is a significant upper airway obstruction 2. If the attempt to give ventilation with bag-valve-mask has failed Learning Method Procedures demonstration that is performed based on the manual
Cricothyroidotomy Activities Description Activity
Time
Description
1. Introduction
5minutes
1. Introduction, arrange the students sitting position 2. Brief explanation of working procedures, the students role, and time allocation 1. All students watch the demonstration of cricothyroidotomy by the instructor on the model 2. Short discussion if there is something that is less understood
2. Short demonstration of 5minutes cricothyroidotomy by the instructor 3. Cricothyroidotomy Practice
4. Discussion
Total time
10minutes 1. One student as the assistant help preparing the cricothyroidotomy practice. One student performs the cricothyroidotomy practice. The other students observe attentively and correct if the practice is not perfect 2. The instructor watches and guides the students in the practice 3. The instructor goes around the students and supervise using the checklist 10minutes 1. Discussion of the students’ impression toward the cricothyroidotomy practice: what is easy and what is hard 2. The students give advice or correction toward the practice on that day. The instructor listens and gives answers 3. The instructor gives general explanation of the cricothyroidotomy practice: is generally the practice runs well, are there some students still need more practice. If it is necessary announce the mark for each students 30minutes
LEARNING MANUAL CRICOTHYROIDOTOMY SKILL Steps/Activities Early preparation before installation 1. Check all the equipments Connect oxygen hose with one of the Y tube whole and make sure the oxygen flows properly through the hose 2. Place the IV catheter sized 14 to the 12 cc syringe Cricothyroidotomy Procedures 3. Disinfect neck area with antiseptic 4. Palpate cricoids membrane, at the anterior between thyroid and cricoids cartilage. Hold the trachea with your thumbs and pointer finger so the trachea won’t move to the lateral in the procedure 5. With the other hand (right hand) puncture the skin at the midline on top of cricoids membrane with big needle sized 12-14 which has been placed on a syringe. To easy the needle penetration, you can make small incision at the puncture point with knife sized 11
Annotation
6. Direct the needle 45 degrees to the caudal, then carefully penetrate the needle while sucking the syringe. If the air is aspirated or there is bubble in the syringe which is filled with aquadest it means that the needle has entered the trachea lumen 7. Release the syringe from the IV catheter, than pull the mandrin and push the catheter gently downward 8. Connect the end of the catheter with one of the end of the oxygen hose with Y form 9. Scheduled ventilation can be done by closing one end of the opened Y hose with your thumb for one second and open it for 4 seconds. This procedure can last from 30 to 45 minutes
GIVING THE BREATHING AID Definition: Giving the breathing aid with or without ant equipment to the breathing failure patient in any cause. Learning Goals: after this study the students are expected to have the ability to: 1. Prepare the equipments that are needed to give the breathing aid 2. Give the breathing aid to the breathing failure patient without any equipments 3. Give the breathing aid to the breathing failure patient with equipments Learning Media and tools : 1. Skills lab students’ manual book of emergency and traumatology system 2. Video and slide of airway management 3. Mannequin dolls of adult and children intubation 4. Oropharyng tubes in any size 5. Orothracheal tubes in any size 6. Nasotracheal tube in any size 7. Bag-valve-mask 8. Oxygen hose and oxygen tank 9. Laryngoscope handle and battery 10. Laryngoscope leaves in any size and extra lamp 11. Plaster 12. Stethoscope 13. Endotracheal tube gel 14. Local anesthetic spray for nasal 15. Semi rigid cervical collar 16. Magill forceps 17. Stylet (introducer) endotracheal tube that is flexible 18. Tongue spatula 19. Hand gloves 20. Dry Gauge 21. Suction 22. Rigid and flexible suction tubes Indication It is done to the breathing failure patients Learning Method Procedures demonstration that is performed based on the manual
Activities descriptions of airway management Activity
Time
1. Introduction
5 minutes
2. Short demonstration of the procedure of giving the breathing aid by the instructor
10 minutes
3. Practice the procedure of giving the breathing aid by the instructor
10 minutes
4. Discussion
10 minutes
Total time
35 minutes
Description 1. Introduction, arrange the students sitting position 2. Brief explanation of working procedures, the students role, and time allocation 1. All students watch the demonstration of the procedure of giving the breathing aid by the instructor on the model 2. Short discussion if there is something that is less understood 1. One student as the assistant helps preparing the equipments. One student performs the procedure of giving the breathing aid. The other students observe attentively and correct if the practice is not perfect 2. The instructor watches and guides the students in the practice 3. The instructor goes around the students and supervise using the checklist 1. Discussion of the students’ impression toward the giving the breathing aid practice: what is easy and what is hard 2. The students give advice or correction toward the practice on that day. The instructor listens and gives answers 3. The instructor gives general explanation of the giving the breathing aid practice: is generally the practice runs well, are there some students still need more practice. If it is necessary announce the mark for each students
LEARNING MANUAL GIVING THE BREATHING AID SKILL Steps/Activities Early Preparation Check all the equipments Bag-valve-mask Ventilation 1. Choose the mask size that is fit to the patient’s face 2. Connect the oxygen hose to the bag-valve-mask and set the oxygen flow up to 12 L/minutes 3. Make sure the patients airway is free and maintain it with the technique that has been explain in the previous chapter 4. Install the oropharynx tube 5. The left hand hold the mask in the position where the mask tight to the face and make sure there is no air that flow out from the mask when the bag is pumped. The right hand holds the bag and pumps it until the patient’s (doll) chest looks inflated. 6. For two helper : one helper hold the mask with two hands and the other helper hold the bag and pump it with two hands 7. The ventilation adequacy is evaluated by watching the movement of the patient’s (doll) chest 8. Ventilation is given in every 5 seconds
Ket
Orotracheal Intubation 1. Make sure that the airway is free and the oxygenation still goes on 2. If the patient is still given the breathing aid with bag-valve-mask, give enough preoxygenation before performing the intubation 3. Pump up the endotracheal tube to make sure that the balloon is not leaked. If it is not leaked, deflate the balloon 4. Connect the laryngoscope leave to the handle and check the lamp light 5. Hold the laryngoscope with the left hand 6. If the oropharynx tube is installed, put it of right away 7. Enter the laryngoscope at the right side of the patient’s mouth and push the tongue to the left 8. Visually identify the epiglottis and then the vocal chord 9. Carefully enter the endotracheal tube in to the trachea without pressing the teeth or the other tissue in the mouth 10. Pump up the balloon with the air from the syringe until there is no air is heard from the interspaces of endotracheal tube and the trachea 11. Connect the endotracheal tube with the bag-valve and then pump it while watching the chest inflation 12. Auscultate the left-right chest to check if the breathing sound is similar. The abdominal auscultation to make sure the tube is correctly installed 13. Install the orotracheal tube and fixate the endotracheal tube to the mouth with plaster
NEEDLE THORACOCENTHESIS Definition Performing puncture toward the chest wall at the second intercostals in order to expel the air in the pleura in the tension pneumothorax cases Learning Goals: After this study the students are expected to have the ability to: 1. Perform the puncture at second intercostals 2. Prepare the equipments that are needed in performing the needle thoracocenthesis Learning media and tools: 1. Skills lab students’ manual book of emergency and traumatology system 2. Video and slide of needle thoracocenthesis 3. Mannequin dolls 4. Table or the place for instruments 5. Gloves 6. Disinfectant liquid (alcohol, povidon iodine) and cotton 7. Two Syringes of 12 cc 8. Lidocain 2 % 9. Two IV polyurethane protective catheter sized 12 to 14 10. Sterile Gauge or sterile bandage 11. NaCl 0,9% 12. Washbasin for hand washing and antiseptic soap Indication In tension pneumothorax cases Learning Method Procedures demonstration that is performed based on the manual
Activities Description of Needle Thoracocenthesis Activity 1. Introduction
2. Short demonstration of the needle thoracocenthesis procedure by the instructor 3. Practice the needle thoracocenthesis procedure by the instructor
4. Discussion
Total time
Time 5 minutes
Description 1. Introduction, arrange the students sitting position 2. Brief explanation of working procedures, the students role, and time allocation 5 minutes 1. All students watch the demonstration of the procedure of needle thoracocenthesis by the instructor on the model 2. Short discussion if there is something that is less understood 10 minutes 1. One student as the assistant helps preparing the equipments for needle thoracocenthesis. One student performs the needle thoracocenthesis procedure. The other students observe attentively and correct if the practice is not perfect 2. The instructor watches and guides the students in the practice 3. The instructor goes around the students and supervise using the checklist 10 minutes 1. Discussion of the students’ impression toward the needle thoracocenthesis practice: what is easy and what is hard 2. The students give advice or correction toward the practice on that day. The instructor listens and gives answers 3. The instructor gives general explanation of the needle thoracocenthesis practice: is generally the practice runs well, are there some students still need more practice. If it is necessary announce the mark for each students 30 minutes
LEARNING MANUAL NEEDLE THORACOCENTHESIS SKILL
Steps/Activities Early preparation before installation 1. Check all equipments 2. Place IV catheter sized 14 to the 12 cc syringe that is filled with 5 ml water Needle Thoracocenthesis Procedures 3. Disinfect the thorax area that is going to puncture with antiseptic 4. Identify the second intercostals area at the middle of clavicle. If the patient is conscious inject the local anesthetic 5. Puncture the needle that is connected to the syringe at the upper part of the third Costa until the air is expelled signed by the appearance of the bubble at the syringe 6. Reevaluate the patient breathing if there is improvement or not
Annotation
CARDIO PULMONER RESCUCITATION Definition: Performing external heart massage to manage the condition of breath stop and heart stop Learning Goals: after this study the students are expected to have the ability to: 1. Perform the resuscitation to the breath stop patient 2. Perform the external heart massage to the heart stop patient Learning media and tools: 1. Skills lab students’ manual book of emergency and traumatology system 2. Video and slide of needle thoracocenthesis 3. Adult and children mannequin dolls Indication Being done to the breath stop and/or heart stop patient in any cause Learning Method Procedures demonstration that is performed based on the manual CPR activities description Activity Time 1. Introduction 5 minutes
2. Short demonstration of the CPR procedure by the instructor
10 minutes
3. Practice the CPR procedure by the instructor
10 minutes
4. Discussion
10 minutes
Total time
35 minutes
Description 1. Introduction, arrange the students sitting position 2. Brief explanation of working procedures, the students role, and time allocation 1. All students watch the demonstration of the CPR procedure by the instructor on the model 2. Short discussion if there is something that s less understood 1. One student as the assistant helps preparing the equipments for CPR. One student performs the CPR procedure. The other students observe attentively and correct if the practice is not perfect 2. The instructor watches and guides the students in the practice 3. The instructor goes around the students and supervise using the checklist 1. Discussion of the students’ impression toward the CPR practice: what is easy and what is hard 2. The students give advice or correction toward the practice on that day. The instructor listens and gives answers 3. The instructor gives general explanation of the CPR practice: is generally the practice runs well, are there some students still need more practice. If it is necessary announce the mark for each students
LEARNING MANUAL CARDIOPULMONER RESCUCITATION Steps/Activities
Annotation
Early preparation Check all equipments Demonstration by one helper 1. Arrange the patient’s position and put the patient on the hard base 2. For the unconscious patient, make sure the patient is unconscious by calling, clapping the patient’s back, shaking, or pinching the patient 3. Ask help immediately by shouting without leaving the patient 4. Check if the patient is breathing 5. If the patient is not breathing, open and free the airway 6. Recheck if the patient is breathing after opening the airway 7. If there is no breathing or the breathing is difficult, give two breathing aid, slow and full while watching the chest inflation 8. Feel the carotid pulse 9. If you can’t feel it, perform external heart massage 30 times at the base point which is two fingers above the processus xyphoideus. Then continue with giving two blows of breathing aid 10. Put one hand at the pressure point, the other hand is on top of the first hand 11. Both arms are straight and vertical at the sternum. Both of the helper’s knee is close to each other, and stick to the patient’s arm 12. Press downward 4-5 cm for adults, by dropping the weight to the patient’s sternum. 13. Compress rhythmically and regularly 100 times/minute. Evaluate at the breathing, pulse, consciousness, and pupil reaction every end of the fifth cycle 14. If the breathing and the pulse are still can’t be felt continue the CPR until the patient is recover Demonstration by two helper 1. Step 1-14 above are still performed by the first helper until the second helper comes 2. When the first helper makes the evaluation, the second helper takes the position for heart massage 3. If the pulse is still can’t be felt, the first helper gives two times breathing aid slowly until the chest is inflated, followed by the second helper giving 30 times of heart massage PERIPHERAL VEIN CANULATION Definition Performing puncture at the superficial vein at the arms, feet, neck, or head using intravenous catheter as indication Learning Goals: after this learning the students are expected to have the ability to: 1. Know the indication of canulation intravenous catheter (infuse) 2. Explain the objectives of the canulation and the procedure to the patient 3. Prepare the equipments which are needed for canulation 4. Perform the vein canulation in the right way 5. Fixate the vein catheter in the right way Learning media and tools: 1. Skills lab students’ manual book of emergency and traumatology system 2. Video and slide of vein canulation 3. Mannequin dolls and vein replacement kit and advanced vein puncture and injection arm 4. Tourniquet 5. Gloves 6. Syringe of 1 cc 7. Lidocain 2 %
8. Infuse set or transfuse set 9. IV polyurethane protective (in any size for adult and children) 10. Sterile Gauge or sterile bandage 11. Antibiotic cream 12. Plaster 13. Washbasin for hand washing and antiseptic soap Indication 1. 2. 3. 4. 5.
For giving fluid As access for intravenous drugs A part of resuscitation action Plan for operation Nutrition giving via peripheral parentheral
Learning Method Procedures demonstration that is performed based on the manual Peripheral vein canulation’s activities description Activity 1. Introduction
Time 5 minutes
2. Short demonstration of
5
the peripheral vein
minutes
canulation procedure by the
Description 1. Introduction, arrange the students sitting position 2. Brief explanation of working procedures, the students role, and time allocation 1. All students watch the demonstration of the procedure of peripheral vein canulation by the instructor on the model 2. Short discussion if there is something that is less understood
instructor 3. Practice the peripheral
15
vein canulation procedure
minutes
by the instructor
4. Discussion
10 minutes
Total time
35 minutes
1. One student as the assistant helps preparing the equipments for peripheral vein canulation. One student performs the peripheral vein canulation procedure. The other students observe attentively and correct if the practice is not perfect 2. The instructor watches and guides the students in the practice 3. The instructor goes around the students and supervise using the checklist 1. Discussion of the students’ impression toward the peripheral vein canulation practice: what is easy and what is hard 2. The students give advice or correction toward the practice on that day. The instructor listens and gives answers 3. The instructor gives general explanation of the peripheral vein canulation practice: is generally the practice runs well, are there some students still need more practice. If it is necessary announce the mark for each students
LEARNING MANUAL PERIFER VEIN CANULATION ACTIVITIES
DESCRIPTION
Preparation 1. Check the patient’s medical record or status card ( search for diagnose, allergic histories, blood abnormalities, etc.) 2. Check all of the equipments Check if the transfusion set is connected to the solution bag Make sure there is no air bubble in the transfusion set Provide 3 different catheter size intravenous ) that may match to the patient 3. Explain the procedure to the patient and his or her Create a pleasant atmosphere in the room by making kind and friendly greetings, or either by family shaking hands and give a slight and friendly touch to your patient if necessary. . Intravenous catheter manual 4. Identify the veins that will be suitable to insert a Choose the most distal vein than the proximal ones. catheter Better to choose extremities that are not dominant Search for dorsal manus area Do not insert the catheter in antecubiti areas 5. Wash hands with antimicrobial soap 6. Use the handgloves 7. Insert the tourniquette
If needed, an assistant will be helpful to immobilize the patient. Force the veins towards the distal direction or set the patient’s arm in a position where the arm is lower than the cardiac level. Place the tourniquette in the middle part of the arm between the wrist and elbow ) or either in the lower part of the leg. Do not place the tourniquette forcely or either too gently. If rubber band is used as a tourniquette, not tie it as a “dead lock”. The tie knot should be able to be easily untied. If the tourniquiette is already placed but veins are not to be visible yet, a mild tapping on the veins using your hands or placing a warm towel would help to dilate the veins.
8. Cleanse the place of nsertiion with desinfektan ( alcohol ) and let it dry by itself. 9. Left arm should hold the area beneath the injection area, use the thumb to stabilize the veins and soft tissue. 10. Do a local anesthetic injection in the injection area using a small needle ( 30 gauge needle/1cc disposable a local anesthetic cream If availabe in advanced, a local anesthetic cream can be used
After cleansing, ”no touch ” should be kept in mind. If the injection area is to be the dorsal manus area, the patient can be asked to hold tight its arm.
(EMLA) 11. Place the bevel catheter i.v. in a upward position, between the point finger and the thumb. 12. Hold the catheter in a 45 degree position, just above Approaches that can be done in penetrating the the skin towards the vein but not yet penetrating vein : the vein. Central : penetrate straight to the vein. This is not a very good approach because whenever the penetration is far too deep, it could harm the tissue beneath the vein causing extravacation. Paraveins : penetrate the vein from its side part first, then direct the needle intowards the vein. This is the best way to penetrate into the vein. 13. Place the catheter lower than or just as in one level with the skin surface dan move the needle tip to pass it althrough the vein. 14. Force the catheter slowly into the vein, make sure If there is a resistant sensation, and followed there is a venous return flow quickly by a smooth penetration, it means that the catheter is already placed inside the vein. 15. Force the catheter with its mandrin about 3-5 mm How far the force goes depends on the size and into the vein to make sure the catheter in placed depth of the veins and the catheter’s size. inside the vein’s lumen. 16. Pull the mandrin out, push the catheter till the end Do not re-insert the mandrin into the catheter of the catheter touches the skin surface. because it could tear up the catheter. 17. Dispose the used mandrin using the catheter’s Be sure that the mandrin is wraped inside the wrap/plastic wrap. catheter plastic bag/wrap until you hear a ”click” and dispose it carefully in a safe place 18. Release the tourniquette 19. Connect the catheter to the infuse/transfusion set If available, connect it with a three way stop cock. 20. Let the saline fluid / i.v. fluid pass through, clean any blood residuals and then dry it with a sterilized gaus so the band aid will attach firmly. I.V. Catheter Fixation 21. Attach one band aid 5mm in width, direct the ends Use two band aids, one for catheter fixation to form the letter “V” just beneath the catheter intravenously, and the other to fixate the origin so it would close the surface where the transfusion set. The length of the band aid is about 15-20 cm long, not too wide nor too catheter was inserted. narrow. ( width 0.5 mm ). Fixation should form the letter “V”, in a way where it wouldn’t detached easily. 22. Attach one band aid to fixate the infuse or transfuse Do not manipulate the transfusion pipe/set set by forming the letter “V” before fixating it to the skin surface, for it may cause difficulties whenever an injection through the transfusion set is needed afterwards. Post fixation 23. Immobilized the extremities wih ada board if there Do not use gause or any other material as a is any indication. For example : when inserted in band in any insertion areas. infants, children and joint areas 24. Instruction for patients : Avoid any unnecessary movements. Call for the nurse/doctor as soon as possible whenever there is a swelling, pain or leakage from the insertion.
25. Labelize the gause with date of insertion, size of catheter and the inisial of the name who inserted it. 26. Write down in the patient’s medical record about : Date of insertion Catheter size Initials of names who inserted the catheter Place of insertion Patient’s tolerance and respond to the therapy
PENUNTUN BELAJAR KETERAMPILAN RESUSITASI PADA BAYI BARU LAHIR Langkah-langkah/Kegiatan Persiapan awal Periksa semua kelengkapan alat Langkah awal 1. Letakkan bayi di bawah pemancar panas yang telah dinyalakan sebelumnya. 2. Letakkan bayi dengan kepala sedikit tengadah/sedikit ekstensi. 3. Hisap mulut kemudian hidung 4. Keringkan tubuh dan kepala dari cairan amnion 5. Singkirkan kain basah. 6. Perbaiki posisi kepala bayi agar leher agak tengadah. Buka jalan napas 1. Bersihkan mulut dan hidung bayi dengan penghisap. 2. Posisikan bayi terlentang, kepala posisi tengadah jangan melakukan ekstensi yang berlebihan 3. Berikan ganjal punggung dengan kain setebal 2.5 cm bila kepala bayi besar atau occiputnya menonjol. 4. Jika pernapasan dangkal atau tersengal-sengal segera hisap lendir mulai dari mulut kemudian hidung. Pengisapan jangan terlalu lama (6 detik). 5. Evaluasi pernapasan, frekuensi jantung, dan warna kulit. 6. Jika ketuban keruh atau bercampur meconium kental bila bayi menunjukkan usaha napas yang baik, tonus otot yang baik, dan frekuensi jantung lebih dari 100 kali/menit, anda cukup membersihkan sekret dan mekonium dari mulut dan hidung dengan menggunakan balon penghisap yang biasa digunakan atau kateter penghisap berukuran 12F atau 14F. Rangsangan taktil Cara rangsang taktil yang aman : 1. Menepuk / menyentil telapak kaki 2. Menggosok punggung/perut/dada/ekstremitas Evaluasi kondisi bayi 1. Nilai pernapasan bayi dengan melihat pengembangan dada dan warna kulit. Dengaran suara napas di seluruh lapangan paru dengan stetoskop. 2. Nilai denyut jantung dengan mendengar irama jantung dengan stetoskop. Hitung frekwensi denyut jantung 3. Nilai warna kulit apakah kemerahan/sianosis perifer atau sianosis sentral. Pemberian napas bantu 1. Jika pernapasan tetap tersengal atau apnu setelah rangsangan singkat, segera berikan pernapasan buatan atau ventilasi tekanan positif dengan oksigen 100 %. 2. Posisikan kepala bayi sedikit ekstensi atau ganjal bahu 3. Bersihkan sekret terlebih dahulu dan pastikan jalan napas bersih. 4. Pasang pipa orofaring 5. Letakkan sungkup di wajah bayi dengan rapat agar tidak bocor melalui sisi sungkup 6. Berikan tekanan positip melalui bag-valve-mask (ambubag) dengan lembut sambil melihat pengembangan dada bayi.
Keterangan
7. Selanjutnya evaluasi lagi pernapasan dan denyut jantung secara simultan. 8. Bila ventilasi tekanan positip tidak efektif dapat dilakukan intubasi endotrakeal. Pijat Jantung (penekanan dada) 1. Indikasi pijat jantung bila setelah 30 detik dilakukan VTP dengan 100% O2 , FJ tetap < 60 kali / menit 2. Diperlukan 2 orang : 1 orang yang melakukan pijat jantung dan 1 orang yang terus melanjutkan ventilasi. Pelaksana kompresi : menilai dada & menempatkan posisi tangan dengan benar Pelaksana ventilasi : menempatkan sungkup wajah secara efektif & memantau gerakan dada. 3. Penekanan dada dilakukan pada sepertiga bagian tengah sternum, dibawah garis imajiner yang menghubungkan papilla mammae. 4. Teknik ibu jari : 1.Kedua ibu jari menekan tulang dada 2.Kedua tangan melingkari dada dan jari-jari tangan menopang bagian belakang bayi 5. Teknik dua jari : 1.Ujung jari tengah dan jari telunjuk atau jari manis dari satu tangan digunakan untuk menekan tulang dada 2.Tangan yang lain digunakan untuk menopang bagian belakang bayi. 6. Lokasi untuk kompresi dada : • Gerakkan jari sepanjang tepi bawah iga sampai mendapatkan sifoid • Letakkan ibu jari atau jari-jari lain pada tulang dada, tepat diatas sifoid dan pada garis yang menghubungkan kedua puting susu. 7. Tekanan saat kompresi dada : • Kedalaman + 1/3 diameter antero-posterior dada • Lama penekanan lebih singkat dari pada lama pelepasan • Jangan mengangkat ibu jari atau jari-jari tangan dari dada di antara penekanan. 8. Frekuensi : ”satu-dua-tiga-pompa-...” Satu siklus kegiatan terdiri atas tiga kompresi + satu ventilasi. Rasio 3 :1 1 siklus ( 2detik) 1½ detik : 3 kompresi dada ½ detik : 1 ventilasi 90 kompresi + 30 ventilasi dalam 1 menit 9. Setelah 30 detik kompresi dada dan ventilasi , periksa frekuensi jantung. Jika frekuensi jantung : a. Lebih dari 60 kali/menit, hentikan kompresi dan lanjutkan ventilasi dengan kecepatan 40-60 kali pompa/menit. b. lebih dari 100 kali/menit, hentikan kompresi dada dan hentikan ventilasi secara bertahap jika bayi bernapas spontan. c. kurang dari 60 kali/menit, lakukan intubasi pada bayi jika belum dilakukan, dan berikan epinefrin, lebih disukai dengan cara intravena. Intubasi menyediakan cara yang lebih terpercaya untuk melanjutkan ventilasi
RESUSITASI BAYI DAN ANAK Pengertian : Melakukan resusitasi bayi dan anak akibat gawat napas dan sirkulasi. Tujuan pembelajaran : setelah pembelajaran ini mahasiswa diharapkan : 1. Mampu melakukan penilaian kegawatan napas dan sirkulasi 2. Mampu melakukan resusitasi bayi dan anak yang mengalami gangguan pernapasan yang mengancam jiwa 3. Mampu membebaskan dan membersihkan jalan napas pada bayi dan anak. 4. Mampu memberikan napas bantu pada bayi dan anak yang tidak bisa bernapas/apnu. 5. Mampu melakukan pijatan jantung luar pada bayi dan anak yang mengalami henti jantung. Media dan alat pembelajaran: 1. Buku panduan peserta skill lab sistim emergensi dan traumatologi 2. Boneka manikin bayi dan anak. 3. Pipa orofaring ukuran bayi dan anak.
4. Kateter penghisap 5. Masker resusitasi 6. Balon resusitasi tipe mengembang sendiri 7. Balon resusitasi tipe tidak mengembang sendiri 8. Pipa lambung (gastric tube) 9. Pipa endotrakeal no. 3.0 – 7,0 Indikasi 1. Dilakukan pada bayi dan anak yang mengalami sumbatan jalan napas 2. Dilakukan pada bayi dan anak yang tidak bernapas/apnu. 3. Dilakukan pada bayi dan anak yang mengalami henti jantung. Metode Pembelajaran Demonstrasi kompetensi sesuai dengan penuntun belajar Deskripsi kegiatan resusitasi bayi dan anak. Kegiatan
Waktu
Deskripsi
1. Pengantar
5 menit
2. Demonstrasi singkat
10 menit
1. Perkenalan, mengatur posisi duduk mahasiswa 2. Penjelasan singkat tentang prosedur kerja, peran masing-masing mahasiswa dan alokasi waktu. 1. Seluruh mahasiswa melihat demonstrasi cara resusitasi bayi dan anak oleh Instruktur pada model 2. Diskusi singkat bila ada yang kurang dimengerti.
tentang cara resusitasi bayi dan anak oleh instruktur. 3. Praktek cara resusitasi
10 menit
bayi dan anak.
4. Diskusi
10 menit
Total waktu
35 menit
1. Satu orang mahasiswa mempraktekkan cara resusitasi bayi dan anak. Mahasiswa lainnya menyimak dan mengoreksi bila ada yang kurang. 2. Instruktur memperhatikan dan memberikan bimbingan bila mahasiswa kurang sempurna melakukan praktek. 3. Instruktur berkeliling diantara mahasiswa dan melakukan supervisi menggunakan ceklis/daftar tilik. 1. Diskusi tentang kesan mahasiswa terhadap praktek cara resusitasi bayi dan anak: apa yang dirasa mudah, apa yang sulit. 2. Mahasiswa memberikan saran atau koreksi tentang jalannya praktek hari itu. Instruktur mendengar dan memberikan jawaban. 3. Instruktur mejelaskan penilaian umum tentang jalannya praktek resusitasi bayi dan anak : apakah secara umum berjalan baik, apakah ada sebagaian mahasiswa yang masih kurang. Bila perlu mengumumkan hasil masing-masing mahasiswa.
PENUNTUN BELAJAR KETERAMPILAN RESUSITASI PADA BAYI DAN ANAK Langkah-langkah/Kegiatan
Keterangan
Persiapan awal Periksa semua kelengkapan alat
RESUSITASI
Instruktur menjelaskan dan
Pendekatan ’SAFE’
memperagakan
menilai tanda-tanda adanya
Shout for help ( minta tolong) Approach with care (tangani dengan hati-hati) Free from danger (jauhkan dari bahaya) Evaluate ABC (nilai jalan nafas, pernafasan, sirkulasi) SAFE approach Are you alright? Airway opening manoeuver Look, listen, feel
Up to 5 breaths Check pulse
Start CPR 1 minute Call emergency services
Tatacara meminta pertolongan: 1. Bila hanya 1 org penolong, lakukan bantuan hidup dasar dulu, baru kemudian meminta bantuan 2. Bila penolong tidak dapat meminta pertolongan, teruskan resusitasi sampai tiba penolong lain atau sampai kelelahan. 3. Bila ada 2 penolong, penolong pertama melakukan resusitasi, penolong kedua mencari bantuan 4. Yang meminta bantuan menyebut lokasi, nomor telpon, jenis kejadian, jumlah korban, pertolongan yg telah diberikan dan informasi lain yg dibutuhkan.
Penilaian sistem kardiovaskuler A. Airway = jalan nafas
bagaimana
gangguan vaskuler.
sistem
kardio
– Dapat dipertahankan tanpa alat atau memerlukan alat bantu jalan nafas B. Breathing = Pernafasan - Frekwensi - Gerak nafas (retraksi, merintih, cuping hidung, otot bantu nafas) - Aliran udara pernafasan (pengembangan dada, suara nafas, stridor, wheezing/mengi, gerakan paradoks) – Warna kulit (ada atau tidaknya sianosis) C. Circulation = sirkulasi -
Frekwensi jantung, denyut sentral, denyut perifer tekanan darah.
-
Perfusi kulit (capillary refill time, suhu, warna kulit, kulit berbercak (mottling)
-
Perfusi SSP
-
Reaksi Kesadaran (AVPU= Alert, Respon to Verbal, Respon to Pain, Unresponsive) (mengenal org tua, tonus
otot,
ukuran
pupil,
postur
(dekortikasi/deserebrasi) Penilaian dilakukan tidak lebih dari 30 detik JALAN NAFAS (AIRWAY) 1. Tentukan derajat kesadaran dan kesulitan nafas a. Periksa tanda cedera kepala, leher, kesulitan pernafasan & kesadaran. Bila ada cedera kepala jangan mengguncang bayi atau anak karena dapat merusak medula spinalis. b. Bila bayi dan anak tidak sadar tapi bernafas baik, letakkan pada posisi pulih (recovery position) c. Bayi dan anak sadar dengan kesulitan bernafas, letakkan pada posisi
senyaman mungkin
yg
memudahkan
bernafas. 2. Mintalah bantuan 3. Atur posisi korban a. Letakkan dengan posisi terlentang diatas dasar yg rata dan keras b. Bila ada cedera kepala/leher pertahankan posis tubuhleher-kepala dalam satu garis. Hindari ekstensi, fleksi dan rotasi kepala karena dapat mencederai medula spinalis. c. Memindahkan ke tempat lain, posisi tubuh-leher-kepala,
harus dalam satu garis kesatuan 4. Membuka jalan nafas -
Bila tidak ada cedera kepala dengan cara head tilt atau chin lift
Head-tilt/chin lift Cara melakukan: 1. Letakkan satu tangan pada dahi tekan perlahan ke posterior, sehingga kemiringan kepala menjadi normal atau sedikit ekstensi (hindari hiperekstensi karena dapat menyumbat jalan napas). 2. Letakkan jari (bukan ibu jari) tangan yang lain pada tulang rahang bawah tepat di ujung dagu dan dorong ke luar atas, sambil mempertahankan cara 1.
-
Bila tidak sadar dan ada cedera kepala dengan cara jaw thrust
Cara melakukannya: 1. Posisi penolong di sisi atau di arah kepala 2. Letakkan 2-3 jari (tangan kiri dan kanan) pada masingmasing sudut posterior bawah kemudian angkat dan dorong keluar. 3. Bila posisi penolong diatas kepala. Kedua siku penolong diletakkan pada lantai atau alas dimana korban diletakkan. 4. Bila upaya ini belum membuka jalan napas, kombinasi dengan head tilt dan membuka mulut (metode gerak triple) 5. Untuk cedera kepala/ leher lakukan jaw thrust dengan immobilisasi leher.
PERNAFASAN ( BREATHING) 1. Nilai usaha nafas dengan melihat gerak nafas, dengar desah nafas, dan rasakan aliran udara pernafasan 2. Caranya a. Pasang sungkup dengan ukuran sesuai umur sehingga menutup mulut dan hidung, lalu rapatkan b. Sambil mempertahankan posisi kepala (jalan nafas) lakukan tiupan nafas buatan dengan mulut atau balon (bag) resusitasi. c. Bila dgn mulut, tarik nafas dalam, tiup dan liat pengembangan dada. Bila
tetap tdk mengambang
kemungkinan obstruksi jalan nafas. 3. Frekuensi nafas buatan yg dilakukan: -
Bayi - < 8 thn : 20 kali permenit
-
Neonatus
: 30 – 60 kali permenit
SIRKULASI DARAH (Circulation) Penilaian sirkulasi : setelah 2-5 kali nafas buatan Tempat penilaian : bayi baru lahir
: arteri umbilikus
bayi
: arteri brakhialis
anak
: arteri karotis
Indikasi pijat jantung : bradikardia ( <60x/m atau henti jantung ) Lokasi pemijatan : 1/2 bagian bawah tulang dada (sternum) dengan kedalaman pijatan 1/3 tebal dada. Cara : - Bayi: pijatan dilakukan dengan teknik ibu jari atau dua jari (telunjuk dan jari tengah) Teknik ibu jari : 1.Kedua ibu jari menekan tulang dada 2.Kedua tangan melingkari dada dan jari-jari tangan menopang bagian belakang bayi Teknik dua jari : 1.Ujung jari tengah dan jari telunjuk atau jari manis dari satu tangan digunakan untuk menekan tulang dada 2.Tangan yang lain digunakan untuk menopang bagian belakang bayi. - Anak < 8 tahun : dengan pangkal telapak tangan - Anak > 8 tahun : pangkal telapak tangan terbuka dan dibantu dengan tangan yang satu diatasnya. Frekuensi pemijatan : -
Bayi dan anak : 100 kali permenit
-
Neonatus
: 120 kali permenit
Koordinasi antara pijat jantung dan nafas buatan: -
Neonatus
: 3:1
-
Anak
: Dua penolong : 15 : 2 Satu penolong : 30 : 2
SUMBATAN JALAN NAFAS Teknik pukulan dan hentakan Bayi dan anak kecil 1. Letakkan bayi dengan posisi tertelungkup kepala lebih rendah. Diatas lengan bawah, topang dagu dan leher dengan lengan bawah dan lutut penolong. 2. Tangan lainnya melakukan pukulan punggung diantara kedua tulang belikat secara hati-hati dan cepat sebanyak 5 kali pukulan. 3. Balikkan dan lakukan hentakan pada dada sebagaimana melakukan pijat jantung luar sebanyak 5 kali. 4. Pada neonatus tidak boleh melakukan cara diatas, hanya dilakukan dengan alat penghisap (suction) Pada anak lebih besar : 1. Pukulan punggung dilakukan 5 kali dengan pangkal tangan diatas tulang belakang diantara kedua tulang belikat. Jika memungkinkan rendahkan kepala di bawah dada. 2. Hentakan perut (Heimlich maneuver dan abdominal thrust). Cara: Penolong berdiri di belakang korban, lingkarkan kedua lengan mengitari pinggang, peganglah satu sama lain pergelangan atau kepalan tangan (penolong), letakkkan kedua tangan (penolong) pada perut antara pusat dan prosessus sifoideus, tekanlah ke arah abdomen atas dengan hentakan cepat 3-5 kali. Hentakan perut tidak boleh dilakukan pada neonatus dan bayi.
Teknik ini digunakan pada penderita
sumbatan
jalan
napas akibat lidah yang jatuh ke belakang
Resume Resusitasi Anak Maneuver
Dewasa
dan
Anak kecil
Bayi
Neonatus
CPR/Resc
anak besar
Airway
Breathing
Breathing
> 8 tahun
1-8 tahun
< 1 tahun
Bayi baru lahir
Head
Head
Head
Head
tilt-chin
tilt-chin
tilt-chin
tilt-chin
Check responnya Buka jalan nafas
lift (jika trauma
lift (jika trauma
lift (jika trauma
lift (jika trauma
jaw thrust)
jaw thrust)
jaw thrust)
jaw thrust)
2-5 nafas kira-
2-5 nafas kira-
2-5 nafas kira-
2-5 nafas kira-
kira 1 ½ detik
kira 1 ½ detik
kira 1 ½ detik
kira
tiap nafas
tiap nafas
tiap nafas
tiap nafas
1
detik
Cek
napas,
korban
jika
bernafas:
recovery position. Jumlah nafas
± 12 kali/min
± 20 kali/min
± 20 kali/min
±30–60 kali/min
Jika
tidak
ada
pengembangan Obstruksi benda
Abdominal
asing
thrusts
Abdominal atau
back blows
thrusts
atau
Back blows atau
Suction (jangan
dada : reposisi dan
chest
abdominal
ulangi
thrust
back blows atau
(jangan
thrust
atau
chest thrust
abdominal
back blows)
sampai
5
kali
thrust) Cek nadi
Carotis
Nilai
Umbilical
Brachial
Carotis
tanda
kehidupan, Titik kompressi
jika
1/2 bgn bawah
1/2 bgn bawah
1 jari dibawah
1 jari dibawah
ada nadi tp napas
sternum
sternum
garis
garis
tidak ada: lakukan
inter-
mammary
inter-
tindakan
mammary
bantu
napas, jika nadi < Metode
Pangkal telapak
1
pangkal
Kompressi
tangan dan tgn
telapak tangan
2 atau 3 jari
2
jari
atau
teknik ibu jari
± 1/3 tebal dada
± 1/3 tebal dada
± 1/3 tebal dada
± 1/3 tebal dada
± 100/min
± 100/min
± 100/min
± 120/min
Rasio Kompressi
15 : 2 (2rescuer)
15 : 2 (2rescuer)
15 : 2 (2rescuer)
ventilation
30:2 ( 1 rescuer)
30:2 ( 1 rescuer)
30:2 ( 1 rescuer)
kompressi
Frekuensi
perfusi
dan jelek
kompresssi dada
satu diatasnya
Kedalaman
50x/mnt
kompressi
3:1
:
HEAD AND NECK TRAUMA Examination and Management
Definition : To do first aid and secondary survey on patients with head and neck trauma Aim : After this study, each student are expected to : 1.1 Remove patient’s helmet in head and neck trauma cases, in a safe way and know how to place a servical collar 1.2 Do physical examination on head and neckMenghitung Glasgow Coma Scale (GCS) 1.3. Identify normal head scan 1.1 Manage primary survey in a brief time 1.2 Count and estimate the GCS on the patient 1.3 Do secondary survey 1.4 Identify epidural hematoma on CT scan 1.1 1.2 1.3 1.4
Estimate and count the derivation of GCS Manage severe head trauma Demonstrate secondary survey on head and neck Identify the possibility to consult to a neurosurgeon
Learning media and tools : 1. Skill guide books of emergency and traumatology system 2. “Mr. Hurt” manequin doll 3. Helmet 4. Cervical collar 5. Print out, of normal head scan, epidural, subdural dan contusion and intracranial hematoma Learning method: Scenario by instructor, demonstrated by students Activity 1. Introduction
Time 5 minute
Description 1. Scenario 2. Brief explanation about the scenario, student’s role and time allocation
2. Remove helme dan put on the collar
10 minute
1.
3. Managemet of severe head trauma
5 minute
4. Management of head trauma that seems worsening
10 minute
5. “Mr. Hurt: 6. CT scan
10 minute 5 minute
1. Estimate GCS 2. Identify signs of high intracranial pressure 1. Re-do primary survey 2. Estimate GCS Differentiate the management between severe head trauma and worsening head trama 1. Do secondary survey head and neck 1. Explanation about CT scan
One student stands as the patient, others as rescuers 2. Estimate GCS
GLASGOW COMA SCALE Variabel Eye (E) response Spontaneous To voices To pain None Motoric (M) response Do as told Localize the pain Normal flexion (pull away from pain ) Abnormal flexion (decortification) Abnormal extension None Verbal (V) response Oriented Confused speaking Unarranged words Unclear voice None Count GCS = (M + M + V ), Best score = 15, worse score = 3
Nilai 4 3 2 1 6 5 4 3 2 1 5 4 3 2 1
LEARNING GUIDE HEAD AND NECK TRAUMA
STEPS / Activities Early preparation Check for all tools I. PRIMARY SURVEY A. ABCDE B. Immobilization and stabilized cervical C. Brief neurological examination 1. Pupil light reflex 2. AVPU or GCS score II. Secondary survey and Management A. Inspect the head carefully, include face 1. Lacertion 2. Any CSS liquid from nose and ear B. Palpate head thoroughly, include the face 1. Fractures 2. Lacerations and fractures C. Inspeect all laserations on head skin 1. Brain tissure 2. Skull depressed fracture 3. Dirt / corpus alienum 4. CSS leakage D. Minineurologis examination and scoring GCS 1. Eye response 2. Motoric response 3. Verbal response 4. Pupil light reflex E. Cervical vertebrae examination 1. Palpate any pain and place on the semirigid collar if necessary 2. Examine cervical vertebrae X-rays on lateral projection if necessary
Description
F. Judge the width of wound Re-examine continously and observe any deteriorate signs : 1. Frequency 2. Parameters 3. Re-do ABCD III. HOW TO REMOVE HELMET Patient who use helmet and needs breathing aid management has to be sured that its head and neck are in neutral positions.2 helpers are needed to remove helmet. One student lie down as the patient with the helmet on. Other students act as helpers doing as follows : 1. One person stabilize the head and neck’s patient, with putting his hand on the helmet, its fingers on the patinet’s mandibula while examining and make sure that the airway is still open. This position prevent the helmet to slip away 2. Second helper cuts the helmet’s belt on release it from the D-ring 3. Second helper stands on the right or the left side of patient with one hand on the mandibule angulus, mother finger in one side and other fingers on the other side. While the other hand makes a pressure under the head on occipital regio. This way 2 helpers are immobilizing the head and neck 4. First helper push the helmet to the lateral side to release both ears from helmet and then remove the helmet slowy. If helmet has face mask, this mask should be removed first. If the helmet has a very complete mask, the nose could be wedged in and complicate the helmet removal. To set free the nose, helmetshould be hold back and upward across the nose 5. As this happens, second helper should maintain imobilizing position to prevent the patients neck from moving 6. After the helmet is removed, straight immobilization mannual starts from top, head and neck are saved from moving during the procedure 7. If by removing the helmet causes pain and parestesia, then it should be removed by gips scissors.If there is any signs of cervical trauma on Xrays, helmet should be removed by gips scissors. During the procedure, head and neck are maintained immobilized and stabilized, while the helmet is cut from the coronal passing through both ears. External layer of the helmet can be easily remove, the internal layer which made of spyrofoam can be cutted and removed from front. Head and neck in neutral position 8. After the removal, immeadiately place the cervical collar followed by primary surveySetelah helm dapat dilepaskan segera pasang cervical collar.
STABILISATION AND TRANSPORTATION Definition : 1. Prepare safe transportation for patients 2. Give first aid and secondary survey on patients with medulla spinalis trauma Aim: Students are expected to : 1. Demonstrate the techniques of examination to check patients with medulla spinalis trauma 2. Discuss the principals of immobilization and log roll on patients with neck trauma/medulla spinalis trauma and indications to remove protections aid. 3. Do neurological examination and estimate the level of trauma 4. Decide whether transferring to other hospital is needed and how to immobilize patient correctly when transfering.
5. Limitize patients risk to worsen with doing the right mobilizaiton 6. Prepare safe transportation for the patient Learning media and tools : 1. Skill guide book of emergency and traumatology system 2. Video and slide 3. Patient models (students may role as patient) 4. Semirigid cervical collar 5. Desk or stretcher or bed. 6. Folded towel to support . 7. Blanket 8. Bandage 9. Scoop stretcher 10. Long spine board. 11. Vacuum mattress 12. KED (Kendrick Extrication Device) Learning method : Scenario by the instructor, demonstrated by students Activity description : Activity 1. Introduction
Time 5 minue
1. 2.
2. Scenario I
10 minute
1.
3. Scenario II
10 minute
2. 1.
4. Scenario III
10 minute
1.
5. Scenario IV
10 mintue
1.
Description Tools introduction Primary and secondary survey scenario judgement Give help on spot using long spine board and cervical collar only Log Roll Help patient on spot, using cervical collar, scoop stretcher, and long spine board Evacuate patient using vacuum matras Extrict patient with KED
LEARNING GUIDE STABILIZATION AND TRANSPORTATION SKILLS STEPS/Activity Preparation Check list all tools I. PRIMARY SURVEY RESUSCITATION – SPINAL CHORD TRAUMA JUDGEMENT II. Airway Judge the airway while positioning the cervical spine. Open and clean up the airway, do the jaw thrust, place oropharynx tube, and do intubation if necessary A. Breathing Judge and give adequate oxygen, and ventilation if necessary B. Circulation a. Judge the circulation by checking pulsations, blood pressure and perifer perfusion. If hypotension occurs, it has to be differiated by hypovolemic shock ( decreased blood pressure, increased heart rate and cold extremities) C. Solution to correct hypovolemia
Descriptin
D. Disability- brief neuorological examination a. Judge the conciousness and pupil. b. Decide whether to use AVPU or GCS to judge patient’s conciousness c. Identify paralysis or paresis d.
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SECONDARY JUDGEMENT
SURVEY
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NEUROLOGICAL
A. AMPLE History Taking History and mechanism of trauma Medical record B. Identify and write down any medication given to the patient before, during, and after treatment C. Re-examine conciousness and D. Re-examine GCS score E. Examine spinal chord 1. Palpation Palpate the whole posterior spinal chord by doing log roll carefully Examine :: a. Any deformities/ swelling b. Crepity c. Increasing pain when palpated d. Contusion and laceration. 2. Pain, paralyze and paresthesia a. Yes/No b. Location c. Neurological level
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3. Sensation Pinprick tes to estimate sensation, is performed in all dermatoms and write down the most caudal dermatom which gives sensation 4. Motoric Sensation III.
PRINCIPALS IN IMMOBILIZING THE SPINAL CHORD AND LOG ROLL A. Log roll: 1. One person hold the head and neck to maintain the immobilization in one line. 2. One person stand by on the side to hold the patient’s body ( pelvis and hips ) 3. Another person hold the pelvis and limb. With the command from the person on the head, move the patient in an angle position carefully 4. The 4th person check on the spine chord and place the long spine board B. Placing the ong spine board 1. Maintain the head and neck in one line when the second person holds the patient on its shoulders and wrists. Third person holds the patient;s hand ad hips with one hand, the other hand holds the bandage that cords patient’s ankles pergelangan kaki. 2. With the commandments from the rescuers whose holding the patient’s head and neck, perfrorm log roll as a unit towards the other persons/rescuer whose beside the patient. It only needs a minimal rotation to place the spine board underneath the patient. Maintain the
one line principal of the head and neck in this procedure 3. Spine board is placed underneath the patient, afterwards perform log roll towards the spine board. 4. Long spine board with its rope/band is inserted to the thoracal regio, above crista iliaca, thighs and ankles. Band or bandage is used to fixate the head and neck to attach to the spine board 5. Perform inline immobilisation of the head and neck manualy, then place the semirigid collar 6. Straighten the arms and place it beside the patients body 7. Straighten the limbs carefully and place it in one line with the spine chord.Both ankles are tied together with a bandage 8. Place a pillow/support under the patient’s neck to avoid any overextended movements and to comfort the patient 9. Pillow, blanket or any other supports is place on the right and left side of the patient’s neck, while the head is tied, attached to the long board 10. Place a bandage above the cervical collar to guarantee there is no movement of the head and neck. C. Scoop Stretcher 1. Prepare scoop stretcher 2. Open the lock to divide in two 3. Arrange the scoop to match patient’s height 4. Place scoop under the patient 5.Scoop stretcher is not for immobilizing the patient. 6.Scoop stretcher not a transport device, do not lift scoop on the edges because it could fold on the middle and will lose the straightnes of the vertebrae
Splint/spalk Installation ( Immobilization of the extremities ) and Musculoskeletal Management. Definition
: To give first aid to musculoskeletal trauma patients
Aim of study : After this study, students are expected to be able : 1. To do quick examination on patients with musculoskeletal trauma 2. To recognise life and limb threatening problems in musculoskeletal trauma 3. To install a spalk/splint correctly. Learning media and tools : 1. Skill guide book 2. Living models ( students can role as patients ) 3. Leg traction splint 4. Air splint 5. Spalk 6. Gloves Learning method : Scenario by the instructor, demonstrated by students
LEARNING GUIDE MUSKULOSKELETAL SKILL EXTREMITIES IMMOBILISATION PRINCIPLES Check the ABCDE and treat conditions which are life threatening first. 1. Loose all clothes thoroughly, including on the extremities 2. Loose watches, rings, necklace and all things that might clamp 3. Check neurovasculars before setting the spalk/splint. Check external bleeding pulsation that has to be stopped, and check also the sensoric and motoric function of the extremities. 4. If there are wounds, close it with sterilized bandage 5. Choose kinds and sizes of spalk that matches the traumatized extremities 6. The spalk setting should also cover joints below and above the traumatized extremities. 7. Place a pillow bag above the bone protrusion 8. Support the extremities with spalk/splint in a position where there is a distal pulsation. If there is not any distal pulsation, try to straighten the extremitis. Make a traction carefully and maintain it until splint is settled. 9. Splint/spalks are settled onto extremities that are straight, if not, try to straighten it.
MASS DISASTER MANAGEMENT Definition
: To carry out triage principles in whenever patients outnumbered rescuers
Aim of study : After this study, students are expected to : 1. Define triage 2. Understood and able to explain principles and factors that effects and includes in the proses of triage
Learning media and tools : 1. Slides of guidlines to do triage scenario 2. Triage scenario booklet
Learning methods : Role’s play
Activity description : Activity 1. Introduction
Time 10 minutes
Description 1. Triage scenario slide presentation 2. Brief explanation about the scenario, student’s roles and time allocation
2. Role play (1)
10 minutes
1. All students have put priorities on which patients they will handle 2. Each student give their suggestions on why they put their priorities on specific patients
10 minutes Role play (2) Fire followed by explosion in settlements
1. All students have put priorities on which patient they will handle 2. Each student give their suggestions on why they put their priorities on specific patients
Role play (3) Car crash
10 minutes
3. All students have put priorities on which patient they will handle 1. Each student give their suggestions on why they put their priorities on specific patients
10 minutes
1. All students have to determine which criteria is used to identify patients and what priorities should be done 2. All students propose the clues and signs that were given by the patient which could help in the triage procces 3. All students propose what can be done before and after the paramedics and ambulance arrives. 4. All students should propose which victims has to go first to the hospital and which type of hospital should the victim goes to.
Role play (4) A football collapsed
stadium
