Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO or the International Committee of the Red Cross logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: "This translation was not created by the World Health Organization (WHO) or the International Committee of the Red Cross (ICRC). WHO and ICRC are not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition". Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization (/ mediation/rules).Basic emergency care: approach to the acutely ill and injured. Geneva: World Health Organization and the International Committee of the Red Cross 2018. Licence: CC BY-NC-SA 3.0 IGO.# INTRODUCTION Overview
Health emergencies happen every day, everywhere. They affect adults and children and include injuries and infections, heart attacks and strokes, acute complications of pregnancy and of chronic disease. While specialised care may never be available at all times in all places, a systematic approach to emergency conditions saves lives. The Disease Control Priorities Project estimates that nearly half of deaths and a third of disabilities in low-and middle-income countries result from conditions that could be addressed by emergency care.
The World Health Organization (WHO), in collaboration with the International Committee of the Red Cross (ICRC) and the International Federation for Emergency Medicine (IFEM), has developed the Basic Emergency Care (BEC) course for frontline providers who manage acute life-threatening conditions with limited resources. These may include students, nurses, prehospital technicians, clinical officers and doctors who are working in field (pre-hospital) or hospital settings. These complaints may represent the early stage of a critical illness requiring rapid intervention even when the person appears relatively well. The complete assessment and management of these conditions is beyond the scope of this course, but they should always trigger transport to, or consultation with, an advanced provider.

# INTRO
In addition, there are certain infectious exposures that require time-sensitive prophylaxis (preventive treatment) whose effectiveness may be reduced by delays. These include: needle stick injury in a health care worker; unprotected sexual encounter, including in the context of assault; exposure to the saliva of an animal with suspected rabies. These exposures should be evaluated as soon as possible at a center capable of providing timely prophylaxis.

# Special considerations for fever
Fever is a very common complaint and may be a sign of a life-threatening condition, or simply a sign of a mild condition that will resolve itself. Because fever does not reliably indicate an emergency condition, it is not addressed in a separate module here, but is covered in each of the core modules. When associated with abnormal ABCDE findings (see "Approach to the emergency patient" section), or any of the acute presentations above (trauma, difficulty in breathing, shock, altered mental status), fever can be an important clue to severe illness and should be taken very seriously. There are many more causes of fever than can be covered in this basic course, but most causes of fever requiring emergency treatment are associated with one of the four key acute presentations.
There is no single approach to fever that is right for all emergencies, but there are some general principles that can help in the assessment and management of emergency patients.
- Always consider infection in a person with fever (e.g. malaria, meningitis, pneumonia).
- Never use the absence of fever to rule out infection. People with overwhelming infection or immune system problems may not be able to produce a fever and may have a normal or low body temperature.
- Fever with abnormal vital signs and/or any of the four key acute conditions listed above will likely require early antibiotic (and/or anti-malarial) treatment.
- Always consider whether local screening protocols for infectious disease outbreaks (e.g. for haemorrhagic fevers) require further action (e.g. special reporting or management) in a person with fever.

# Obstetric delivery and neonatal resuscitation
Management of obstetric delivery and neonatal resuscitation are critical topics covered elsewhere in existing WHO materials and are not covered in this course. See the WHO Maternal, Newborn, Child and Adolescent Health department website ( child_adolescent/documents/en/) for training materials on these topics.

# Expected participant background knowledge
This course assumes a basic knowledge in the following areas:
Use of personal protective equipment Basic human anatomy

# Basic history taking
Basic physical examination skills, including taking vital signs, chest auscultation and abdominal assessment

# Use of a glucometer
Set up of an intravenous (IV) infusion

# Safe intramuscular injection
Cardiopulmonary resuscitation (CPR)

# Cardiopulmonary resuscitation (CPR)
The decision about whether or not CPR is appropriate for a specific patient depends on many factors, including understanding of the cause of the condition, knowledge of available resources, and awareness of relevant institutional protocols and practices. There are many situations where it may be appropriate to initiate and then terminate CPR after a certain interval, and others where it may not be appropriate to initiate CPR. While this course addresses several aspects of resuscitation, it does not cover general CPR protocols, as they may vary greatly by setting. Course facilitators should direct participants to the appropriate source for relevant CPR protocols.

# Medication
The medications discussed in this course are widely available and appropriate for use by the frontline providers for whom the course is designed. They can be used in pre-hospital or facilitybased settings and are important early treatments for emergency conditions. The included medications provide a foundation for initial emergency care, but almost every condition discussed in this workbook will require treatments beyond those listed. Many important emergency treatments used by advanced providers are not included in this course.

# Handover/transfer
This course is designed to help providers identify and provide initial management for acute, life-threatening conditions. Most acutely ill patients will require care beyond this initial stage. This may be ongoing care delivered by the same provider, but more often will require handover to a more advanced provider or facility. This process of deciding the appropriate disposition -or next step of care -for the acutely ill patient is a vital part of emergency care.
Choosing an appropriate disposition involves assessing severity; estimating how rapidly the condition may progress; considering whether transfer for a specific intervention (e.g. surgery, blood transfusion) is needed; and identifying any specific risks based on a suspected or known diagnosis (e.g. risk of recurrent seizure/convulsion, or worsening airway blockage). The special disposition considerations for each key acute presentation and its associated diagnoses are covered in the modules.

# INTRODUCTION 6 6
The secondary survey is a complete physical examination based on the specific condition. The essential relevant components of the secondary survey are listed in the modules for each of the four key presentations. Further details are covered in the Skills section.

# INTRODUCTION 8
Case scenarios. All participants must successfully lead and manage a case scenario to pass the course. These scenarios give participants an opportunity to practise an integrated approach to management in small groups of 3-4 participants. Facilitators will discuss with the group how to approach the case scenarios using the ABCDE approach. In the later modules, each participant will be assessed on the ability to lead and manage a case scenario. Leading a case scenario includes identifying critical aspects of assessment and management, as well as presenting a handover summary (see the Handover section in Skills). Facilitators will complete the checklist below to assess the participant leading the case. Participants who are unsuccessful in identifying and managing the critical conditions in the scenario will be given a second case in the same or a subsequent session. Assessments are based on a standardized guide and reported on the form below.
Module 1: The ABCDE and SAMPLE history approach

# OBJECTIVES
On completing this module you should be able to:
1. list the hazards that must be considered when approaching an ill or injured person;
2. list the elements to approaching an ill or injured person safely;
3. list the components of the systematic ABCDE approach to emergency patients;
4. assess an airway;
5. explain when to use airway devices;
6. explain when advanced airway management is needed; 7. assess breathing; 

# OVERVIEW
Approaching every patient in a systematic way ensures that life-threatening conditions are recognized promptly and that the most critical interventions are done first. In a stable patient, the initial ABCDE approach may only take seconds to a few minutes. The ABCDE should be followed by a rapid history using the SAMPLE approach (Signs and Symptoms, Allergies, Medications, Past medical history, Last oral intake and Events). The SAMPLE history categories are described in general below, and essential questions for a specific presentation are listed in the relevant module. Using the standard SAMPLE and ABCDE approach together ensures that different providers can easily communicate about acutely ill patients.
The goal of the ABCDE approach is to rapidly identify life-threatening conditions; ensure the airway stays open; and ensure that breathing and circulation are adequate to deliver oxygen to the body.
The goal of the SAMPLE approach is to rapidly gather history critical to the management of the acutely ill patient. This module will address:

# Safety considerations

# Elements of the ABCDE approach
In-depth: acute life-threatening conditions (signs, symptoms and management) Paediatric considerations in the ABCDE approach

# Elements of the SAMPLE history

# Disposition considerations

# SAFETY CONSIDERATIONS
A critical part of the approach to any ill or injured patient is keeping providers and others safe. An ill or injured provider will be unable to help anyone, and instead becomes an extra patient for other responders to treat. Safety consideration involves checking for: scene hazards. Is there a fire, electrical wire or chemical spill that could injure providers or bystanders? At a road traffic crash, is the scene closed to oncoming traffic? If a building has collapsed, is it safe to enter? At the scene of an explosion, always consider the possibility of further explosions. Remember that delayed building collapse may follow explosions, fires and earthquakes.
violence. Is there a chance that providers may be harmed by the patient or by others? For patients who are aggressive or agitated, request help as needed from security personnel or police before beginning your assessment. infectious disease risk. Is there a possibility for disease exposure (such as flu or haemorrhagic fever)?

# USE PERSONAL PROTECTIVE EQUIPMENT
You may not know the cause of illness or injury when you first approach a patient, and without appropriate personal protective equipment (PPE), may expose yourself to diseases, chemicals or poisons. You must use appropriate PPE every time you approach a patient. Always protect yourself from any exposure to bodily fluids. This will almost always require gloves and eye protection, and may require a gown and mask. Some circumstances, such as suspected or confirmed haemorrhagic fever outbreaks, require specific protective practices. Always be sure that you are up-to-date on current local recommendations.

# CLEANING AND DECONTAMINATION
Infectious disease exposure is a significant risk. Use PPE and wash your hands before and after every patient contact. At the scene, hand washing may not be immediately possible; carry an alcohol gel cleanser if possible. Between patients, clean and disinfect all facility and vehicle surfaces and all reusable equipment. Decontamination may be required after exposure to pesticides or other chemicals (dry or wet) and, depending on the chemical, may include washing or brushing to remove the substance. Not all chemicals can be safely washed away, and some must be removed in specific ways to avoid further injury. You must wear appropriate PPE for this. Refer to local decontamination protocols for people and equipment.

# ASK FOR MORE HELP IF NEEDED
If multiple people are injured or ill, call for help or send someone to call.
If advanced care is needed, begin making arrangements as early as possible for consultations or transfers.
Know the relevant local agencies to contact for suspected outbreaks or hazardous exposures, such as chemical spills or radiation. There is often support and guidance available for containment and decontamination. 

# Workbook question 1: Safety

# ELEMENTS OF THE ABCDE APPROACH

# The ABCDE approach
The ABCDE approach provides a framework for the systematic and organized evaluation of acutely ill patients in order to rapidly identify and intervene for life-threatening conditions:
A -Airway: check for and correct any obstruction to movement of air into the lungs B -Breathing: ensure adequate movement of air into the lungs C -Circulation: evaluate whether there is adequate perfusion to deliver oxygen to the tissues; check for signs of life-threatening bleeding D -Disability: assess and protect brain and spine functions E -Exposure: identify all injuries and any environmental threats and avoid hypothermia This stepwise approach is designed to ensure that life-threatening conditions can be identified and treated early, in order of priority. If a problem is discovered in any of these steps, it must be addressed immediately before moving on to the next step. The ABCDE approach should be performed in the first 5 minutes and repeated whenever a patient's condition changes or worsens. If the patient cannot talk normally:

# THE ABCDE ASSESSMENT AND MANAGEMENT
- look to see if the chest wall is moving and listen to see if there is air movement from the mouth or nose. - listen for abnormal sounds (such as stridor, grunting, or snoring) or a hoarse or raspy voice that indicates a partially obstructed airway.
-Stridor plus swelling and/or hives suggest a severe allergic reaction (anaphylaxis).
- Look and listen for fluid (such as blood, vomit) in the airway. - Look for foreign body or abnormal swelling around the airway, and altered mental status. - Check if the patient is able to swallow saliva or is drooling.
- If the patient is unconscious and not breathing normally and:
- If breathing is adequate, move onto "Circulation".

# Circulation

# C
- Look and feel for signs of poor perfusion (cool, moist extremities, delayed capillary refill greater than 3 seconds, low blood pressure, tachypnoea, tachycardia, absent pulses). - Look for both external AND internal bleeding, including bleeding: -into chest; -into abdomen; -from stomach or intestine; -from pelvic or femur fracture; -from wounds.
- Look for hypotension, distended neck veins and muffled heart sounds that might indicate pericardial tamponade.
- For cardiopulmonary arrest, follow relevant CPR protocols. - If signs of poor perfusion, give IV fluids and oxygen  and: -For external bleeding, apply direct pressure or use other technique to control.  -If internal bleeding or pericardial tamponade are suspected, refer rapidly to a centre with surgical capabilities.
If cause unknown, remember the possibility of trauma: Bind pelvic fractures and splint femur fractures, or any fracture with compromised blood flow. 
If circulation is adequate, move onto "Disability".

# ASSESSMENT IMMEDIATE MANAGEMENT
Disability D
- Assess level of consciousness with the AVPU scale (Alert, Voice, Pain, Unresponsive) or in trauma cases, the Glasgow Coma Scale (GCS).  - Always check glucose level in the confused or unconscious patient.
- Check for pupil size, whether the pupils are equal, and if pupils are reactive to light.
- Check movement and sensation in all four limbs. - Look for abnormal repetitive movements or shaking on one or both sides of the body (seizure/convulsion).
- If altered mental status and no evidence of trauma, place in recovery position. [ The airway can become obstructed by secretions, vomit or foreign bodies.
- Remove the foreign body if possible and suction fluid. Be careful not to push a foreign body further into the airway. Do not try to remove a foreign body unless clearly visible. - Use age-appropriate chest thrusts/abdominal thrusts/back blows if the airway is completely obstructed.  - The tongue may obstruct the airway in patients with a decreased level of consciousness.
-Open the airway using a head-tilt and chinlift manoeuvre, or use jaw thrust (if there is concern for trauma); and place an oral or nasopharyngeal airway as needed.  -These patients may also not be able to protect their airway and need to be watched for vomiting and aspiration.
- Plan for rapid handover/transfer to advanced provider capable of advanced airway management if the obstruction cannot be removed.

# Obstruction due to burns
- Burns to head and neck - Burned nasal hairs or soot around the nose or mouth - Abnormal sounds from the airway (such as stridor) - Change in voice - Poor chest rise Burns can cause airway swelling due to inhalational injuries.
- Give oxygen to ALL patients with suspected airway burn even if they do not show signs of hypoxia.  - Open the airway using appropriate manoeuvre and place an oral or nasopharyngeal airway as needed.
 - Maintain cervical spine immobilization if there is evidence of trauma.  - The airway can swell and close off very quickly in burn patients. Plan for rapid handover/transfer to a provider capable of advanced airway management.

# CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT
Obstruction due to severe allergic reaction (anaphylaxis)
- Mouth, lip, and tongue swelling - Difficulty breathing with stridor and/or wheezing - Rash or hives (patches of pale or red, itchy, warm, swollen skin) - Tachycardia and hypotension - Abnormal sounds from the airway (such as stridor, snoring, gurgling) - Poor chest rise Severe allergic reactions can cause swelling of the airway that can lead to obstruction.
- Give intramuscular adrenaline for airway obstruction, severe wheezing or shock.  -Adrenaline can wear off in minutes so be prepared to give additional doses.
- Place an IV and give IV fluids. 
- Reposition airway as needed (sit patient upright if no trauma) and give oxygen.  - If severe or not improving, prepare for rapid handover/transfer for advanced airway management.

# Obstruction due to trauma
- Neck haematoma or injuries to head and neck - Abnormal sounds from the airway (such as stridor, snoring, gurgling) - Change in voice - Poor chest rise Airway obstruction may result from injuries to the head or neck. Blood, bone or damaged tissue may block the airway. Penetrating wounds to the neck may also cause obstruction due to swelling or expanding haematoma.
- Suction to remove any blood that might block the airway. - Open the airway using jaw thrust only (do not use head-tilt/chin-lift); and place an oral airway as needed (do not use nasopharyngeal airways if there is facial trauma).  - Plan for rapid handover/transfer to advanced provider capable of advanced airway management or surgical intervention.
For any abnormal airway sounds, re-assess airway frequently as partial obstruction may worsen rapidly and block airway. Any pneumothorax can become a tension pneumothorax. Air in the cavity between the lungs and the chest wall can collapse the lung (simple pneumothorax). Building pressure (tension) from a large pneumothorax can displace and block flow from the main vessels back to the heart, causing shock (tension pneumothorax).
- If tension pneumothorax is suspected, perform emergency needle decompression.  - Give oxygen.  - Give IV fluids.  - Arrange for rapid handover/transfer to an advanced provider capable of placing a chest tube.

# Suspected opioid overdose
- Slow respiratory rate - Hypoxia - Very small pupils Opioid medications (such as morphine, pethidine, and heroin) can decrease the body's drive to breathe.
- Give naloxone to reverse the effects of opioids.
 -Monitor closely as naloxone will wear off and additional doses may be needed. 

# Seizure/ convulsion
Signs and symptoms of active seizure:
- Repetitive movements, gaze fixed to one side or alternating rhythmically and not responsive.
Sign and symptoms of recent seizure:
- The goal of managing snake bites is to limit the spread of the venom and the effects of venom on the body.
- Immobilize the extremity. 
- Take a picture of the snake when possible and send with the patient (for example, with the patient's mobile phone). - Give IV fluids if evidence of shock.  - These patients may have delayed shock or airway problems. Monitor closely and plan early for rapid handover/transfer.

# Vital signs should be checked at the end of the ABCDE
A full set of vital signs (blood pressure, heart rate, respiratory rate, and oxygen saturation if available) should be performed after the ABCDE approach. Do not delay ABCDE interventions for vital signs.

# ABCDE SHOULD BE REPEATED FREQUENTLY
The ABCDE approach is designed to quickly identify reversible life-threatening conditions. Ideally, the ABCDE approach should be repeated at least every 15 minutes or with any change in condition.

# Workbook question 2: ABCDE approach
Using the workbook section above, list the management for airway blocked by a foreign body. 

# PAEDIATRIC ABCDE CONSIDERATIONS
While the ABCDE approach is used in both adults and children, there are some aspects of assessing and managing children that are different from adults. The "Paediatric considerations" sections throughout the workbook highlight these differences.

# Paediatric considerations

# Pediatric airway conditions

# A
Excessive drooling, stridor, airway swelling and unwillingness to move the neck are all high-risk signs in children. Look carefully in the airway for foreign bodies, burns or obstruction. Allow the child to remain in a position of comfort. Position airway as needed below.

# Compared to adults, children have: So you must do this:
Bigger tongues.
- Place the child in the "sniffing" position (modified head-tilt, chin-lift -like the slight upward and forward tilt of the head when sniffing a flower).
Shorter necks with airways that are softer and more easily blocked.
- Avoid over-extending or flexing the neck.
A larger head compared to the rest of the body.
- Watch closely for airway obstruction.

# Pediatric disability conditions

# D
- LOW BLOOD GLUCOSE is a very common cause of altered mental status in sick children.
-If possible, check blood glucose in children with altered mental status. -When it is not possible to check the blood glucose level, administer glucose.
- Always check for seizure/convulsions.
- It is sometimes difficult to determine if infants are acting normally. Always ask the person caring for the child.

# Pediatric exposure conditions

# E
- INFANTS AND CHILDREN HAVE DIFFICULTY MAINTAINING TEMPERATURE and can very quickly become hypothermic (low body temperature) or hyperthermic (high body temperature).
-Remove wet clothing and dry skin thoroughly. Place infants skin-to-skin when possible.
-For hypothermia, be sure to cover infants' heads (but do not obstruct face).
-For hyperthermia, unbundle tightly wrapped infants.

# PAEDIATRIC DANGER SIGNS IN ABCDE
In addition to performing a thorough ABCDE approach, all paediatric patients should be evaluated for the presence of danger signs. Children with danger signs need URGENT attention and referral/ handover to a provider able to provide advanced paediatric care.

# Paediatric danger signs include:
- Signs of airway obstruction (stridor or drooling/unable to swallow saliva) - Increased breathing effort (fast breathing, nasal flaring, grunting, chest indrawing or retractions)
- Cyanosis (blue colour of the skin, especially at the lips and fingertips) - Altered mental status (including lethargy or unusual sleepiness, confusion, disorientation)
- Moves only when stimulated or no movement at all (AVPU other than "A") 

# Elements of the SAMPLE history
The SAMPLE approach is a standard way of gathering the key history related to an illness or injury. Sources of information include: the ill/injured person, family members, friends, bystanders, or prior providers. SAMPLE stands for:

# S: Signs and symptoms
The patient/family's report of signs and symptoms is essential to assessment and management.

# A: Allergies
It is important to be aware of medication allergies so that treatments do not cause harm.
Allergies may also suggest anaphylaxis as the cause of acute symptoms.

# M: Medications
Obtain a full list of medications that the person currently takes and ask about recent medication or dose changes. These may affect treatment decisions and are important to understanding the person's chronic conditions.

# P: Past medical history
Knowing prior medical conditions may help in understanding the current illness and may change management choices. 

# Workbook question 4: SAMPLE history

# DISPOSITION CONSIDERATIONS
If you have to intervene in any of the ABCDE categories, immediately plan for handover/ transfer to a higher level of care.
Once you have completed the ABCDE approach, take a SAMPLE history and complete a physical examination based on the specific condition (secondary examination).
A good handover summary  to the next provider requires:
-brief identification of the patient;
-relevant elements of the SAMPLE history;
-physical examination findings;
-record of interventions given;
-plans for care needed next and other concerns you may have. 

# Location of brachial pulse in a child

# FACILITATOR-LED CASE SCENARIOS
These case scenarios will be discussed in small groups. These cases in this module will NOT be assessed and are for practice only. It is important that you practise with these scenarios since you will be assessed on how you lead a case in later modules. To complete a case scenario, the group must identify the critical findings and management needed and formulate a 1-2 line handover summary that includes assessment findings and interventions. You should use the Quick Cards to manage these scenarios.

# CASE #1: ADULT ABCDE
A 70-year-old man is brought in by taxi. The driver states the patient lost consciousness while talking with his daughter. There was no trauma, but the daughter poured water on him to try to wake him up. Initially he was confused and vomiting. Now he is unconscious with a respiratory rate of 3 breaths per minute. 

# CASE #2: PAEDIATRIC ABCDE
A mother brings in her 2-year-old son for difficulty in breathing. She reports that he has had a fever for 3 days and has had worsening difficulty in breathing. He has been coughing a lot and today will not eat or drink.
What is your initial approach to this patient?
2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator for specific findings when you look, listen and feel; use the Quick Card for reference as needed. 

# MULTIPLE CHOICE QUESTIONS
Answer the questions below. Questions and answers will be discussed within the session. 

# Overview

# GENERAL PRINCIPLES OF TRAUMA CARE
Early priorities for an injured person include managing airway and breathing emergencies, controlling bleeding, treating shock and immobilizing the spine if needed.

# The goal of INITIAL ASSESSMENT is to identify life-threatening injuries.
The goal of ACUTE MANAGEMENT is to ensure oxygenation and perfusion, to control pain and to plan ongoing care. This module will guide you through the: 

# APPROACH TO TRAUMA
Approach to the trauma patient consists of three phases: Trauma primary survey: The ABCDE approach for injured patients SAMPLE history: Signs and Symptoms, Allergies, Medications, Past medical history, Last oral intake, and Events surrounding the injury Trauma secondary survey: A complete head-to-toe examination to look for injuries not identified by the primary survey During primary and secondary surveys, if life-threatening problems are identified, STOP AND MANAGE them.

# ABCDE: TRAUMA PRIMARY SURVEY
The ABCDE approach in injured patients is often also called the trauma primary survey. As for all patients this should be conducted within the first 5 minutes and repeated whenever the patient's condition worsens. This trauma-specific ABCDE approach includes the initial assessment and management for all immediately life-threatening injuries. Always suspect head and spine injury in a trauma patient with altered mental status.

# ASSESSMENT IMMEDIATE MANAGEMENT

# Airway with cervical spine immobilization
A Haemothorax (blood in the space between the lungs and the chest wall) can present with decreased or absent breath sounds and dull sounds with percussion on the affected side.
- Give oxygen and IV fluids.
- Plan for rapid handover/transfer to a centre with surgical capacity. and explosion or fire in an enclosed space.
Use the SAMPLE approach to obtain a history. Remember that you may be able to obtain information from bystanders, family, police, fire service or other health-care workers.

# If the history identifies a primary survey condition, STOP AND RETURN IMMEDIATELY TO
PRIMARY SURVEY to manage it.

# S: SIGNS AND SYMPTOMS
Is there a history of hoarse or raspy voice, or other voice changes?
Changes in voice in the setting of injury to the head, neck or with burns may suggest that the airway is swelling and that it may obstruct.

# Is there any difficulty in breathing?
Problems with breathing may develop over time and might not be present in the initial primary survey. Difficulty in breathing may suggest that the person has an injury to the lungs, ribs, muscles, chest wall or spine.

# Is there reported bleeding?
It is usually quite difficult for patients to estimate the volume of blood loss, but it may be helpful to know how long there has been bleeding, how many bandages have been soaked and if the bleeding is getting lighter or heavier.

# Is there confusion or unusual sleepiness?
Confusion after injury may be a sign of head injury, lack of oxygen or shock (with decreased blood flow to the brain). A head injury can cause bleeding or increased pressure on the brain leading to confusion, lethargy (increased sleepiness) and coma.

# Is there pain? Where is the pain, what does it feel like and how severe is it?
Pain is a sign of underlying injury. Headache may suggest that the person has an injury to the skull or the brain. Pain along the spine can suggest an injury that may progress to cause damage to the spinal cord. Pain in the chest or abdomen may suggest damage to the heart, lungs or other organs. Pain in the pelvis or hips may suggest a fracture in the pelvis which can cause serious bleeding and shock. Pain may be the first sign of an internal injury in the chest, abdomen or pelvis.

# Is there nausea or vomiting?
This may indicate an abdominal or head injury.

# Is there reported numbness or weakness?
This may indicate a spinal injury.

# Are there reported vision changes?
Direct trauma to the eye, fractures of bones around the eye, and head injuries can all cause vision changes.

# A: ALLERGIES
Any allergies to medications?

# M: MEDICATIONS

# Currently taking any medications?
Medications that affect blood clotting (e.g. aspirin, warfarin, clopidigrel) can make bleeding more difficult to control and increase the risk of delayed bleeding. Blood pressure medications can make it hard to manage shock. Obtain a full list of medications if possible or ask family members to bring in medications.

# P: PAST MEDICAL HISTORY

# Is the person pregnant?
Pregnancy causes some of the organs to be moved out of their usual position and causes changes in the body that need to be considered when managing trauma. Always ask women of childbearing age about the date of last menstrual period.

# Tetanus status?
A person who has not had a tetanus vaccination within the past 5 years and who has an injury that damages the skin needs a tetanus vaccination.
Are other conditions present that put the person at higher risk for serious injury?

# RISK FACTORS FOR POOR OUTCOMES FROM INJURY:
- -Bleeding disorder or taking blood-thinning medications (medications that prevent clotting)

# L: LAST ORAL INTAKE
When did the person last eat or drink?

# E: EVENTS SURROUNDING INJURY
Certain mechanisms of injury are so high risk that patients should be observed closely, even if they do not appear to be significantly injured.
Was there a fall from 3 metres or more (or twice the height in children)?
Falls are a common cause of injury for both adults and children. A greater distance fallen increases the chance of serious injury. Falls in adults are often associated with older age, alcohol intoxication, or the failure of workplace equipment, including scaffolding and ladders. Children often fall from trees, windows or balconies.

# Was a pedestrian or a cyclist hit by a vehicle?
Adults and children who are hit by a vehicle while walking or using non-motorized forms of transport (such as bicycles) are always at high risk of serious injury. Young children may be less able than adults to report events, even major events like being hit by a vehicle. Always consider the possibility of unwitnessed trauma in young children. Children and adults can sustain multiple injuries when hit by a vehicle -both from direct impact to the body, especially the lower extremities, and from secondary impact if they are thrown against the windscreen or road, which may cause injuries anywhere in the body, including to head, neck, chest or limbs. In a motorcycle (or powered 3-wheeler) crash, was the rider thrown?
Motorcycles collisions often result in a rider being thrown. Ask if the motorcyclist was wearing a helmet and how far away from the vehicle the rider was found. Common injury sites include head (especially when no helmet was worn), spine, chest, abdomen and pelvis (as the rider hits the handlebars), as well as limbs and skin (as the rider hits the road).
Was there a road traffic crash at high speed? Was the person thrown from or trapped inside a vehicle? Did any vehicle occupants die in this crash? With higher-speed crashes, greater force is transmitted to vehicle occupants increasing the risk of serious injury. Vehicle occupants may be injured by impact with the windscreen or steering wheel, or by the forces that result from the sudden stopping of the vehicle. A person thrown from a vehicle is at very high risk of serious injury. If a person was trapped within a vehicle it is important to find out what part of the body was trapped (arm/leg, etc.) and for how long. Consider crush injury in a person who has been trapped. A death at the scene of a road traffic crash suggests that there was significant force exerted on the vehicle and its passengers. All passengers involved in the crash, even if they appear unhurt, are at high risk for serious injury.
In a motor vehicle crash, was the patient wearing a seatbelt? Some types of injuries are more common in patients who were not wearing a seat-belt (being thrown from the vehicle, head strike on the windscreen, chest strike on the steering column). However, in very high-speed crashes, seat belts can also cause certain types of injuries (cervical spine injury, abdominal injury).

# Was a weapon used?
Any time there is a history of a stab or gunshot wound, there may be multiple wounds.
Always check the full body for wounds. After a bullet enters the body it may not follow a direct path and can twist throughout the body. Many internal organs can be injured by a single bullet. A stab wound creates a direct path (it is important to know the length of the blade that was used). Remember that blunt injuries from objects such as sticks and bats can cause damage to internal organs in addition to obvious injuries such as fractures, bruises and lacerations.

# Was there a burn? If so, what type of burn was it?
Burns from fires (flame burns) are the most common. A history of flame burn in an enclosed space can also suggest an inhalation or airway injury. Scald burns (due to hot liquids) are common in children. Electrical injuries often come from high-voltage sources such as overhead electrical wires coming in contact with the body. On the surface, these electrical injuries may look small but they can cause extensive tissue and muscle damage. The electrical current often crosses the body, taking the shortest path from the point of contact with the skin to the ground, often leaving entry and exit burn marks. In the case of chemical burns, information about the specific chemical may be needed to remove it properly.

# For burns, was first aid provided at the scene?
It is important to know if the burning process was stopped, and in the event of a chemical exposure, if decontamination was performed. If the burn is less than 3 hours old and no first aid was provided, the wound will need to be washed with clean water to stop the burning process. If there is a history of chemical exposure, protect yourself from the chemical and ensure that it is properly removed from the skin.
Did the person sustain a crush injury? Is there severe pain or numbness? Is there dark urine? Crush injuries may damage skin, muscle, blood vessels and bone. Damaged muscle can release a muscle by-product (called myoglobin) that can build up and damage the kidneys.
It is important to know how long a body part was crushed. Even a small crushed area can cause the release of a dangerous amount of myoglobin (for example when a limb is caught under falling debris for an extended time). If a person with a crush injury has dark urine, this may be a sign of build-up of myoglobin in the kidneys. Tissue damage and swelling from crush injury can also cause a build-up of pressure (particularly in limb-crush injuries) that can limit blood flow to the muscles and nerves (compartment syndrome).

# Did the person sustain a blast injury?
Blast injuries (from explosions) can involve all systems of the body, especially the hollow organs. Common blast injuries include damage to the lungs, intestines and ears. Patients involved in explosions need to be checked carefully and repeatedly because these injuries are easily missed. Blasts may also be associated with foreign bodies in the skin and eyes, burns or chemical injury, and toxin or radiation exposure.

# Workbook question 3: Approach to trauma
Using the workbook section above, list five questions you would ask when taking a SAMPLE history from a person injured in a road traffic crash: Severe pain or bruising to the abdomen is concerning for organ injury or internal bleeding.
- If you suspect abdominal injuries, give IV fluids. - Do not give the patient anything to eat or drink. - If bowel is visible:
-leave it outside the body; -cover it with sterile gauze soaked in sterile saline; -give antibiotics.
- If there is any concern for abdominal injury, plan for rapid handover/transfer to a unit with surgical capabilities. 

# NOTES:
- Spinal trauma is not always obvious. Fractured spinal bones can injure the spinal cord, causing paralysis. If the spinal cord injury is in the cervical spine, paralysis could involve the muscles that control respiration and could lead to death. Examination findings should be carefully documented so that future providers can evaluate if the patient's condition has changed. - Spinal injuries can also cause shock. This can occur when nerves that control the contraction of the blood vessels in the body are damaged. When the walls of a blood vessel relax, the vessel dilates and pressure drops, leading to poor perfusion and shock. Risk is higher if there is also blood loss, so patients must be monitored closely. Always consider spinal injury in a patient with shock that does not improve with treatment. - Spine boards should only be used to move patients. Leaving patients on spine boards for long periods of time can cause pressure sores. Remove patients from boards as soon as they arrive at the facility and can be laid flat.

# Internal bleeding (not seen on primary survey)
- Bruising around the umbilicus or over the flanks can be a sign of internal bleeding - Pelvic fracture - Femur fracture - Decreased breath sounds on one side in the chest (haemothorax) - Signs of poor perfusion (hypotension, tachycardia, pale skin, diaphoresis)
A large quantity of blood can be lost into the chest, pelvis, thigh, and into the abdomen before bleeding is recognized. Crush injuries can have serious complications. Look for compartment syndrome (a build-up of pressure within the muscle compartments that can limit blood supply to muscles and nerves) and kidney damage due to by-products of muscle injury.
- It is important to monitor urine output and look for redbrown urine (a concern for possible kidney damage). - Give IV fluids to help the kidneys maintain urine output.
- Splint fractures to keep bone ends from causing further damage. - Plan for early surgical referral to release the pressure if compartment syndrome develops. - Patients may have many systemic problems related to muscle damage and should always be handed over to an advanced provider. Burns can affect the whole body and cause soft tissue injury, swelling and shock resulting from fluid loss due to the burn. The goal of burn management is to stop the burning process, watch for swelling and compensate for fluid loss. In significant burn injury, fluid leaks into the skin and surrounding tissue causing swelling and shock.

# Blast injury
- Burns involving the airway can rapidly cause airway obstruction. - It is crucial to replace fluid loss and anticipate ongoing losses.
-In order to calculate the IV fluid requirements, it is important to determine the depth of the burn and the percentage of body surface area (BSA) that is burned.
[ Even minor trauma may cause harm to the mother and fetus. Women suffering trauma in the third trimester are at risk for placental abruption (where the placenta can separate from the uterus wall, resulting in bleeding), uterine rupture, and premature labour. Remember resuscitation of the mother resuscitates the fetus.

# KEY ELEMENTS OF PATIENT HISTORY
Gestational age (age of the fetus or number of weeks since last menstrual period).
Any pregnancy complications.

# PRIMARY SURVEY
Airway: swelling in pregnancy can make airway obstruction more likely, so monitor closely.
Breathing: the diaphragm is pushed up by the pregnant uterus, leaving less lung space for breathing.
Circulation: check for vaginal bleeding; a pregnant uterus can also compress large blood vessels, causing hypotension. Place on left side with cervical spine precautions.
 Disability: always consider eclampsia if seizures/convulsions occur.
Exposure: keep patient warm.

# COMMON CONDITIONS CAUSED BY TRAUMA
Preterm (early) labour with or without premature rupture of membranes (loss of the fluid surrounding the baby).
Placental abruption or uterine rupture: causing blood loss and shock.
Seizures/convulsions.

# SPECIAL MANAGEMENT CONSIDERATIONS
Plan early for handover/transfer to a specialist unit with obstetric care.
If the uterus can be felt at the level of the umbilicus (belly button), this generally indicates that the patient is at least 20 weeks pregnant.
If the woman is more than 20 weeks (5 months) pregnant, the pregnant uterus can compress the inferior vena cava, the large vessel that brings blood back to her heart, and can cause shock. When lying the pregnant patient flat, always place on the left side (on a spine board if immobilization necessary). 
Trauma in late pregnancy may trigger early labour. Prepare for neonatal resuscitation as well when trauma occurs in late pregnancy.

# Workbook question 6: Approach to Trauma
Using the workbook section above, list the common conditions in a pregnant woman that can be caused by trauma. 

# SPECIAL CONSIDERATIONS IN CHILDREN
Children can appear well after an injury, and yet deteriorate quickly. They have different injury patterns, and serious internal organ injuries may occur without overlying skull or rib fractures (paediatric bones are more flexible). Common management problems include over-or under-resuscitation, medication errors and failure to recognize hypothermia and hypoglycaemia.
Below are special considerations for injured children. Refer also to the ABCDE module for normal paediatric vital signs and additional details.

# AIRWAY
- When neck trauma or cervical spine injury is suspected, use jaw thrust to manually open airway while maintaining cervical spine immobilization. Children have big heads and large tongues that may easily obstruct their airways. Young children and infants may require a pad under the shoulders to align the airway. 

# BREATHING
- If the child is not breathing adequately after opening the airway, assist breathing with a bag-valve-mask, ideally with oxygen. -place IV;
-give IV fluids and re-assess.
- For malnourished children, fluids MUST be adjusted.
- For severe burn injury, initial bolus is with dextrosecontaining fluids. 
- If significant haemorrhage, arrange for blood transfusion or rapid handover/transfer to a centre capable of blood transfusion.

# DISABILITY
- Monitor child's level of consciousness with the AVPU scale (Alert, responsive to Verbal stimuli, responsive to Painful stimuli, Unresponsive). AVPU is preferred to GCS in young children.
- Assess for and manage seizures/convulsions.
- Assess for and manage hypoglycaemia.

# EXPOSURE
- Expose the entire body but watch for hypothermia.
- Protect the child's modesty at all times.
- Use log-roll to assess remainder of child's back and head.

# Estimate weight in children based on age
Weight in kilograms =   2 or use weight-estimation tools such as PAWPER tape, Mercy TAPE, or Broselow tape, etc.

# GENERAL
Young children may be less able than adults to report events, even major events like being hit by a vehicle. Always consider the possibility of unwitnessed trauma in young children. 

# Location of brachial pulse in a child

# HEAD INJURIES
Head injuries are a common cause of death in children, and children frequently suffer from acute brain swelling after a severe head injury. If a paediatric patient has signs of traumatic brain injury, transport urgently to a facility with critical care and/or surgical capacity.

# CHEST INJURIES
Chest injuries can be life-threatening, and children require less force for more serious internal injuries. The ribs are more flexible than in adults, and there may be extensive chest injuries without rib fractures.

# ABDOMINAL INJURIES
Children's abdomens are relatively larger than adults, and the abdomen is a common site of injury in children. Injuries to the spleen and liver are especially common. Abdominal injuries should be considered in all paediatric trauma patients as they can be lifethreatening and can cause severe internal bleeding.

# BURN INJURIES
Burns in children can be difficult to manage. They require careful fluid resuscitation, close observation for airway swelling, and pain medications for dressing changes. In children who are burned, plan for rapid handover/transfer to a burn unit.

# Workbook question 7: Approach to Trauma
Using the workbook section above, list the circulation considerations in children who suffer trauma. 

# DISPOSITION CONSIDERATIONS
Trauma patients can have complex injuries that may be hidden, and can worsen and die very quickly. Always refer seriously injured patients to a higher level of care for specialized treatment.
The following high-risk conditions always require handover/transfer to a specialist unit for ongoing care:
Airway problem requiring intervention.

# Signs of shock:
-Tension pneumothorax: perform needle decompression prior to transfer (will need urgent chest tube placement).
-Pericardial tamponade: ensure IV fluids started and continued on transfer.
Altered mental status (drowsy, lethargic, confused or unconscious).
Trauma in pregnancy: place on left side for transport (needs specialist obstetric care).
Child with ABCDE problem, burn, or any head, chest or abdominal injury.
Any serious burn injury: assess the burn depth and total burn surface area, commence fluid resuscitation (transfer preferably to a specialist burns unit). 
Other considerations for transfer:
If a patient has required oxygen, arrange to continue it during transport and after handover.
If an injured person is displaying signs of shock, ensure IV fluid started and continued during transfer. Ensure any external bleeding is controlled and monitored during transport. 

# FACILITATOR-LED CASE SCENARIOS
These case scenarios will be presented in small groups. The following cases WILL NOT be assessed and are for practice only. It is important that you practise these scenarios as you will be assessed on how you lead a case in the following modules. For each case scenario the group must identify the critical findings and management needed and formulate a oneline summary for handover, including assessment findings and interventions. You should use the Quick Cards for these scenarios.

# CASE #1: ADULT TRAUMA
A taxi driver brings in a man that was severely injured. You come outside to find a 30-year-old male lying in the back seat of the taxi in severe pain. He was in a car crash a few kilometers away. His jeans are soaked with blood, with bone sticking out of the right thigh. 

# CASE #2: PAEDIATRIC TRAUMA
A 5-year-old boy pulled a pan of boiling water off the stove at 8pm tonight. The boiling water spilled on him, burning his right side. His mother used a container of cool water to wash him down and then brought him in for evaluation. The child is crying and tells you he is in pain. He has burns to his right palm, and right inner arm up to the elbow, and the front of his chest and abdomen and the front of his right thigh. The mother does not know how much the child weighs. - Then do a SAMPLE history.
- Then do a secondary exam.

# ABCDE: KEY ELEMENTS FOR PATIENTS WITH DIFFICULTY IN BREATHING
For the patient with difficulty in breathing, the following are key elements that should be considered in the ABCDE approach.  

# ASK: KEY HISTORY FINDINGS FOR PATIENTS WITH DIFFICULTY IN BREATHING
Use the SAMPLE approach to obtain a history from the patient and/or family.

# If the history identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it.

# S: SIGNS AND SYMPTOMS
When did the symptoms start and was onset sudden? Do they come and go and how long do they last? Have they changed over time and has there been a similar episode previously? Sudden difficulty in breathing can suggest airway obstruction such as by a foreign body; swelling of the airway from allergic reaction or infection; trauma to the airway, lungs, heart or chest wall; or inhalation of hot gases or smoke. Acute heart problems such as heart attack, abnormal heart rhythm or valve problems can cause rapid onset DIB. A history of rapid or deep breathing may suggest poisoning, high acid levels in the blood (infection or diabetic ketoacidosis) or anxiety. DIB that starts slowly is more common with infection and chronic conditions such as a gradual build-up of fluid around the lungs (as occurs in TB and heart failure), fluid around the heart (from TB or kidney disease), lung cancer or diseases affecting the function of the chest wall. Recurrent difficulty in breathing associated with wheeze may suggest asthma or COPD.

# Did anything trigger the difficulty in breathing and what makes it better or worse?
A history of allergies may suggest that the airway is blocked by swelling due to a severe allergic reaction. Inhaling smoke or hot gas (such as in fires) or some chemicals may cause E D DIB through upper airway injury and swelling. Exposure to some chemicals (such as certain pesticides) can cause fluid to build up in the airways and can cause weakness in the muscles involved in breathing. Difficulty in breathing that gets worse when the person lies flat can be due to fluid in the lungs.

# Is there any tongue or lip swelling, or voice changes?
Swelling to the mouth, lips, tongue or upper throat, or a change in voice can suggest a severe allergic reaction or other inflammation of the airway.

# Are there abnormal sounds with breathing?
High-pitched or 'squeaking' sounds when breathing IN may be stridor, which is caused by narrowing of the upper airway and may suggest severe allergic reaction or other airway obstruction. Wheezing -a high-pitched sound with breathing OUT -is caused by narrowing or spasm of the lower airways in the lungs and can suggest asthma, COPD, heart failure or allergic reactions. Gurgling sounds with breathing suggest that there is mucus, blood or other fluid in the airway.

# Is there pain associated with the difficulty in breathing?
Difficulty in breathing with chest pain can suggest heart attack, pneumothorax, pneumonia or trauma to the lungs, ribs or ribcage muscles. In particular, pain that is worse with deep breaths (pleuritic pain) may suggest infection or blood clot in the lung (pulmonary embolism).

# Is there fever or cough?
Fever suggests infection. Lung infection and any severe infection may cause fluid in the lungs. A cough may indicate fluid in the lungs from pneumonia or oedema. Cough and wheezing may suggest asthma or COPD.

# Is there foot or leg swelling or recent pregnancy?
Difficulty in breathing with oedema of both feet or legs can suggest heart failure with fluid back-up to the lungs and body. Difficulty in breathing with swelling and pain in one leg may suggest a clot in a leg vein that has travelled to the lung (pulmonary embolism). Pregnancy is a risk factor for both pulmonary embolism and heart failure.

# A: ALLERGIES

# Any allergies to medications or other substances? Any recent insect bites or stings?
Severe allergic reactions may cause difficulty in breathing due to airway swelling. People can have severe allergic reactions to almost anything, but food, plants, medications and insect bites/stings are the most common.

# M: MEDICATIONS

# Currently taking any medications?
Ask about new medications and changes in doses. New medications can cause allergies with associated difficulty in breathing. Accidental overdose of some medications can stop or slow breathing. 

# P: PAST MEDICAL HISTORY

# Is there a history of asthma or chronic obstructive pulmonary disease (COPD)?
Asthma and COPD often cause episodes of difficulty in breathing. A history of prior hospitalization or intubation for these conditions suggests a high-risk patient.

# Is there a history of heart disease or kidney disease?
People with a history of heart or kidney failure may have fluid in the lungs. Heart attack may present with difficulty in breathing.

# Is there a history of tuberculosis (TB) or cancer?
Conditions such as tuberculosis and cancer can cause build up of fluid in the sac around the heart (pericardial effusion) or build-up of fluid outside the lung (pleural effusion), both of which can cause a feeling of difficulty in breathing.

# Is there a history of diabetes?
Diabetes can cause diabetic crisis (diabetic ketoacidosis or DKA). DKA causes fast breathing that may be reported as difficulty in breathing.

# Is there a history of smoking?
Smoking increases the risk of asthma, COPD, lung cancer and heart attack.

# Is there a history of HIV?
HIV infection increases the risk of other infections.

# L: LAST ORAL INTAKE

# When did the person last eat or drink?
A full stomach puts the patient at risk of vomiting and possible choking.

# E: EVENTS SURROUNDING ILLNESS

# What was the person doing when the difficulty in breathing started?
Always consider choking if DIB started while eating or drinking. DIB with exercise might be due to heart attack, especially when there is also chest pain.

# Was the patient found in or near water?
Always consider drowning (inhalation of water) in a person found in or near water. Even a small amount of inhaled water can cause serious lung damage, which can worsen over time.

# Has there been exposure to pesticides or other chemicals?
Inhaled chemicals can cause DIB by irritating the airways and lungs. Some pesticides used in farming can be absorbed through the skin, causing fluid buildup in the airways and lungs. Exposure to gases from a fire is often associated with chemical inhalation.

# Has there been any recent trauma?
DIB with trauma is concerning for rib fractures, pneumothorax, haemothorax, and heart or lung bruising.

# Workbook question 1: Difficulty in breathing
Using the workbook section above, list five questions about past medical history you would ask when taking a SAMPLE history.  Poor chest wall movement.

# Cyanosis (blue skin colour, especially lips and fingertips).

# Look at the pupils for size and reactivity:
Very small pupils suggest possible opioid overdose or exposure to chemicals (including pesticides).
Unequal or abnormally shaped pupils suggest head injury which can cause abnormal breathing. 

# TRAUMA

# Look at the face, nose and mouth:
Cyanosis around the lips or nose suggests low oxygen levels in the blood.
Pale inner surface of lower eyelids suggests severe anaemia.
Swelling of the lips, tongue and mouth suggests an allergic reaction.
Soot around the mouth or nose, burned facial hair or facial burns suggest smoke inhalation and airway burns.
Bleeding or swelling of the airway may be due to trauma.

# Look at the neck and chest:
Distended neck veins can be due to a back-up of blood due to heart failure, tension pneumothorax or pericardial tamponade.
Excessive muscle use in the neck and chest (between the ribs) suggests significant respiratory difficulty.
If the trachea is shifted to one side, think about tension pneumothorax or tumour.
Swelling or redness of the neck suggests infection or trauma.
Examine the entire neck and chest carefully for bruising, wounds or other signs of trauma.

# Look at the rate and pattern of breathing:
People with wheeze may take longer to breathe out because of narrowing of the lower airways in the lung.
Fast breathing can be due to dehydration, severe infection, chemical imbalance in the blood, poisoning or anxiety.
Slow and shallow breathing might be due to opioid overdose. Look for very small pupils and altered mental status.
Chest wall injury is often associated with pain that limits the ability to take deep breaths.
A flail chest occurs when multiple rib fractures cause a segment of the rib cage to be separated from the rest of the chest wall. The segment may appear to be moving in the opposite direction from the rest of chest wall during breathing.

# Look at the legs:
Swelling to the both lower legs suggests heart failure as a cause of difficulty in breathing.
Swelling to one leg may be due to a blood clot in the leg. If there is also difficulty in breathing, this may mean that part of the clot has traveled to the lung.

# Look at the skin:
Bites can be a source of allergic reaction.
Rashes, such as hives, can indicate allergic reaction. When associated with difficulty in breathing, rashes can indicate widespread (systemic) infection.
Pallor (pale skin) can indicate anaemia as a cause of DIB.
Circumferential burns (a burn that goes entirely around a body part) to the chest can restrict chest wall expansion and limit breathing.

# LISTEN

# Listen to the breath sounds:
Stridor suggests partial upper airway obstruction, which may be due to a foreign object, mass, or swelling from trauma or infection.
Decreased or absent breath sounds suggest abnormal air movement in the lungs. This can be due to air or fluid around the lung (pneumothorax, haemothorax, effusion), narrowing or foreign body blockage of the airways, and infection or tumour in or around the lung.
Wheezing, in particular, suggests lower airway obstruction such as from asthma, COPD, allergic reaction, foreign body or tumour.
Crackles or crepitations suggest fluid in the airspaces of the lung.

# Listen to the heart sounds:
Abnormal heart rhythms can cause the heart to pump blood abnormally, leading to poor perfusion and a feeling of difficulty in breathing.
Difficulty in breathing accompanied by heart murmurs can suggest damage to the heart valves.
Muffled or distant heart sounds accompanying low blood pressure, fast heart rate and distended neck veins suggest pericardial tamponade.

# FEEL

# Feel the ribs and chest wall:
Deformities and abnormal movement when pressing on the chest wall suggest rib fracture.
Crepitus (crackling or popping when pressing on the skin of the chest wall) may suggest underlying fracture or air under the skin (associated with pneumothorax).
Unequal expansion of the chest wall suggests pneumothorax, haemothorax, or flail chest.

# Percuss the chest wall :
Hollow sounds (hyperresonance) on one side when tapping the chest wall suggest pneumothorax.
Dull sounds when tapping the chest wall may indicate fluid or blood either inside the airspaces of the lungs or between the lungs and the chest wall. 

# DO: MANAGEMENT

# FIRST PERFORM ABCDE ASSESSMENT AND INTERVENE FOR LIFE-THREATENING CONDITIONS.
Assess and manage airway and provide bag-mask-ventilation (BVM) for any patient who is not breathing or not breathing adequately (too slow for age or too shallow); any unconscious patient with abnormal (slow, shallow, gasping or noisy) breathing; or any patient with a pulse who is not breathing. For patients without a pulse, follow relevant CPR protocols.

# CONDITION MANAGEMENT CONSIDERATIONS

# Airway inflammation or burns

# Keep patients calm. Give oxygen if you can do this without upsetting the patient. 
If the patient is fully alert and no spinal injury suspected, the seated position may be more comfortable.
Patients with airway burns may require early intubation as the airway can swell and block quickly; delays may make intubation more difficult.
A person with airway inflammation or burns requires urgent handover/ transfer. 

# Choking

# Chronic, severe anaemia
Give IV fluids more slowly and check the lungs for crackles (fluid overload) frequently.  These patients may need handover/transfer for blood transfusion.

# Diabetic ketoacidosis Give IV fluids. 
A person with diabetic ketoacidosis is extremely ill and requires urgent transfer to an advanced provider.

# Opioid overdose
Support breathing with a bag-valve-mask as needed. Give naloxone.

# Pleural effusion or haemothorax
Give oxygen.  Arrange for handover/transfer immediately. Many of these patients will need a chest tube or other drainage.

# Trauma
All trauma patients with difficulty in breathing should be given oxygen. IV fluid should be given to help fill the heart if either pericardial tamponade or tension pneumothorax is suspected. Needle decompression should be performed if tension pneumothorax is suspected. Treat sucking chest wounds with a 3-sided dressing.  The patient will need urgent handover/transfer for a chest tube if needle decompression is performed or a 3-sided dressing is applied.

# Acute chest syndrome
Give oxygen, IV fluids, antibiotics. May need transfer for advanced management. 

# SPECIAL CONSIDERATIONS IN CHILDREN
The following are danger signs in children:
- Signs of airway obstruction (unable to swallow saliva/drooling or stridor).
- Increased breathing effort (fast breathing, nasal flaring, grunting, chest indrawing or retractions).
- Cyanosis (blue colour of the skin, especially at the lips and fingertips).
- Altered mental status (lethargy or unusual sleepiness, agitation).
- Poor feeding or drinking.
- Vomiting everything.
- Seizures/convulsions.
- Low temperature (hypothermia).

# REMEMBER...
- Wheezing in children can be caused by viral infection, asthma or an inhaled object blocking the airway.
- Stridor in children can be caused by an object stuck in the upper airway OR airway swelling.
- Children may present with rapid breathing as the only sign of pneumonia.
- Rapid breathing can also indicate diabetic crisis (DKA), which may be the first sign of diabetes in a child. 

# DISPOSITION CONSIDERATIONS
Keep in mind that the effects of inhaled medications such as salbutamol last for only approximately 3 hours. Patients need to be monitored closely.
If a patient with a severe allergic reaction is given adrenaline, the reaction can return when the adrenaline wears off. Patients need to be monitored closely.
Naloxone only lasts about 1 hour. Most opioid medications last longer than this, so patients may need repeat naloxone doses.
Following immersion in water (drowning), a person may develop late signs of breathing problems after several hours and should be observed closely.
Never leave patients who might need definitive airway placement unmonitored during handover/transfer. Ensure that a new provider is monitoring the patient before leaving.
Make transfer arrangements as early as possible for any patient who may require assisted ventilation.

# FACILITATOR-LED CASE SCENARIOS
These case scenarios will be presented in small groups. One participant will be identified as the lead and will be assessed while the rest of the group writes the responses in the workbook. To complete a case scenario, the group must identify the critical findings and management needed and formulate a one-line summary for handover, which includes assessment findings and interventions. You should use the Quick Cards for these scenarios while being assessed.

# CASE #1: ADULT WITH DIFFICULTY IN BREATHING
A 22-year-old man arrives by taxi. He was robbed on the street, and was stabbed in the left chest with a knife. He is now having severe difficulty in breathing. 

# CASE #2: PAEDIATRIC PATIENT WITH DIFFICULTY IN BREATHING
A mother brings in her 6-year-old son for difficulty in breathing. The mother states that her son has been having difficulty breathing for the past 3 days. She says he makes funny noises when he breathes. 

# MULTIPLE CHOICE QUESTIONS
Answer the questions below. Questions and answers will be discussed in the session  

# Overview
Poor perfusion is when the body is not able to get enough oxygen-carrying blood to vital organs. When organ function is affected, this is called shock and can lead rapidly to death. Infants, children and older adults are more likely to be affected by shock.
Causes of poor perfusion which may lead to shock include:
loss of blood (haemorrhage); loss of fluid due to diarrhoea, vomiting, extensive burns or excess urination (such as caused by high blood sugar); poor fluid intake. Small children, the elderly and the very ill may be unable to drink enough fluids without assistance and are at risk of dehydration; abnormal relaxation and enlargement (dilation) of the blood vessels (with the same amount of blood inside the vessel) can lower blood pressure. This can occur in severe infection, spinal cord injury and severe allergic reaction;
poor filling of the heart can result from blood or other fluid in the sac around the heart (pericardial tamponade), or increased pressure in the chest that can shift and block the vessels returning blood to the heart (tension pneumothorax); failure of the heart muscle to pump effectively can be due to a heart attack (vessel blockage that causes acute heart muscle damage); inflammation or other disease of the heart muscle itself; an abnormal rhythm or valve problems. (Shock due to failure of the heart to pump effectively is sometimes called cardiogenic shock.)
The goal of INITIAL ASSESSMENT is to identify shock and any reversible causes of shock.
The goal of ACUTE MANAGEMENT is to restore perfusion (oxygen delivery to the organs) and address ongoing fluid loss where possible. Then do a SAMPLE history.
Then do a secondary examination.

# ABCDE: KEY ELEMENTS IN SHOCK
For the person in shock, the following are key elements that should be considered in the ABCDE approach.

# AIRWAY
Face/mouth swelling or voice changes can indicate an allergic reaction. A severe allergic reaction can cause shock.

# BREATHING
Wheezing can indicate a severe allergic reaction which can cause shock. Shock, difficulty in breathing and absent breath sounds on one side can indicate a tension pneumothorax. Poor perfusion itself can sometimes cause rapid breathing when vital organs do not receive enough oxygen. Severe heart failure can cause poor perfusion with difficulty in breathing when fluid backs up into the lungs. Any infection severe enough to cause shock may be associated with lung inflammation that causes difficulty in breathing.

# CIRCULATION
Shock can be caused by many types of bleeding (from the stomach or intestines, pregnancy-related, and internal and external haemorrhage from trauma). Shock can also result from the fluid loss associated with diarrhoea, vomiting, extensive burns, or excess urination (such as caused by high blood sugar). 

# ASK: KEY HISTORY FINDINGS IN SHOCK
Use the SAMPLE approach to obtain a history from the patient and/or family. 

# If the history identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it.

# S: SIGNS AND SYMPTOMS
Has there been vomiting and/or diarrhoea? For how long?
Fluid losses through vomiting and diarrhoea can be severe and can lead to shock. The amount of vomiting or diarrhoea can help give a rough estimate of the risk for shock, so always ask about frequency of episodes.

# Has the person had blood in stool or vomit?
Bleeding in the stomach and/or intestines can be severe before it is recognized. A person can lose a significant portion of his or her blood volume in the intestines. Blood may appear black in both vomit and stools.

# Has there been any vaginal bleeding?
Vaginal bleeding may be related to pregnancy in women of childbearing years. Always ask about pregnancy status, last menstrual period, any missed periods, or known recent pregnancy. Blood loss from normal delivery or miscarriage can cause shock. A pregnancy developing outside the uterus (ectopic pregnancy) can also be life-threatening if it ruptures. Ectopic pregnancy rupture can occur before a woman even knows she is pregnant. Other causes of vaginal bleeding are masses in the cervix or uterus.

# Has the person had any chest pain?
Chest pain may suggest the person has had a heart attack. The muscle damage to the heart from a heart attack can reduce its ability to pump blood around the body, which can cause shock.

# Has there been fever?
Fever may suggest infection as the cause of shock. Severe infection causes both dilation of the blood vessels (which lowers blood pressure) and fluid leakage from the blood vessels (with fluid loss into the tissues).

# Has there been any exposure to toxins, medications, insect stings or other substances?
Severe allergic reactions can lead to shock. Additionally, many medications, including blood pressure and seizure/convulsion medications, can cause shock.

# Has there been altered mental status or unusual sleepiness?
The brain is one of the last organs to be affected by poor perfusion, so altered mental status may be a sign of severe shock.

# A: ALLERGIES

# Does the person have any known allergies?
Allergic reactions can lead to shock by causing abnormal relaxation of the blood vessels.

# M: MEDICATIONS

# Currently taking any medications?
Obtain a full medication list from the person or the family. Knowing the patient's medication list can help understand why the patient is in shock (such as heart medications). Overdose of blood pressure or seizure/convulsion medications can cause shock, and it may be more difficult to treat shock from any cause in patients taking these medications. Medications that thin the blood can worsen bleeding. Always ask about new medications in particular and recent dose changes to evaluate for allergic reaction or unexpected side effects.

# P: PAST MEDICAL HISTORY

# History of pregnancy or recent miscarriage or delivery?
Blood loss following delivery can be severe if the uterus does not contract well. Hidden blood loss leading to shock can occur with ruptured ectopic pregnancy, even in women who do not know they are pregnant. Any woman of childbearing age with shock should be evaluated for pregnancy.

# History of recent surgery or induced abortion?
Internal bleeding or infection after surgery can lead to shock.

# History of heart disease (heart attack or heart valve problems)?
Patients with heart disease are at risk for worsening heart function that may lead to shock or worsen shock from other causes.

# Is there a history of HIV?
HIV increases the risk of infection.

# L: LAST ORAL INTAKE

# When did the person last eat or drink?
A person who is not eating or drinking well can develop severe dehydration, leading to shock.

# E: EVENTS SURROUNDING ILLNESS

# Has there been any recent trauma?
Trauma can cause hidden internal bleeding, tension pneumothorax, and bruising or bleeding around the heart, all of which may reduce blood flow and cause shock. In addition, trauma to the neck or back causing spinal cord injury can interfere with the blood vessels' ability to maintain blood pressure.

# Has there been any recent illness?
Any infection can cause a blood infection that can spread throughout the body and lead to shock. 

# CHECK: SECONDARY EXAMINATION FINDINGS IN SHOCK
A person with shock will have signs of poor perfusion, which may include a fast heart rate, a low systolic blood pressure, fast breathing, pale and cool skin, slow capillary refill, dizziness, confusion, altered mental status, decreased urine output or excessive sweating.
REMEMBER: Perfusion can be limited even before blood pressure falls, especially in the young. Low blood pressure with poor perfusion is a very serious sign.
Always assess ABCDE first. The initial ABCDE approach identifies and manages life-threatening conditions. The secondary exam looks for changes in the patient's condition or less obvious causes that may have been missed during ABCDE. If the secondary examination identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it.

# REMEMBER:
Children have different normal vital signs ranges, and children with shock may not have changes in vital signs until they are very ill. Always do a careful exam for any signs of shock.

# Check breath sounds and respiratory rate:
-Abnormal or noisy breathing can indicate pneumonia as a source for system-wide infection causing shock. -High sugar levels can result in chemical imbalance (diabetic ketoacidosis) that the body tries to address by faster or deeper breathing. This condition may also result in sweet or 'fruity' smelling breath. Since elevated blood glucose levels cause increased urination, severe dehydration and shock can result.

# Check for bleeding:
-All external bleeding should be controlled with direct pressure.  Arterial bleeding may appear as pulsing or high pressure bleeding, and significant blood volume can be lost in minutes.
-Vaginal bleeding may be an important source of blood loss from pregnancy-related bleeding (even in those who think they are not pregnant) or from masses in the cervix or uterus.

# Check fluid status:
In dehydration states, the patient may feel thirsty or may have dry lips and mouth, abnormal skin pinch, lethargy, and delayed capillary refill. Patients with heart failure can be in shock with fluid overload, and may have lower body swelling (usually in both legs), crackles on lung examination, and distended neck veins.

# Check for pale conjunctiva (the inside of the lower eyelid):
No matter the person's skin color, the inside of the eyelid should appear pink and moist. If the inner portion of the eyelid (conjunctiva) is pale, it may indicate significant blood loss. You can compare the patient's conjunctiva to another healthy person or look at your own in a mirror.

# Check mental status:
Confusion in a patient with other signs of poor perfusion suggests severe shock.

# Check for fever:
Fever in a patient with shock suggests severe infection.

# Check blood sugar:
Low blood glucose can sometimes look like shock. If you cannot check blood glucose, but the person has altered mental status, a history of diabetes or another reason to have low sugar (for example, is taking quinine for malaria, is very ill, or is very malnourished), give glucose. 

# Check for severe abdominal pain or a very firm abdomen:
If the person has severe abdominal pain, this can be a sign of bleeding or infection in the abdomen. In a patient who might be pregnant, this can be a sign of an ectopic pregnancy.

# Check urine:
Check the urine colour and volume. Small amounts of darker urine may indicate substantial dehydration.

# Check stool:
Any significant diarrhoea can cause dehydration. A large amount of watery, "rice-water" stool suggests cholera, which can rapidly cause severe dehydration and shock. Black, dark, or reddish colored stool can suggest stomach or intestinal bleeding. - In all forms of shock, the primary management is administration of IV fluids appropriate for age and condition.
- The specific conditions below require additional considerations. 

# SPECIAL CONSIDERATIONS IN CHILDREN
Shock can occur quite rapidly in children and is life-threatening. Children have a relatively larger surface area (compared to their body volume) and are thus likely to become dehydrated more rapidly. Infants and young children are particularly at risk as they are unable to say when they are thirsty and cannot drink more on their own.

# Assessing shock in children:
The clinical definition of shock in children varies. The 2016 WHO guidelines for the care of critically ill children use the presence of three clinical features: cold extremities, capillary refill greater than 3 seconds, and weak and fast pulse.
There are also other important signs of poor perfusion, including low blood pressure, fast breathing, altered mental status, and decreased urination (always ask parents how much urine the child is passing). 

# Signs of dehydration in children
- Very dry mouth and lips
- Lethargy (excessive drowsiness and slowness to respond), child not interactive
- Sunken eyes
- Small amounts of dark urine (ask about number of nappies for infants)
- Sunken fontanelles in infants under 1 year
- Delayed capillary refill (normal capillary refill is less than 3 seconds)
- Abnormal skin pinch 
- Pallor (anaemia makes dehydration even more difficult to treat )
Abnormal skin pinch in a child page 34

# Abnormal skin pinch in a child
Common causes of shock and dehydration in children include:
- Vomiting and diarrhoea: Gastroenteritis causes sudden onset of vomiting and diarrhoea with some abdominal pain and fever. Large amount of watery diarrhoea may suggest cholera, and needs to be reported to public health authorities.
- Vomiting without diarrhoea: Vomiting without diarrhoea or fever may suggest raised pressure on the brain (trauma, tumour, brain swelling), or intestinal blockage. It is important to examine the child for signs of trauma. Vomiting associated with fever may suggest infection.

# Special management considerations:
- Malnourishment: Malnourished children are at high risk for hypoglycaemia and will need sugar in addition to fluids. Give specialized fluids if available.  Give less IV fluid more slowly, and check the lungs for crackles (fluid overload) every 5 minutes. Stop IV fluids if fluid overload develops (crackles in the lungs, increased respiratory rate, increased heart rate). Switch to oral fluids as soon as signs of poor perfusion improve. These patients need rapid handover/transfer over to an advanced provider at a centre with blood transfusion capabilities.

# Workbook question 5: Shock
Using the workbook section above, list signs of severe dehydration in children. 

# DISPOSITION CONSIDERATIONS
People with shock can worsen and die quickly. They must be monitored very closely.
Additionally, the same illnesses that cause shock interfere with the body's ability to manage fluids, so these patients must be monitored very closely for signs of difficulty in breathing.
Patients with shock may be confused and anxious. Ensure they are safe and contained during transfer.
Patients with shock are often transferred for transfusion or general or obstetric surgery. Always communicate directly with the receiving facility to make sure that these resources are actually available at the time of transfer.

# FACILITATOR-LED CASE SCENARIOS
These case scenarios will be presented in small groups. One participant will be identified as the lead and will be assessed while the rest of the group writes the responses in the workbook. To complete a case scenario, participants must identify the critical findings and management needed, and formulate a one-line summary for handover, including assessment findings and interventions. You should use the Quick Card for these scenarios while being assessed.

# CASE #1: ADULT SHOCK
A 48-year-old male with a history of alcohol abuse is brought in by his wife to be evaluated for weakness. His wife states that he has been having very dark stools for the past 2 days and now cannot stand up. 

# CASE #2: PAEDIATRIC SHOCK
The patient is a 4-year-old girl brought in by her mother. She has been having almost constant diarrhoea for the past 3 days and vomiting every time she tries to drink anything. The mother thinks she may have had a fever as well. She has no signs of malnutrition. 

# MULTIPLE CHOICE QUESTIONS
Answer the questions below. Questions and answers will be discussed in the session. 

# Overview
Altered mental status (AMS) is a term used for a range of presentations, from sudden or gradual changes in behaviour to disorientation, confusion and coma. Changes in mental status and/or level of consciousness may be due to conditions that affect the brain (such as lack of oxygen or glucose; or shock causing lack of perfusion) or problems with the brain itself (such as infection, inflammation or injury). While chronic psychiatric problems and dementia can cause changes in mental status, altered mental status is often an indication of severe disease, and other lifethreatening causes must always be considered. The presence of delirium -a rapidly changing state of confusion with agitation, loss of focus and inability to interact appropriately -always requires a full assessment. Always ask family/friends about baseline mental status when possible.
The goal of INITIAL ASSESSMENT is to identify rapidly reversible causes of altered mental status, and to recognize dangerous conditions requiring transfer.
The goal of ACUTE MANAGEMENT is to ensure that blood, oxygen and glucose reach the brain; and to protect the brain from additional injury. Then do a SAMPLE history.
Then do a secondary exam.

# ABCDE: KEY ELEMENTS FOR ALTERED MENTAL STATUS
For the person with altered mental status, the following are key elements that should be considered in the ABCDE approach.

# AIRWAY
People with altered mental status may not be able to protect their airways and may be at risk of choking on vomit.
BREATHING Hypoxia (lack of oxygen) can be a cause of altered mental status. Search for any signs of difficulty breathing, or cyanosis (blue colouring of the skin).
Abnormal breathing can reflect diabetic ketoacidosis or poisoning.

# CIRCULATION
Lack of perfusion to the brain can cause altered mental status. Look for and manage signs of shock (low blood pressure, elevated heart rate, delayed capillary refill).

# DISABILITY
Check AVPU or GCS (in trauma). Look for abnormal glucose (hypoglycaemia or hyperglycaemia can cause altered mental status). Very small pupils suggest opioid overdose or poisoning (consider pesticides). Very dilated pupils suggest stimulant drug use. Unequal pupils suggest an increased pressure on the brain. If the patient can follow commands, test for strength and sensation in face, arms and legs. Weakness or loss of sensation on one side suggests a mass, bleeding, or blocked blood vessels in the brain (stroke), though hypoglycemia can also present this way. Altered mental status with general muscle weakness may suggest salt (electrolyte) imbalance in the blood. Look for abnormal repetitive movements or shaking on one or both sides of the body (seizure/ convulsion) -this may be due to a tumour, bleeding, brain infection, hypoglycaemia, or salt (electrolyte) imbalance.

# EXPOSURE
Remember that patients with altered mental status may not report their history accurately. Examine the entire body for infections, rashes, and any evidence of trauma, bites or stings. Needle marks on the arms may suggest drugs as a cause.

# ASK: KEY HISTORY FINDINGS FOR PATIENTS WITH ALTERED MENTAL STATUS
Use the SAMPLE approach to obtain a history from the patient and/or family. It is important to obtain a history from bystanders, friends or family as it may be difficult to obtain accurate history from a confused patient. For example, a person with hypoglycaemia may be too confused to relate a history of diabetes. 

# If the history identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it.

# S: SIGNS AND SYMPTOMS

# How does the current condition compare to baseline mental status?
Always ask family/friends about baseline mental status when possible.

# Is there difficulty breathing?
Altered mental status associated with difficulty in breathing may indicate lack of oxygen to the brain.

# Is there headache?
Headache with altered mental status can indicate infection, tumour or bleeding.

# Is there vomiting/diarrhoea?
Vomiting without diarrhoea can be a sign of increased pressure in the brain. Any source of dehydration, including vomiting and diarrhoea, may cause altered mental status from poor perfusion. Vomiting and diarrhoea can also cause hypoglycaemia leading to altered mental status.

# Has there been any dizziness or fainting?
These may be signs of poor perfusion (lack of oxygenated blood) to the brain.

# When did the symptoms start? Do they come and go? How long do they last? Have they changed over time?
Rapid onset of altered mental status may suggest infection, inflamation, bleeding or drugs/ toxic exposures. A more gradual onset (over weeks or months) may indicate a spaceoccupying lesion in the brain, such as a tumour or slow bleeding in the brain. Altered mental status that comes and goes with normal intervals between episodes may suggest other causes, such as seizures/convulsions or psychiatric disease.

# Has there been any recent fever?
Any person with altered mental status and fever may have an infection. Brain infections often present with altered mental status and fever. In small children and the elderly, any serious infection, such as urine, lung, or blood infection can cause altered mental status. Also consider prolonged outdoor exposure, poisonings, medications and drugs as these may present with fever as well. Very high fever itself from any source may cause altered mental status.

# Is there any weakness, clumsiness or difficulty walking?
Change in mental status with weakness or sensory loss in one area of the body, or problems with walking and balance, suggest that the altered mental status comes from a cause in the brain itself, such as a stroke or tumour.

# Is there neck pain or stiffness?
Fluid that circulates around the brain also circulates around the spinal cord, meaning any bleeding, inflammation or infection in the brain (meningitis, encephalitis) can also cause neck pain and stiffness.

# Is there a recent history of trauma or falls?
Bleeding in or around the brain can cause altered mental status some days after an injury. Remember that chronic alcohol drinkers and the elderly are more prone to brain bleeding and may not remember falls. Always consider slow bleeding around the brain as a cause, even several days after a fall, and consider unwitnessed trauma in a patient who is found altered with no known cause.

# Has there been any recent depression or changes in behaviour?
Drug and alcohol use or psychiatric problems can present as altered mental status. Always consider the possibility of a suicide attempt by poisoning.

# Does anyone else from the same family or location have symptoms?
Gaseous poisoning, like carbon monoxide poisoning, can cause altered mental status in multiple people. Carbon monoxide poisoning is usually seen in cold climates when people use indoor heating.

# A: ALLERGIES

# Any allergies or recent exposure to a known allergen?
Severe allergic reactions (anaphylaxis) may present with altered mental status due to low blood oxygen levels or poor blood circulation to the brain as a result of shock.

# M: MEDICATIONS

# Currently taking any medications?
Many common medications can cause altered mental status as a side effect, including those for seizures/convulsions, pain and sleeping. Ask about new medications and changed doses, and consider medication interactions. A medication list should be collected and can provide clues for underlying disease (such as convulsions, liver disease, diabetes) if the person cannot communicate. Opioid medications (such as morphine, pethidine and heroin) can cause altered mental status.

# P: PAST MEDICAL HISTORY

# History of diabetes?
In any patient with diabetes and altered mental status, suspect diabetic crisis, or low blood sugar caused by medications. Recent increase in urine output, increased thirst, and fast or deep breathing suggest diabetic crisis (diabetic ketoacidosis).

# History of heart disease?
Heart attack can cause decreased blood flow and oxygen to the brain leading to confusion. Those with heart disease are also at an increased risk of stroke. 

# History of stroke?
Altered mental status in a patient with a history of stroke may suggest an additional stroke or bleeding in the brain. Be sure to ask people who know the patient about his or her usual mental and neurological status. Symptoms of old stroke may return with severe illness of any kind.

# History of high blood pressure?
High blood pressure increases the risk for bleeding in and around the brain (such as stroke).

# History of seizure/convulsion?
Altered mental status in a patient with a history of seizures/convulsions may suggest that the patient is having or recovering from a convulsion. If there is a history of epilepsy (primary seizure/convulsion disorder), ask about regular medication and any recent dose changes or missed doses. With a witnessed convulsion, ask about fall or head trauma. Always ask if the convulsion was the same or different compared to prior. Remember that recovery of normal mental status after convulsions usually takes only a half hour to several hours at most, though patients may feel tired for longer. Longer altered mental status suggests another cause.

# History of HIV infection?
Altered mental status in a person with HIV may suggest infection in or around the brain (meningitis, encephalitis).

# History of tuberculosis?
Tuberculosis can infect the brain and cause altered mental status.

# History of liver or kidney failure?
Liver or kidney failure can cause problems with the clearing of toxins and waste from the blood, which can lead to altered mental status.

# History of heavy alcohol use?
Alcohol intoxication and alcohol withdrawal can present with altered mental status. People with a history of heavy alcohol use also have a high risk for head injury (and may not remember falls) and hypoglycaemia, both of which can cause altered mental status.

# Use of drugs of abuse?
Several drugs of abuse cause altered mental status, including stimulants, sedatives and opioids.

# History of pregnancy?
High blood pressure during pregnancy can lead to eclampsia (or seizures/convulsions and high blood pressure) during pregnancy.

# L: LAST ORAL INTAKE

# When did the person last eat or drink?
Low blood glucose levels and dehydration can cause altered mental status.

# E: EVENTS SURROUNDING ILLNESS

# Recent trauma?
Both head injury and poor perfusion resulting from blood loss can cause altered mental status.

# Recent travel to areas where certain types of infections might be more common?
Specific infections that can cause altered mental status may be more common in certain areas. Malaria is a key consideration in many areas.

# Recent exposures: contact with a sick person, recent bites, chemical exposures, hot or cold environments etc.?
Sick contacts may suggest infectious cause. Chemical exposures (such as pesticides) or bites may suggest intoxication or envenomation. Altered mental status can be caused by both very low and very high body temperatures.

# Recent alcohol or drug use?
Both alcohol intoxication and alcohol withdrawal can cause altered mental status. Methamphetamines and cocaine may cause severe agitation, while heroin (and other opioids) may cause lethargy and coma. See also "Past medical history" section above.

# Workbook question 1: Altered mental status
Using the workbook section above, list seven questions about signs and symptoms you would ask about when taking a SAMPLE history. 

# Check for safety:
Agitated and violent behaviour is a common presentation. It is very important to identify and treat the underlying cause if possible, while prioritizing the safety of the patient and providers. Keep calm and work as a team. Ensure that the space is safe from possible weapons and make sure that the patient is not between you and the door. Avoid making the patient feel threatened. Do not sit too close and speak with a calm, soft and sympathetic voice. Continually explain what is happening. Many aggressive patients will cooperate when faced with a team, so call for help and approach a patient as a group if necessary. Check vital signs, including temperature and glucose, and treat abnormalities. Call for help early and arrange handover/transfer to an advanced provider.

# Check and monitor level of consciousness with the AVPU scale:
-A: Alert 

# Check the blood glucose level:
Hypoglycaemia can cause altered mental status. Diabetic ketoacidosis can present with hyperglycaemia and altered mental status.

# Check the pupils:
Very small pupils and slow breathing suggests opioid overdose. Very large (dilated) pupils suggest stimulant drug use. Unequal pupils suggest increased pressure on the brain.

# Check for orientation:
If the patient is alert and responds to voice, ask simple questions (for example: What is your name? Where are you? What time is it? What day of the week is it?).

# Check for trauma:
Any patient with altered mental status and history or evidence of trauma should be considered to have a possible head injury -even if the trauma occurred several days before. Bruising around the eyes, behind the ears, or leaking of clear fluid from the nose or ears suggests head injury with skull fracture.

# Check temperature:
Fever should raise concerns about an infectious cause, and fever with stiff neck suggests an infection in or around the brain. Poisonings, medication overdoses, alcohol withdrawal and changes in body hormones can also present with fever. Hypothermia may indicate infection, low body hormone levels (e.g., thyroid) or exposure to wet or cold environments.

# Check for stiff neck (Remember, if you suspect trauma, do not move the neck):
Stiff neck is suggestive of infection (meningitis) or bleeding around the brain. If you suspect infection, anyone who comes in contact with the patient should wear a mask.

# Check strength and sensation:
If the patient can follow commands, test for strength and sensation in face, arms and legs. Weakness or loss of sensation on one side suggests a mass, bleeding or blocked blood vessels in the brain (stroke), though hypoglycaemia can also present this way. Altered mental status with general muscle weakness may suggest salt (electrolyte) imbalance in the blood.

# Check for signs of dehydration:
Dehydration can cause altered mental status. Check for dry mouth and abnormal skin pinch. Dehydration may also suggest diabetic ketoacidosis.

# Check the abdomen:
Feel if the liver is enlarged or tender. A palpable or tender liver suggests liver disease.

# Check the skin:
Cool, pale, and moist skin suggests shock or hypoglycaemia. Yellow skin (jaundice) suggests liver disease. Bruising suggests trauma. Rashes can indicate systemic infection. Check for bites and stings.

# Monitor for changes in mental status:
People who are initially confused and rapidly return to normal without treatment may have had a seizure/convulsion or head trauma. People with altered mental status require close monitoring to make sure they do not worsen again. (This can happen in patients who have low blood sugar or head trauma).

# Workbook question 2: Altered mental status
Using the workbook section above, list five secondary examination findings you would check for in a patient with altered mental status. 

# Ingestions of chemicals or toxins
- Common in younger children - History of medications or substances found around child

# Workbook question 3: Altered mental status
Using the workbook section above, list the possible cause of altered mental status from the history and physical findings below.

# HISTORY AND PHYSICAL FINDINGS LIKELY CAUSE
A 15-year-old girl presents with altered mental status, fever and: Poisoning or envenomation Try to identify the poison and refer to an advanced provider for specific treatments. If pesticide poisoning, make sure the patient has been decontaminated, and monitor the airway closely as the secretions can cause obstruction. Snake bites should be treated as described in the "Wound Management" section  and referred as soon as possible for antivenom.

# Rabies
There is no specific treatment for rabies. Symptomatic rabies is almost always fatal. See TRAUMA for management of suspected exposure from animal bite.

# Violent or very agitated patient
Protect the patient from harming self or others.
Ensure that staff have a clear exit path (do not place the patient between staff and the door).
Remove potential weapons and unsafe objects. 

# SPECIAL CONSIDERATIONS

# MANAGEMENT OF ACTIVE CONVULSIONS
- Check ABCDE.
- Maintain the airway -do not put anything in the mouth.
- Give oxygen if concern for hypoxia or prolonged seizure/convulsion.
- Place patient on his/her side, if possible.
- Protect the patient from harm or further injury.
- Check glucose or give glucose (if unable to check).
- Give a benzodiazepine.
- If pregnant and seizing, give magnesium sulphate.
- If no response, give another dose of benzodiazepine (repeat three times if needed) and monitor for low blood pressure and slow breathing. - If the patient does not wake between seizure/convulsions, consider this a life-threatening condition. Arrange for rapid handover/transfer to an advanced provider. - If the seizures/convulsions stop, place patient in recovery position and monitor closely.

# Workbook question 4: Altered mental status
Using the workbook section above, list what you would do to manage these patients. 

# SPECIAL CONSIDERATIONS IN CHILDREN
Children with altered mental status may have seemingly mild signs such as sleeping more than usual or being less interactive. Manage ABCDE first, and then look for and manage causes of altered mental status. Remember that very ill or injured children may have normal vital signs until they rapidly deteriorate.
Hypoglycaemia occurs frequently in severely ill children and is a common cause of altered mental status in children. Check blood glucose (or give glucose if you are unable to check) in any child with altered mental status.
Hypoxia can occur as a result of many conditions, including respiratory infections and shock; birth hypoxia is a consideration in newborns.
Hyperthermia with altered mental status suggests infection, but can also be seen with excessive heat exposure, exercise, seizure/convulsion, hormonal imbalance and some medications and poisons.
Hypothermia with altered mental status can also suggest infection, particularly in infants, but can be due to drug intoxication, exposure to cold or hormonal imbalance.
Young infants are more affected by variation in temperature. Keep the child warm by using blankets and a hat to prevent heat loss and using skin-to-skin contact (also called "kangaroo care") with a family member 24-hours per day while ill.
Seizures/convulsions can be due to fever alone but (as in adults) can also suggest infection, hypoglycaemia or hyponatremia (low sodium). Do not delay antibiotics in patients with suspected serious bacterial infection. Always consider trauma.
Infection in or around the brain can cause altered mental status. Look for a bulging or swollen fontanelle (in a child under 1 year) and/or rash to the legs and lower abdomen, which can indicate infection or increased pressure on the brain. Do not delay antibiotics in children with suspected serious bacterial infection.

# Flat fontanelle Bulging fontanelle
page 31

# Flat fontanelle Bulging fontanelle
Poor perfusion can cause altered mental status. Children can become dehydrated very quickly. Check for signs of dehydration: abnormal skin pinch, dry mucous membranes (the inner, pink part of the mouth), irritability, sunken or depressed fontanelle (in a child under 1 year), slow capillary refill (greater than 3 seconds), cold extremities, tachycardia, and hypotension. Give IV fluids and re-assess frequently.
Malaria may be more severe in children than adults. Children with severe malaria may present with severe anaemia, seizure/convulsions, coma, and hypoglycaemia.
Ingestion of chemicals or drugs is common in children. Try to identify the poison (talk to parents) and try to get a photograph of the package. Consult advanced provider immediately for management.

# Consider unwitnessed ingestions in children aged under 6 years (especially aged 1-3):
- Ask about signs and symptoms depending on the substance ingested.
- Take a thorough history from the family.
- Examine the bottles of the ingested substance or medicine.
- Determine what time it took place.
- Ensure that no other children were involved.
- Check for signs of burns in or around the mouth
- Check for stridor (high-pitched noises) suggesting ingestion of chemicals that burned or damaged the airway and are causing swelling.
- Children with ingestion of drugs or chemicals need to be monitored closely and may require handover/transfer to a referral unit for further management.

# Workbook question 5: Altered mental status
Using the workbook section above, answer the following questions about altered mental status in children: 

# DISPOSITION CONSIDERATIONS
Disposition depends on the cause of altered mental status. Causes of altered mental status that cannot be rapidly corrected or which might return after medications wear off need management in a hospital setting.
Any patient with altered mental status must be closely monitored for airway problems. Consider handover/transfer to a provider with advanced airway capabilities.
If the underlying cause of the low blood glucose is not identified and treated, patients with hypoglycaemia who improved with glucose may develop low blood glucose again and may require repeat treatments. These patients need to be monitored closely.
Naloxone (opioid reversal agent) effects only last approximately 1 hour. Many opioid medications are longer-acting and may need more doses of naloxone to reverse the opioid effects. Any patient treated with naloxone must be monitored closely. Make sure the new provider knows the patient has been given naloxone and may need additional doses.

# FACILITATOR-LED CASE SCENARIOS
These case scenarios will be presented in small groups. One participant will be identified as the lead and will be assessed, while the rest of the group writes the responses in the workbook. To complete a case scenario, the group must identify the critical findings and management needed, and formulate a one-line summary for handover, including assessment findings and interventions. You should use the Quick Card for these scenarios while being assessed.

# CASE #1: ADULT WITH ALTERED MENTAL STATUS
A 42-year-old man is brought in after he was found slumped over at a bus stop. When the bystanders went to him he was awake but very confused. They do not know him, but because he is so confused they brought him to you for care. 

# CASE #2: PAEDIATRIC PATIENT WITH ALTERED MENTAL STATUS
A mother brings her 3-year-old child to you for evaluation after she had two seizures/ convulsions today. The child is wrapped in multiple blankets. The mother states that the child has been increasingly confused over the past 2 days and has had high fevers.  PARTICIPANT WORKBOOK
- Use suction to remove any liquids or secretions from the airway.
- Hold the head as below in position to keep the airway open.

# Neutral position in infants Head-tilt and chin-lift in children (no trauma)
Opening the airway: adult and paediatric jaw thrust Use when the patient has altered mental status and may not be able to protect the airway and there IS a history of trauma (cervical spine fracture is possible):
- Ask an assistant to immobilize the cervical spine while you perform the jaw thrust.  - Place fingers behind the angle of mandible (the curve on the jaw bone) on both sides of the jaw and push up so that the lower jaw moves. The head and neck should NOT move. - Inspect the mouth and remove foreign bodies if visible.
- Use suction to remove any liquids or secretions from the airway if needed.
- Hold the jaw in place to keep the airway open -do not let the jaw drop back as this will close the airway.

# Jaw thrust in children Jaw thrust in adults
Head-tilt and chin-lift in children (no trauma) Neutral position in infants 

# AIRWAY SKILL STATION: MANAGEMENT OF CHOKING

# Managing choking in an adult or larger child
If respiratory distress occurs suddenly while eating, a person is clutching the throat, or there is silent coughing, cyanosis (skin turns blue in colour), stridor or noisy breathing, suspect a foreign body obstructing the airway.
Encourage the person to speak or cough if possible and observe if the obstruction is removed. Do not perform the manoeuvres described below if the person is audibly coughing and/or able to make sounds.
A person who is unable to speak or cough has complete airway obstruction and needs immediate help:
- Tell the person that you are going to provide help.
- Deliver five abdominal thrusts (see below for modifications for pregnant women).
-Stand behind the person and lean the person forward.
-Form a fist with one hand and place it in the centre of the abdomen between the umbilicus (belly button) and the bottom portion of breastbone. -Place your other hand over your fist.
-NOTE: If the patient is pregnant, place the side of your fist in the center of the chest and pull sharply inward. -Pull in and up five times using hard, quick thrusts. This forces the air out of the patient's lungs to try to "blow out" the obstruction. -If the obstruction persists, have the person bend at the waist and give five back blows (with the heel of your hand, strike the back between the shoulder blades in the direction towards the head). -Re-assess. -Repeat abdominal thrusts followed by back blows until patient speaks, coughs or becomes unconscious. -If the choking person becomes unconscious, lie him/her face up on a firm surface. Performing chest thrusts may relieve the obstruction. If a series of chest thrusts is not successful, continue with rescue breaths and chest compressions based on relevant CPR protocols.

# Chest thrusts for choking in late pregnancy
Abdominal thrusts for choking adult page 5

# Abdominal thrusts for choking adult Chest thrusts for choking in late pregnancy
Managing choking in an infant or small child - Lay the infant on your arm or thigh in face down position with the head lower than the abdomen.
- Give five back blows (with the heel of your hand, striking the back sharply between the shoulder blades in the direction towards the head). - If obstruction persists, turn the infant over.
- Give five chest thrust with two fingers, just below the nipple line in the midline of the chest.
- If obstruction persists, check infant's mouth for any visible obstruction that can be removed.
(Caution for biting.) - If necessary, repeat entire process until the foreign body is removed. 

# Chest thrusts for choking in infants

# AIRWAY SKILL STATION: AIRWAY SUCTIONING
The purpose of suctioning is to remove any liquids or secretions from the upper airway. Suctioning may be necessary to maintain an open airway if a person cannot clear secretions without help.
- Check to see if your suction canister or handheld device is working.
- Attach a rigid or soft suction catheter to the end of the suction tubing.
- Explain what you are doing.
- Insert the suction catheter into the back of the mouth (only as far back as you can see), cover the side hole on the catheter (NOT the tip of the catheter) to create suction. Suction only while pulling the catheter out and release suction when advancing the catheter forward (advancing the catheter further into the mouth while suctioning can cause injury). Repeat to suction all of the fluid in the back of the mouth. - Do not suction for more than 10 seconds at a time unless the airway is completely blocked with fluid.
- To avoid trauma to the mouth, do not place the end of the suction tip directly against the soft tissue or hold it in just one place. Suction only in the oral cavity, do not suction up the nose.

# AIRWAY SKILL STATION: BASIC AIRWAY DEVICE INSERTION
Oropharyngeal airway (OPA) insertion
- An oropharyngeal airway (OPA) should only be inserted when the person is unconscious. A conscious person will not tolerate an OPA and will push it out. If the person resists, gags or vomits, remove the device immediately. - Always protect the cervical spine when there is a history of trauma.
- Measure the appropriate size of the OPA by measuring from the tip of the earlobe to the corner of the mouth. - Open the person's mouth using care not to insert your fingers between the teeth (to avoid accidentally being bitten). - Insert the OPA with the curved portion sideways and the tip pointing towards the cheek.
- Push the OPA gently into the mouth and, when you can push no further, rotate the OPA 90 degrees, so that the tip now points down the throat and follows the curve of the tongue (see figure). - Push the OPA the remainder of the way in if necessary so that the flange (the wide, flat end) rests on the person's lips. If you have to do this, be sure that the tip of the OPA does not push the tongue down to obstruct the back of the throat. - Check again to make sure the OPA did not push the tongue down and obstruct the airway.
- Give oxygen if available.
Oropharyngeal airway (OPA) insertion page 10

# Oropharyngeal airway (OPA) insertion

# Nasopharyngeal airway (NPA) insertion
Nasopharyngeal airways (NPA) are better tolerated in people who are semi-conscious or when there is a possibility of gagging with oropharyngeal airways. DO NOT use an NPA in people with head and facial trauma.
- Assess the nasal passage for any obvious airway obstruction.
- Determine the appropriate size NPA to insert. Measure from the base of the nostrils to the earlobe.
The diameter of the NPA itself needs to be smaller than the person's nasal passage. - Lubricate the NPA well and insert it into the nostril, directing it along the floor of the nose posteriorly towards the throat until the wide, flat portion (flange) of the tube rests against the nostril. - Give oxygen if available.
Nasopharyngeal airway (NPA) insertion page 9

# Nasopharyngeal airway (NPA) insertion

# Airway skill station assessments

# Skills station marking criteria 1st pass 2nd pass 3rd pass
Safety: Personal protective equipment used or verbalized.

# BASIC AIRWAY MANOEUVRES Skill 1 -Open the airway: head-tilt and chin-lift
List the indications for use -non-trauma cases only.
Tilt the head with one hand on the forehead and lift chin with fingers.
State that a baby must be placed in a neutral (sniffing) position.
Remove foreign bodies if visible.
Suction airway if required.
Hold the airway open. Do not let the head drop back as this will close the airway.

# Comments:
Skill 2-Open the airway: jaw thrust List the indications for using jaw thrust versus head-tilt and chin-lift (trauma with possible cervical spine injury).
Ask for an assistant to immobilize the cervical spine. Place fingers behind the angle of mandible (the curve on the jaw bone) on both sides of the jaw and push up so that the lower jaw moves. Note that the head and neck should NOT move.

# AMS
Remove any visible foreign bodies.
Hold the airway open -do not let the jaw drop back as this will close the airway.
Comments:

# MANAGEMENT OF CHOKING Skill 3 -Choking: adult and larger child
Be able to give the indication for abdominal thrusts (the person is unable to speak or cough).
Tell the person what you are going to do.
Stand behind the person and lean the person forward.
Form a fist with one hand and place it in the centre of the abdomen between the umbilicus and the bottom portion of breastbone.
Cover one fist with your other hand.
Pull in and up five times using hard quick thrusts. This forces the air out of the patient's lungs to try to "blow out" the obstruction.
Assume the victim is still choking: have the person bend at the waist.
Deliver five back blows with the heel of one hand between the shoulder blades, striking the back in the direction towards the head.
State that you will re-assess the patient Repeat abdominal thrust then back blows until patient speaks or coughs or becomes unconscious.
State how this would be modified for a pregnant woman:
- Rather than abdominal thrust, place the side of fist in the centre of the chest, cover fist with other hand, and pull sharply inward.
Comments:

# Skill 4 -Management of the choking infant and small child
Lay the infant over your arm or thigh in the face down position with the head lower than the abdomen.
Give five back blows to the infant's back between the shoulder blades with the heel of one hand.
If obstruction persists, turn the infant over.
Give five chest thrusts with two fingers placed just below the nipple line in the middle of the chest.
If obstruction persists, check infant's mouth for any obstruction that can be removed.
Repeat until obstruction is removed.
Comments:

# Skill 5 -Suctioning the airway
Check your suction canister or handheld device to make sure it is working.
Attach a hard (yankauer) or soft suction catheter to the end of the suction tubing.
Tell the person what you are doing.
Insert the suction catheter into the back of the mouth (ONLY as far back as you can see) and cover the side hole on the catheter (NOT the tip of the catheter). Do not suction while inserting the catheter into the mouth. Suction only while pulling catheter out.
State how long the patient should be suctioned for (no more than 10 seconds at a time unless the airway is completely covered with fluid).
State the need to constantly move the suction catheter and not put the suction tip against the soft tissue.
Comments:

# BASIC AIRWAY DEVICE INSERTION Skill 6 -Oropharyngeal airway (OPA)
List the indication for using an oropharyngeal airway (person is unconscious with no gag reflex).
Determine the appropriate size OPA to insert: (participant should explain how to do this out loud).
- Measure from the earlobe to the corner of the mouth on that side.
Open the mouth using care not to insert your fingers between the teeth (to avoid accidentally being bitten).
Insert the OPA with the curved portion sideways and the tip pointing to the cheek.
Once the OPA is in as a far as it will go, rotate the oropharyngeal 90 degrees so that the tip now points down the throat and the curve follows the tongue.
Push the OPA the remainder of the way in so that the flange (the flat end) rests on the person's lips.
Check to make sure the OPA did not push the tongue down to obstruct the airway. State that oxygen will be given if available.

# AMS
Comments:
Skill 7 -Nasopharyngeal Airway (NPA)
List the indications for an NPA. (Better tolerated in a person who is semi-conscious or who may still have a gag reflex).
State that NPAs should not be used in people with head and facial trauma.
Assess the nasal passage for any obvious airway obstruction.
Explain how to determine the appropriate size NPA to insert:
- Measure from the external portion of the nostril to the bottom of the earlobe. - The diameter of the tube should not be bigger than the nostril (nasal passage).
Lubricate the NPA.
Lift up the tip of the nose.
Insert the lubricated NPA into the nostril and gently push it along the floor of the nose until the flared-out base (flange) rests against the nostril.
State that oxygen will be given if available.
Comments:

# Competency demonstrated YES NO

# Remediation required YES NO
Signature of facilitator:

# BREATHING SKILL STATIONS

# BREATHING SKILL STATION: BREATHING EXAM
- Assess and count the rate of breathing (normal is between 10-20 breaths per minute in an adult. See ABCDE module for normal paediatric values). - Look for increased work of breathing (nasal flaring, retractions or chest in-drawing).
- Feel for chest rise and chest wall tenderness.
- Percuss the chest wall:
-Place one hand on the chest with fingers separated (the middle finger should lie between the ribs).
-With the other hand, tap on the middle finger of the first hand and listen for changes in tone (hollow or dull). - Listen to the chest:
-Always expose the chest. Never listen through clothes.
-Make sure your stethoscope is not too cold.
-Place your stethoscope lightly on the chest wall. Ask the patient to open his or her mouth and take a complete deep breath in and out. Listen to the sounds of the breathing and compare the left side to the right. Listen in the upper zone, middle zone and lower zones and listen to the front of the chest and the back. -Normal breath sounds like wind moving in and out, while abnormal breathing sounds like air going through water, crumpling paper bags, or no air moving at all.  -Respect modesty and avoid placing the stethoscope directly on the breasts when possible.

# BREATHING SKILL STATION: GIVING SUPPLEMENTAL OXYGEN
Supplemental oxygen should be given when the patient has signs and symptoms of hypoxia -fast breathing, anxiety, excessive sweating, cyanosis or chest pain. Where available, a pulse oximeter should be used to measure oxygen saturation.
- If hypoxia does not appear severe, lower levels of oxygen (24-40% oxygen) can be provided to children and adults through nasal cannula (nasal prongs), but monitor closely in case a mask is needed. (Remember, regular air is approximately 21% oxygen) -Nasal cannula should be about half the size of the nostril.
-Position the cannula in each nostril, making sure that it does not extend too far back or press on the tissues. -Secure the tubing to the cheeks or loop the tubing over the ears so that the nasal prongs and the tubing are both on the front side of the patient's body (never put the head through the loop in the tubing -if patients become confused and hypoxic, they can accidentally strangle themselves). -Oxygen is delivered at a low rate: max 5 L/min.
- If hypoxia appears more severe (or if signs of hypoxia continue with maximum oxygen flow via nasal cannula), a simple facemask may be used. Simple facemask is usually used with oxygen flow rates of 6-10 L/min and can deliver approximately 40-60% oxygen.
-The facemask is applied to the face, ensuring the bridge of the nose is covered and as little as possible leaks along the side. The mask should rest below the lower lip, but not past the chin.
The elastic strap should be placed over the head to secure the mask. - For patients who appear extremely hypoxic or who still have signs of hypoxia with a simple facemask, oxygen can be delivered through a non-rebreather facemask. This provides close to 100% oxygen if the reservoir bag is full.
-To prepare the non-rebreather facemask, put one finger over the valve at the top of the reservoir bag inside the mask to inflate the bag. Then apply the non-rebreather facemask in the same way as the simple facemask, ensuring as little leakage as possible. -Make sure that the oxygen is attached to the wall or cannister and that the flow rate is between 10-15 L/min depending on the pressure in your oxygen system and how fast and deep the patient breathes. If the patient is still hypoxic or the non-rebreather facemask bag does not fill, increase the oxygen flow rate. -NEVER put a non-rebreather facemask on before it is connected to oxygen. A true nonrebreather mask will not allow outside air in and can worsen difficulty in breathing and hypoxia if there is no oxygen flowing through the tubing.

# AMS

# Nasal cannula/prongs Simple facemask Non-rebreather

# BREATHING SKILL STATION: BAG-VALVE-MASK VENTILATION
Assess and manage airway and provide bag-mask-ventilation (BVM) for any patient who is not breathing or not breathing adequately (too slow for age or too shallow), any unconscious patient with abnormal breathing (slow, shallow, gasping or noisy), or any patient with a pulse who is not breathing (for patients without a pulse, follow relevant CPR protocols).
CAUTION! Avoid over-aggressive ventilation (using bag-valve-mask too fast or with too much pressure) as this will damage the lungs. Children have smaller lungs that are especially fragile. When ventilating a child, be particularly careful to only give enough pressure to make the chest rise and be sure to allow enough time between breaths for exhalation (for the air to escape). Large volumes of air or high pressures may result in pneumothorax or irreversible lung damage.

# Bag-mask-ventilation steps:
- If you have oxygen available, attach the BVM tubing and set the flow to the highest rate available. DO NOT DELAY bag-mask-ventilation to prepare oxygen. (Oxygen can be attached later.) - Place the mask over the patient's mouth and nose (if you have two people available one person squeezes the bag and other holds the mask on the patient's face and keeps the airway open). - Create a seal so that air does not leak out. Put your hand or hands in the "EC" position -your thumb and first finger should make a "C" around the top of the mask and push down evenly, your last three fingers should reach just under the bony part of the jaw (looking like an "E") and pull the jaw upward to open the airway.
-Think about pulling the face up to the mask (thus opening the airway) and pushing the mask down onto the face (creating a seal). -If you push down too hard without pulling the face up to the mask, you will block the airway and the patient will be difficult to bag. If you have problems ventilating, reposition your hands and the mask and try again. - If the patient is breathing on his or her own, deliver breaths when the patient takes a breath (during inspiration). Do not attempt to deliver a breath as the patient exhales. - If you are still unable to ventilate the person after repositioning the mask, consider the possibility of foreign body obstruction or air leak. Insert an oral or nasopharyngeal airway device if not already in place (See SKILLS).

# Nasal cannula/prongs
Simple facemask Non-rebreather
- Hold the bag in one hand and depress the bag enough to make the chest rise (to about one third of its volume for an adult -make sure you are using the appropriate-sized bag: an adult bag should have a volume of about 2 litres). - Squeeze bag over 1-2 seconds to provide chest rise (giving the breath faster can cause lung damage). - Give one breath every 6 seconds (10 breaths per minute) in an adult; one breath every 4 seconds (15 breaths per minute) in older children; or one breath every 3 seconds (20 breaths per minute) in infants. CAUTION with volume of breaths given in small children (see SKILLS). Giving large volume breaths can cause pneumothorax. - After each breath allow the chest to fall before giving another breath.
- Watch the chest rising and falling evenly with each breath.

# BVM: One provider BVM: Two providers BVM: Child

# BREATHING SKILL STATION: EMERGENCY NEEDLE DECOMPRESSION
Needle decompression of the chest is a life-saving emergency procedure for suspected tension pneumothorax (presence of air or gas in the cavity between the lungs and the chest wall causing excessive pressure on the opposite lung, the great vessels, and the heart). Patients can die very quickly from a tension pneumothorax. These patients need an emergent chest tube, but emergency needle decompression will relieve the immediate pressure and allow time for handover/transfer for chest tube. Emergency needle decompression should only be performed for tension pneumothorax.
- Expose the chest and assess breathing.
- A tension pneumothorax is identified if shock and the following are present: -Difficulty in breathing -Absence of lung sounds on the affected side -Hypotension -Distended neck veins -Hyperresonance with percussion on the affected side -Tracheal shift away from affected side - Insert a large-bore (14-16G preferred) IV cannula along the upper edge of the third rib through the second rib (intercostal) space in line with the midpoint of the clavicle on the affected side.
-In tension pneumothorax, there will be a gush of expelled air - Give oxygen at high concentration (non-rebreather mask).
- Start IV lines and give IV fluids. Chest tube should be placed as soon as possible following needle decompression (even if there was no rush of air) or for any suspected haemothorax.

# Needle decompression

# BREATHING SKILL STATION: MANAGEMENT OF OPEN PNEUMOTHORAX (SUCKING CHEST WOUND)
An open pneumothorax is an open chest wall wound that sucks air in when the patient breathes in. Normally, when the chest wall is expanded, air is drawn into the lungs through the airway (through a vacuum effect). If there is another hole in the chest wall (due to trauma) air will also be drawn in that hole, but, rather than going into the lungs, it goes into the space between the chest wall and lungs, creating a pneumothorax. A 3-sided dressing is placed to prevent more air from coming in during inhalation, but to allow air from the pneumothorax to escape during exhalation to avoid developing a tension pneumothorax. To manage a sucking chest wound (open pneumothorax):
- Give high flow oxygen.
- Cover the sucking chest wound with petroleum gauze or other non-adhesive dressing such as the plastic wrapper from gauze packaging. - Tape three sides of the dressing, leaving one side un-taped to act as a flap valve. - These patients need to be transferred as soon as possible to a centre where a chest tube can be placed. (DO NOT place a chest tube through the injury.)
Caution! There is a danger of the dressing becoming stuck to the chest wall with clotted blood. When this happens, air cannot escape from the chest cavity and pressure can build up, leading to a tension pneumothorax. Remove the dressing completely if there is worsening respiratory status or evidence of worsening perfusion. If the patient cannot be observed continuously, a three-sided dressing should NOT be placed.

# Needle decompression
page 13

# BREATHING SKILL STATION: HOW TO MAKE A SPACER FROM A PLASTIC BOTTLE
The purpose of a spacer is to hold the medication (salbutamol) released from a metered dose inhaler so the person has time to effectively inhale the medication. (Without experience and proper training, it can be difficult to use a metered dose inhaler effectively and medication is often lost into the mouth or throat). Spacers should be made in advance, however. Do not delay salbutamol delivery to make a spacer.

# Spacer made from a plastic bottle
- Use a clean 300-500ml plastic bottle (wash with detergent and rinse and dry well).
- Take the cap off the metered dose inhaler and trace the shape of the opening of the inhaler on the base of the bottle directly opposite the mouth of the bottle. - Cut an opening into the base of the bottle slightly smaller than the traced shape. You can cut this with scissors or a heated paper clip. - Insert the inhaler into the spacer to check the size (the inhaler should fit tightly into the cut opening). - Always remember to prime the spacer with five puffs before use to clear the dead space.

# Breathing skill station assessments

# Skills station marking criteria 1st pass 2nd pass 3rd pass
Safety: Personal protective equipment used or verbalized use.

# Skill 1-Assess breathing
Assess and count rate of breathing.
Look for increased work of breathing (nasal flaring, retractions).
Feel for chest rise and chest wall tenderness.
Percuss the chest wall.
Listen to the chest (auscultate).
Comments:

# Skill 2 -Supplemental oxygen administration
State the indication for oxygen (hypoxia, indicated by fast breathing, anxiety, excess sweating, cyanosis (blue tinted skin), or chest pain). Explain when nasal cannula should be used (mild hypoxia).
Demonstrate applying a nasal cannula with a nasal prong in each nostril.
Secure the tubing to the cheek or loop over the patient's ears.
(The participant should NOT put the patient's head through the loop in the tubing.)
State that the oxygen flow rate should be no more than 5 l/min.
If the patient still has signs of hypoxia, explain which oxygen delivery method should be used next. (Simple facemask)
Apply simple facemask -mask over nose bridge and below lower lip.
Ensure minimal air leak -adjust elastic to hold in place.
Explain that the oxygen flow rate should be between 6-10 L/min.
If the patient still has signs of hypoxia, explain which oxygen delivery method should be used next. (Non-rebreather facemask)
To prepare the non-rebreather facemask, put one finger over the valve at the top of the reservoir bag inside the mask to inflate the bag. Ensure that the bag is inflated.
Apply non-rebreather facemask -mask over nose bridge and below lower lip.
Ensure minimal air leak -adjust elastic to hold in place.
Turn on oxygen to 10-15 L/min depending on patient's breathing.
Adjust non-rebreather mask, and adjust flow to ensure bag is filled partially.
Comments:

# Skill 3 -Bag-valve-mask ventilation
State the indication for bag-valve-mask ventilation.
State that if oxygen is available, connect it to the bag -but do not delay BVM to prepare oxygen.
Ensure adequate mask-face seal.
State correct rate of ventilation.
State relevant cautions when ventilating a child.
Verbalize that over-aggressive ventilation can damage lungs and cause vomiting.
State or demonstrate correct volume of ventilation.

# Assess chest rise.
If no chest rise, reposition airway. Consider OPA or NPA.
Comments:

# Skill 4 -Emergency needle decompression
State the indication for this procedure.
Explain procedure to patient.
Expose the chest and clean the skin.
Identify landmark: second intercostal space (between the 2nd and 3rd ribs) in the midclavicular line.
Insert 14-16G IV cannula into the identified location.
Slide cannula over needle, and remove needle.
State plan to handover/transfer for chest tube Give oxygen and assess respiratory rate, vital signs and oxygen saturation (if available).
Start IV line and give IV fluids.
Comments:

# Skill 5 -Management of open pneumothorax (sucking chest wound)
Give high flow oxygen.
Cover with petroleum gauze.
Tape 3 sides of gauze.
State the need for a chest tube to be inserted.
Describe the risk of a clotted dressing blocking outflow of air.
Comments: 
Competency

# CIRCULATION SKILL STATIONS

# CIRCULATION SKILL STATION: CIRCULATION EXAM
- Check for anxiety, confusion or altered mental status.
- Feel for a pulse, assessing rate and quality (normal range is 60-100 beats per minute in adults. See ABCDE for normal paediatric values). - Assess capillary refill (checked by pushing on the fingernail, palms, or soles and releasing to see how long it takes for the colour to return to the skin). The normal range is less than 3 seconds.
- Assess the skin colour and touch the skin to assess the temperature.
- Measure other vital signs: respiratory rate and blood pressure (normal adult values: RR 10-20 breaths per minute and systolic BP greater than 90 mmHG. See ABCDE for normal paediatric values).

# CIRCULATION SKILL STATION EXAM: EXTERNAL BLEEDING CONTROL

# Direct pressure for external bleeding
A wound that is deep and bleeding heavily may not stop bleeding on its own. Applying direct pressure with a clean dressing such as gauze can help to slow or stop the bleeding (see figure).
- Put on gloves.
- Use gauze or another clean non-adherent dressing.
- Do not use bulky dressings as they can make it difficult to put enough pressure in the right place.
- Apply firm pressure as directly as possible to the source of bleeding, usually with two or three fingers.
- If the wound is on a limb, elevate the limb above the heart.
- If the first dressing becomes soaked with blood, do not remove as this will dislodge any clots that have formed. Instead add another pad and apply firm pressure. - When bleeding stops, apply a bandage to keep the gauze/pad in place.
- If bleeding does not stop, consider deep wound packing or tourniquet (see next section). 

# Applying direct pressure to a wound

# CIRCULATION SKILL: UTERINE MASSAGE FOR POSTPARTUM HAEMORRHAGE
Some bleeding will occur with every delivery. After delivery, the uterus should contract, which compresses vessels and limits bleeding. Failure of the uterus to contract is the top cause of abnormal bleeding after delivery (postpartum haemorrhage). Call for help, arrange for rapid handover/transfer, start uterine massage and give oxytocin immediately. 

# Performing uterine massage for postpartum haemorrhage
- Explain to the woman what you will do and why.
- The goal is to compress the uterus between your hand and bony structures behind the uterus (e.g. sacrum/lower back). - Place your hand on the woman's abdomen. Through the abdominal wall, feel for the uterus and cup it with your hand. This will ensure it stays under your hand whilst you are massaging it. Do not simply squeeze the uterus, but ensure that you are applying strong pressure toward the patient's back while massaging with a circular motion. - Massage the uterus until it is very firm. It should feel like a 10 cm rock in the lower abdomen when contracted. - Do not stop massaging until the uterus is contracted (hard).
- Make sure the uterus does not become relaxed (soft) after you stop uterine massage. If it becomes relaxed, resume massage. - Continuously re-assess for vaginal bleeding.
- Perform frequent vital signs. 

# Uterine massage for postpartum hemorrhage

# CIRCULATION SKILL: IV CANNULATION

# Insertion of IV cannula (adult)
Inserting an IV cannula is an essential skill required for the treatment of shock. If an adult displays any signs and symptoms of shock, insert two large-bore cannulae (14 or 16 gauge).
- Prepare cannula, IV fluid of choice, tourniquet, gloves, dressing to cover the cannula and alcohol swab.
- Put on gloves.
- Place an elastic band or glove around the arm to function as a temporary tourniquet to help the veins engorge (this "tourniquet" is different from the one above and should not be so tight as to cut off arterial blood flow). Avoid placing an IV in any arm that might have a fistula for treatment of kidney disease. - Look and feel for a vein that is straight. Avoid blood vessels that have a pulse. If a person is in shock, it may be difficult to find a vein. In this case search for a vein in the antecubital fossa (where the elbow bends, see figure).

# IV in antecubital fossa
- Use alcohol or other appropriate skin cleanser to wipe the skin around the vein you plan to use.
- DO NOT insert an IV through skin that is broken or appears infected.
- Prepare the cannula. Preparation may vary depending on local resources and types of cannula.
- Tell the patient what you are doing.
- Remove the safety covering over the cannula (the only thing that should be inserted is the needle with overlying plastic cannula). - Insert the needle directly over and in line with the vein as flat and parallel to the skin as possible.
Watch for flashback (flash of blood in the cannula) when you enter the vein.
-If blood has a regular pumping pattern, you have likely hit an artery and you should remove the needle/catheter and apply firm pressure to the site for at least 5-10 minutes. - After seeing the flash of blood, insert the needle a few millimeters further, then advance the plastic cannula over the needle fully into the patient's vein. (Do NOT let the needle move forward when you start to move the plastic cannula.) - Hold the cannula in place, applying pressure to the base of the cannula (to occlude it and stop the flow of blood) and withdraw the needle, leaving the cannula positioned in the vein. If needed, withdraw blood to send for laboratory testing. - Remove the IV tourniquet and flush the cannula with normal saline.
- Place a cap on the end of the cannula, secure the cannula well and dress the site. Document the date the cannula was inserted in the notes. - Ensure the needle is placed into a sharps container.
Check IV site daily for signs of infections such as skin redness, pain and swelling. Ensure the cannula is still in the vein and not sitting in the skin next to the vein allowing fluid to be infused under the skin creating pain and swelling. If any sign of swelling or infection, remove the IV cannula and re-assess.

# IV in antecubital fossa
page 16

# Insertion of IV cannula (paediatric)
Attempt to place the cannula in the hand of the child first.
Other sites that can be used to insert a cannula include:

# - Scalp veins - External jugular veins - Antecubital veins - Femoral veins
When preparing for IV cannulation in children ask another assistant or parent to help keep the child's arm still.

# Veins in infants
- Prepare a 21 or 23 gauge cannula.
- When inserting the cannula into the back of the hand, keep the hand bent to obstruct venous return and make the veins visible. Place an "IV tourniquet" (as above) if needed. If you use an IV tourniquet, be sure you don't forget to remove it. - Insert the cannula using the same technique used in adults. Again, be sure that the blood flows smoothly from the catheter and is not pumping. After insertion, withdraw blood if required for laboratory investigation. Remove the tourniquet and flush the cannula with a small amount of normal saline after insertion. - Secure the cannula well. Children will attempt to remove the cannula and will undo dressings.
Avoid placing a single piece of tape (plaster) that goes all the way around an extremity as this may limit blood flow. - If the IV is placed near a joint (hand, antecubital fossa, femoral area) splint the joint to stop it from bending and preventing the IV fluid flowing in, and lightly bandage the IV site with bulky dressings to prevent the child from pulling at the adhesive dressing underneath. Securing an IV in a child page 20

# Veins in infants

# Securing an IV in a child
Inserting IV in a small child's hand page 19
Inserting IV in a small child's hand Check IV site daily for signs of infections such as skin redness, pain and swelling. Ensure the cannula is still in the vein and not sitting in the skin next to the vein allowing fluid to be infused into the skin creating pain, swelling and another source of infection. If any sign of infection, remove the IV cannula and re-assess.

# CIRCULATION SKILL: IV FLUID -ADJUSTING FLUID VOLUME FOR SPECIAL CONDITIONS
Shock should be treated with IV fluids. Fluid volume must be adjusted for patients with three conditions: malnutrition, severe anaemia and fluid overload. When administering IV fluid to any patient, look for signs of new or worsening fluid overload: difficulty in breathing, crackles in the lungs, increasing respiratory rate or increasing heart rate. Stop IV fluids if there are any of these signs and plan for immediate handover to an advanced provider.
Recognizing conditions needing IV fluid adjustment in patients with shock -fluid overload, malnutrition, and severe anaemia.

# Is there fluid overload?
In some patients, such as those with heart or kidney failure, there may be extra fluid in the tissues (for example, in the lungs or the soft tissues of the legs). These patients can be fluid "overloaded" even when they have poor perfusion (because the extra fluid is not in the blood vessels). These patients still need IV fluid if they are in shock, but IV fluid must be given more slowly with careful monitoring so that the fluid overload does not get worse.
CHECK FOR: Signs of fluid overload.
- Difficulty in breathing with crackles on chest exam - Lower body swelling (usually in the legs)
- Unable to lie flat - Distended neck veins -If signs of fluid overload are present, you must adjust fluids: Small amount of fluids may be given (250-500 ml boluses in adults). Slow the rate of fluid administration.
Monitor closely for worsening signs of fluid overload (increasing respiratory rate or heart rate, new or worsening difficulty breathing and increasing crackles in the chest).
Stop IV fluids if any of these signs develop. REMEMBER: It is important to go slowly so you can stop for early signs of fluid overload. If you don't stop IV fluid when these early signs develop, too much IV fluid can cause a patient's lungs to fill with fluid and create severe difficulty in breathing, or even death.

# Does the patient have severe anaemia?
In patients with severe anaemia, IV fluid can dilute the blood and lower its capacity to carry oxygen to dangerous levels. Additionally, patients with severe anaemia tend to show signs of fluid overload more quickly with IV fluid administration. Remember: you should only give IV fluids to someone with severe anaemia if there are signs of shock (see figure ).
CHECK FOR: Signs of severe anaemia.
- Severe pallor to the palms of the hands (compare to your own palm) or the mucous membranes.
- Fast breathing or fast heart rate - Confusion or restlessness - May also have signs of heart failure/fluid overload - If these signs of severe anaemia are present, you must adjust fluids: Slow the rate of fluid administration.
Monitor closely and stop IV fluids for worsening. Rapid handover/transfer to a centre capable of blood transfusion.

# Is the patient severely malnourished?
- IV fluid can cause life-threatening swelling and heart failure in malnourished patients and must be adjusted very carefully. Malnourished patients are also at very high risk of hypoglycaemia. CHECK FOR: Signs of malnourishment.

# AMS
- Visible wasting: a child with severe wasting does not look just thin, but is visibly bony with skin that appears too large for the body. The arms, legs and buttocks may be thin, and the head may appear relatively large because of wasting of the body. - Oedema of both feet: take shoes or socks off and assess both feet for oedema. Press the top of the foot gently with your thumb for a few seconds to see if a dent remains in the tissues. Remember that a severely malnourished child may not appear very thin if there is a lot of oedema.
- Visible severe wasting in a child: Assessing for bilateral oedema in severe malnutrition in children:
- Skin looks too large for the body - There is no fat on the child - Outlines of ribs can be seen - Severe muscle wasting of the arms, legs and buttocks - The head may appear relatively large because of wasting of the body (see figure ) Visible severe wasting in a child
- Use your thumb to press gently for a few seconds on the top of each foot -the child has oedema if there is an impression when you lift your thumb - Repeat on the other foot (see figure)

# Assessing for pitting edema in children with malnutrition
Visible severe wasting in a child page 23
Assessing for pitting edema in children with malnutrition page 22

# CIRCULATION SKILL: IV FLUID -ADMINISTRATION
Fluid administration for shock in adults
- Attach normal saline or Lactated Ringer's solution to the cannula.
- In adults give 1 litre over less than 30 minutes.
- Assess response to fluid immediately after the fluid bolus. Assess perfusion (capillary refill, mental status, urine output), and check for pulse rate and blood pressure. If improving, the pulse rate should lower and the blood pressure should increase. Mental status may also improve. - Assess for fluid overload (see signs above).
- If still in shock with no evidence of fluid overload, give another 1 litre bolus.
- If still in shock after 2 litres of IV fluid, re-assess for ongoing blood loss (external and internal) or spinal injury, and call for advanced provider.
If there is evidence of severe malnutrition, severe anaemia or fluid overload:
- Patients with shock still need IV fluids, but it is important to re-assess frequently for signs of worsening overload.
-For these adult patients who are at high risk for fluid overload, bolus with 500 ml IV fluid initially, then re-assess. If no signs of fluid overload or fluid in the lungs, give additional 500 ml.

# Fluid administration for shock in children
The appropriate amount of fluid for critically ill children is controversial given recent evidence that bolus fluids can worsen outcomes in some children. In addition, relevant criteria for poor perfusion and shock may vary by context. The 2016 WHO guidelines for the care of critically ill children (see WHO Sources section) use the presence of three clinical features to define shock requiring bolus fluids: cold extremities, capillary refill greater than 3 seconds, and weak and fast pulse.
For children with poor perfusion that is due to loss of fluid, such as those with bleeding, burns or severe diarrhoea/vomiting, bolus fluids are also recommended.
For other children with evidence of poor perfusion, smaller amounts of fluids given more slowly may be safer.
Country teams should consider the clinical presentation of the child, the capacity of providers to detect signs of fluid overload, and the availability of monitoring and support equipment when adapting recommendations to the national context.
To give IV fluid resuscitation to a child in shock WITHOUT severe malnutrition, severe anaemia or overload:
- Insert IV cannula as described above.
- Weigh the child or ask the parents for a recent weight.
- Give normal saline or Lactated Ringer's: 10-20 ml per kilogram of body weight over 30 minutes.
Re-assess the child after the first infusion.
- If no improvement, repeat 10 ml per kilogram of body weight over 30 minutes.
Call for help and plan to handover to an advanced provider and unit with the capacity for blood transfusion.

# IV fluid resuscitation for a child in shock WITH severe malnutrition
Children that are in shock AND have severe malnutrition require specialized fluids (if available) with different rates of infusion. Children with severe malnutrition and shock are at very high risk of hypoglycaemia and will need sugar in addition to fluids. Re-assess the child after the first 5-10 minutes of the infusion and then every 5 minutes:
If the child worsens during rehydration (increased difficulty in breathing, breathing rate increases by 5/min and pulse rate increases by 15/min or lung crackles develop):
- Stop the fluids.
- Call for help and plan for handover to an advanced provider.
If there is no improvement after the first infusion:
- Call for help. Plan for handover to an advanced provider at a centre with blood transfusion capabilities.
- Give fluid at 4 ml per kilogram over 1 hour while awaiting transfer to the advanced provider.
If the child displays signs of improvement (improved capillary refill, lower pulse rate and respiratory rate):
- Switch to oral or nasogastric rehydration with ReSoMal (low sodium oral rehydration solution) 10 ml per kilogram per hour for up to 10 hours. - Transfer to a malnutrition unit.

# SPECIAL CONSIDERATIONS:
Children with severe anaemia and poor perfusion need urgent handover to an advanced provider and unit with the capacity for blood transfusion.
Children who need IV fluids, but in whom bolus fluids are not indicated should be given maintenance fluids.
See the WHO Child Health publications page (www.who.int/maternal_child_adolescent/ documents/child/) for recommended maintenance fluid rates in children.

# Circulation skill station assessments

# Skills station marking criteria 1st pass 2nd pass 3rd pass
Safety: Personal protective equipment used or states intent to use   

# EXTENDED PHYSICAL EXAMINATION SKILL STATIONS EXTENDED PHYSICAL EXAMINATION SKILL STATION: NEUROLOGIC EXAM

# Glasgow Coma Scale (GCS)
The GCS is a 15-point scale for assessing and monitoring people with head injury. The person is assessed for eye opening, verbal and motor response, and given a score for the highest level of function in each area. The totals are combined to determine the overall score. The lower the score, the more severe the head injury may be. Please note that the lowest score a patient can receive is 3. 

# IMMOBILIZATION SKILL STATIONS

# Approach to spinal immobilization
There are two types of spinal immobilization: cervical spine and thoracic/lumbar spine. Together, these are called full spine immobilization. Immobilization stabilizes the bones to avoid further injury to the spine. Provide spinal immobilization to any person with a history of polytrauma who is unconscious; or who is conscious and has neck pain, spine tenderness, numbness or weakness. Remember, immobilized patients cannot move normally and are at a higher risk of airway blockage (by secretions or vomit) and pressure sore development. Monitor closely.

# IMMOBILIZATION SKILL STATION: CERVICAL SPINE IMMOBILIZATION
To immobilize the cervical spine:
- Keep the patient flat on his or her back and face up on a level surface such as a bed.
- Tell the patient what you are doing.
- Hold the patient's head in line with the spine with two hands on either side of the head.
- Prevent the patient's neck from moving with locally available materials (towel rolls, newspaper, sandbags, or bags of IV fluids) or cervical collar if available. These can be secured to the head with tape (plaster) but should never be secured to the bed. (If the patient vomits, you will not be able to turn him or her and if the patient falls, the tape (plaster) could cause a cervical spine injury.) - If the patient vomits, use the log-roll technique (see below) to turn the whole patient onto his or her side, keeping the head in line with the body. - Keep someone with the patient at all times to watch the airway.
- Remember, a patient who has severe pain/injury elsewhere may not be able to feel neck pain, even if there is a fracture. A concerning mechanism should raise suspicion.

# IMMOBILIZATION SKILL STATION: LOG ROLL
To move any immobilized patient or anyone with a suspected spine injury (e.g. if the patient has to vomit or needs to be transferred), use the log-roll technique (see figure):
- Ask for assistance. Ideally, have one person at the head to hold the neck, one or two people to hold the body and one for the legs. - The provider at the head must keep the head, neck and torso aligned with the rest of the spine.
The provider should place their forearms tightly alongside the head with hands gripping the shoulders to keep the head and neck in line with the rest of the spine. Keep this alignment when turning the patient. - The person controlling the head and neck leads the team and will say, "1-2-3 roll" to guide timing of the roll for all assistants. - Working together, roll the patient onto his or her side, keeping the spine in line.
- During the roll, the person providing head and neck control must ensure the cervical spine remains aligned with the rest of the spine. The people rolling the body should also ensure that the rest of the spine stays in as straight a line as possible. - When the patient is turned onto one side, a provider can examine the back, place or remove a backboard and/or manage back wounds as needed. - To lie the patient flat again, the person controlling the head and neck uses the "1-2-3 roll" command to ensure coordinated movement.
- Always remove a backboard as soon as possible using the log-roll technique. Time on a backboard increases the risk of pressure sores. Check pressure areas frequently using the log roll.
Preparing for log roll page 24
Preparing for log roll 

# IMMOBILIZATION SKILL STATION: FULL SPINAL IMMOBILIZATION
To immobilize the thoracic and lumbar spine (see previous section for cervical spine immobilization):
- Immobilize the cervical spine as in previous section.
- Keep the person on a flat surface with instructions to lie flat and not to move.
- For transport, log roll the patient onto a flat surface (such as a backboard) to prevent movement of the spine. Do not attach the backboard to the bed, as you will be unable to log roll (see above) if needed. - Before immobilizing, be sure there is no glass or debris on or under the patient's back. Use the log roll to check. Immobilized patients must be checked regularly to avoid pressure point wounds. - If the person needs to vomit, use the log-roll technique to roll the person to the side so that no vomit enters the airway. - Spine boards should ONLY be used to move patients. Leaving patients on spine boards for long periods of time can cause pressure sores. Remove patients from boards as soon as they arrive at the facility and can be laid flat.

# Spinal immobilization for moving a patient page 25
Spinal immobilization for moving a patient

# IMMOBILIZATION SKILL STATION: POSITIONING OF THE PREGNANT PATIENT
- If a patient is over 20 weeks pregnant and needs spinal immobilization, immobilize the spine as above. Then place padding under the side of the board near the back and hips to tilt the patient onto her left side. This helps to prevent compression of the large internal blood vessels by the pregnant uterus which could decrease blood returning to the heart.

# IMMOBILIZATION SKILL STATION: RECOVERY POSITION
- If the patient is unconscious or semiconscious and if there is NO TRAUMA, place the patient on his or her left side. Stabilize the patient by bending the top leg forward. The left arm should be straight with the patient's head resting on the arm to elevate the head and position the mouth downward. This position will allow for vomit and other secretions to drain from the mouth with less risk of airway obstruction. This is called the recovery position (see figure).

# Recovery position
page 26 Splints are used for immobilizing suspected fractured limbs, preventing pain caused by movement of broken bones and minimizing further bleeding and damage. Always assess and record perfusion of the limb beyond the fracture by assessing pulses and capillary refill time. Always assess pulses, capillary refill and sensation before AND after dressing or splinting any wound.
- If no perfusion (limb cold, pale, no pulse, slow or no capillary refill), rapid re-alignment (reduction) of the limb is required to restore circulation. - If there is still no perfusion after re-alignment of the limb, splint and plan for rapid handover/ transfer to a specialist unit. - If you cannot re-align the limb, rapidly handover/transfer to an advanced provider.

# Goal of fracture management:
- Restore circulation - Treat and reduce pain - Prevent further injury and bleeding - Re-align bony fragments so that healing and union can take place and normal function is restored - Remove all jewelry.
- Check pulses, capillary refill, sensation and movement of the limb. Document this before and after application of the splint. - Size the splint to immobilize the joint above and below the fracture site.
- If the limb is visibly deformed and pulses beyond the fracture are weak or absent, first straighten (reduce) the fracture prior to applying the splint. Do not force realignment of a deformed limb if the limb has a good pulse. - Place the joint in the desired position and if the injury involves fingers or toes, pad between toes and fingers. - If stocking gauze is available, place it over the limb without wrinkles to avoid skin damage.
- Pad the side of the splint that will be in contact with the skin, and pad the limb, especially bony protrusions (like the elbow). - Wrap the limb and splint with a bandage to hold the splint. Ask the patient how it feels to ensure it is not too tight. The splint should be secure, but remember that the limb will swell, so it is important that the splint and bandaging are not too tight. - Check pulses, sensation and movement of the limb following the application of the splint and every hour afterward. Hold the patient's head in line with the spine using your two hands on either side of the head.

# SHOCK
A partner should use rolled sheets, shoes, or IV fluid bags on either side of the head. May be secured with tape (plaster) but do not secure to the bed.
State that if the patient vomits, log-roll technique will be used to protect the airway, keeping the head aligned with the rest of the body.

# Comments:

# Skill 2 -Log roll
State indications for a log roll.
Ask for assistance.
Place one person at the head to hold the neck, one or two people to hold the body and one for the legs.
The person with head control must hold the cervical spine firmly aligned with the rest of the spine before and during the roll.
When the provider at the head and neck instructs, roll the patient onto the side. Use "1-2-3 roll" to guide the roll.
The person controlling the head and neck uses the "1-2-3 roll" to return the patient to his or her back.
State that the patient should be removed from the backboard as soon as possible to prevent pressure sores.
Comments:

# Skill 3 -Full spine immobilization
State indication for full spine immobilization.
Ask for assistance to help with the movement.
Perform log roll on to backboard for transfer.
Ensure no glass or debris on or under the patient's back.
Secure patient to backboard device for transfer (Do NOT attach backboard or patient to bed).
State to log roll if patient needs to vomit.

# Skill 4 -Positioning of the pregnant patient
Verbalize the indications for positioning (greater than 20 weeks pregnant and needs spinal immobilization).
Left lateral position with cervical spine immobilization and a pillow or wedge under the backboard or bed.
Comments:

# Skill 5 -Recovery position
Verbalize the indications.

# Controlled manoeuver into left lateral position ensuring open airway.
Appropriately position the patient (top leg bent forward, left arm straight with the patient's head resting on the arm to elevate the head and position the mouth downward).
Comments:

# Skill 6 -Fracture immobilization
Remove clothing to clearly see the injury, remove all jewelry.
Check pulses, sensation and movement of the limb and document findings.
Size the splint against the limb. Immobilize the joint above and below the injury. Place the joint in the desired position.

# Pad in between toes and fingers if injury involves digits.
If stockinette is available, place it over the limb without wrinkles or pad the side of the splint that will be in contact with the skin.
Pad the patient's limb, especially bony prominences.
Wrap the limb and splint with a bandage to hold the splint.
Check pulses, sensation and movement of the limb following the application of the splint.
State patients with an open fracture will require tetanus vaccination, if not up to date, and antibiotics.

# Comments:
Skill 7 -Applying a pelvic binder Identify pelvic pain after trauma.
Place bed sheet under the pelvis. If bed sheet is wide, fold it over so that it is the size of the pelvis (lower back to end of buttocks).
Push the binder under the small of the back and pull it into position or log roll patient onto binder.
Centre over the great trochanters (hip bones) and firmly cross over at the front.
Pull firmly and tie, but do not cause the person undue pain. It should feel firm but not overly painful. Document the time the pelvic binder was applied.

# Comments:

# Competency demonstrated YES NO

# Remediation required YES NO
Signature of facilitator:

# WOUND MANAGEMENT SKILL STATIONS WOUND MANAGEMENT: GENERAL WOUND MANAGEMENT
- Haemorrhage control: stop bleeding as above.
- Prevent infection: -Clean wound of blood clots, dirt, dead or dying tissue, foreign bodies.
-Clean skin around the wound thoroughly with soap and water or antiseptic.
-Thoroughly wash out wound by flushing with at least 1 litre of clean water. The water should be under pressure to thoroughly clean the wound. To create a high pressure stream, use a syringe (with 14 g needle or IV catheter attached) or poke a small hole in a clean bottle and squeeze the bottle.
Be sure to use the entire litre. -If not vaccinated or not up to date, give tetanus vaccination.
- Dressing wounds:
-Dress wound with sterile gauze if available.
-Use a pressure dressing if the wound is still bleeding.
-Check perfusion (capillary refill and/or distal pulses) and sensation beyond the wound before AND after dressing wounds.
- Pain management: -Give local anaesthetic before cleaning the wound if staff and equipment are available.
-Splint large lacerations and fractures.

# WOUND MANAGEMENT: BURN MANAGEMENT
It is important to cover burns early in order to keep the area moist and reduce the risk of infection. Burns can be very painful so ensure you give pain relief.
- Use sterile technique and normal saline to clean the burn.
- Carefully remove any loose, dead skin and broken, tense or infected blisters.
- Apply a non-adherent dressing to the burn to provide a moist healing environment. Clean clear plastic wrap can be used over the burn as an interim measure and if you are transferring the person to a surgical unit shortly. - Ensure the entire burn is covered with the dressing. - If the person has presented with an old burn that is now infected, apply a topical antibiotic (such as bacitracin or silver sulfadiazine). This person may also require IV or intramuscular antibiotics. - If there is delay in handover or transfer, ensure the dressings are changed daily. Always give pain control with dressing changes. 

# AMS

# BURN MANAGEMENT: ESTIMATE DEPTH OF BURN
The best way to estimate burn depth is by gently pressing two fingers onto the burn to assess capillary refill.
- Put gloves on.
- With care, press down on the centre of the burn with two fingertips for 3-4 seconds, and then let go. The faster the capillary refill the more superficial the burn is. - Now assess the outer edge of the burn (burn depth can vary for different areas of the burn).
- Use the chart below to guide your assessment findings. 

# AMS

# WOUND MANAGEMENT: SNAKE BITE BANDAGING AND IMMOBILIZATION
Note: When possible, take a picture of the snake and send with the patient.
Immobilizing a limb after a snake bite is important to reduce movement and absorption of venom.
- Always assess pulses, capillary refill and sensation before and after dressing or splinting any wound.
- You may choose to use a broad pressure bandage and wrap upwards from the lower portion of the bite. The bandage should be firm, but should not cut off pulses in the limb. Extend the bandage as high up the limb as possible.
-This is recommended if the snakes in your area produce a toxin that damages the nerves, causes paralysis, causes the person to become very ill or if there will be prolonged transport time. -This is NOT recommended if the snakes in your area produce toxins that primarily cause tissue damage near the wound and do not cause body-wide symptoms.
- Bind a splint to the limb to immobilize as much of the limb as possible.
- Note the time the bandage was placed.
- Keep the person still and lying down.
- DO NOT put a tourniquet around the snake bite or limb.
- DO NOT cut the bite out as this will lead to unnecessary bleeding.
- DO NOT suck on the bite to remove the venom.

# Wound management skill station assessments

# Skills station marking criteria 1st pass 2nd pass 3rd pass
Safety: Personal protective equipment used or verbalized use

# SKILL 1-General wound management
Haemorrhage control: stops bleeding as per earlier taught skill.

# Preventing infection
Cleans wound of blood clots, dirt and foreign bodies.
Cleans skin around the wound thoroughly with soap and water or antiseptic.
Thoroughly washes out wound by flushing with water (state 1 litre of clean water or more).
Gives tetanus vaccination as needed.

# Dressing wounds
Assesses pulses, capillary refill and sensation before dressing or splinting any wound.
Dresses wound with sterile gauze if available.
Applies pressure dressing if the wound is still bleeding.
Checks perfusion beyond the wound (capillary refill and/or distal pulses) before and after dressing wounds. Assesses pulses, capillary refill and sensation after dressing or splinting any wound.
Comments:

# BURN MANAGEMENT Skill 2 -Burn wound management
Uses a sterile technique and normal saline to clean the burn.
Removes any loose, dead skin and broken, tense or infected blisters.
Applies a non-adherent dressing to the burn to provide a moist healing environment.
Ensures the entire burn is covered with the dressing.

# Considers antibiotics.
States transfer or handover plan.
Comments:

# Skill 3 -Fluid resuscitation in burn injury
Correctly states indications:
- Partial or full thickness burns greater than or equal to 15% total burn surface area in adult. - Partial or full thickness burns greater than or equal to 10% total burn surface area in children.
Estimates depth of burn. 

# Medication administration skill discussion
The table below summarizes the medications discussed in this course, which represent only a very basic set of treatments for emergency conditions. They have been included based on their wide availability, their appropriateness for use by all of the frontline providers targeted by this course, their feasibility of use in pre-hospital or facility settings, and for their potential importance as early treatments for emergency conditions. Be sure to check locally available drug concentrations, as these can vary. The most common concentrations are used in this table for dosing reference. Almost every condition discussed will require additional treatments beyond these, and many important emergency treatments that may be used by advanced providers are not included here. 

# Transfer and handover skills discussion
This course is intended for providers working in the field, on ambulances and in health-care facilities. Transferring patients from the scene to first facility, or between facilities, require special attention to destination planning, ongoing management and handover.

# DESTINATION PLANNING
Many patients treated on the scene will require transport to a health-care facility for further management. Additionally, patients already at a facility may require transfer to a different facility for more advanced care. For example, a pregnant woman with seizures will need handover for advanced care and emergency delivery; a patient with severe burns will require transfer for advanced airway management and surgical care; a patient in shock from blood loss will require handover to a centre capable of blood transfusion.
When planning any transport, make sure that: the level of services at the destination facility matches the needs of the patient (e.g. there is an operating theatre if surgery is needed); that the expected resources are currently available (e.g., the operating theatre is running, and there is blood for transfusion); and that the destination can be reached in the necessary time frame given the patient's condition. Do not delay transport for tests or interventions that are not critical to patient safety if they can be performed at the receiving facility.
Follow local transfer and destination protocols where they exist. Where there are no clear protocols, balance transport times with facility capabilities -the goal is to reach needed care as soon as possible. It is usually better to have a longer initial transport time than to arrange a second transfer because appropriate care was not available at the first destination.
Once the appropriate facility has been determined, communication with a provider at the receiving facility is essential (see 'Handover' below). This will allow the receiving centre to prepare for the patient's arrival and arrange resources (e.g. blood, operating theatre preparation). Follow specific local communication protocols where they exist. Wherever possible, formal protocols for both pre-hospital transport and transfer between facilities should be in place. These should include explicit criteria for when a patient should be transferred.

# TRANSPORT
Transfer includes two aspects: transporting the patient and caring for the patient at all times during transport. One person cannot do both jobs. During transport, at least one provider should always be in the same part of the vehicle as the patient to allow for ongoing monitoring, assessment and management. The ABCDE approach should be used to assess and re-assess ALL patients during transportation; vital signs (including AVPU or GCS) should be checked every 15 minutes, and patients should be closely monitored for response to treatments and for signs of worsening. Remember to plan overall transportation time and route, and check road conditions and weather. This is essential in order to anticipate the patient's needs during transport (e.g. IV fluid and medication needs). Ensure that the patient and family are aware of the transport plan. Allow a family member to accompany children whenever possible.

# HANDOVER
Formal handover should be given any time care is transferred to a new provider, including: between providers within a facility, to or from transport providers, or remotely from a sending facility to a receiving facility provider. In addition to a verbal report at the time a patient is handed over to a new provider, written documentation of the clinical condition and treatment should accompany the patient at all times.
You will practise handover summaries throughout the course in the case scenarios. The Situation, Background, Assessment, Recommendations (SBAR) format is a structured way of communicating key information and can be used for all of the handovers mentioned above. SBAR components and examples are: SITUATION Basic patient information (e.g. age, sex).
Chief complaint (the patient's initial description of the problem, such as difficulty in breathing for 3 days, or arm pain after a fall, etc.).

# BACKGROUND
The 2-4 most important and relevant aspects of the patient's case and/or condition (these may be elements of the history, physical exam, or testing results, depending on the case).
Include any important ABCDE findings/interventions.

# ASSESSMENT
What you think is wrong with the patient.
The reason for the handover/transfer.

# RECOMMENDATIONS
Specific things the new provider should prepare for:
-next steps in the treatment plan; -potential worsening of the patient's condition (e.g. need for close airway observation if inhalation burn is suspected);
-cautions regarding prior therapies or interventions (e.g. time of last adrenaline dose to anticipate return symptoms, need to monitor mental status if sedating medications have been given, need to monitor 3-way dressing for clotting, etc.). Case 2: A 14-year-old girl had a seizure/convulsion at school. She was brought to you by her teachers because she did not stop seizing. You administered a benzodiazepine, which caused the seizures to stop. After, you were able to perform the ABCDE survey and then a complete head-to-toe exam. She does not have a fever; she has a normal heart rate, blood pressure, and respiratory rate. She responds to voice. Her tongue is bitten and she urinated on herself; she has no other injuries or rashes.
Handover summary: This is a 14-year-old girl who had a prolonged convulsion and was convulsing on arrival; her seizures were stopped with one 10 mg dose of diazepam and now she remains sleepy, has normal vital signs and no fever. She is being transferred for further evaluation of her seizure.
Monitor the airway as she has received sedating medications (diazepam).
Case 3: A 75-year-old man had chest pain while walking home from the market. He was brought to you by taxi. He says that the chest pain started 30 minutes ago and felt like a lot of pressure in the centre of his chest. He has no allergies. He takes a blood pressure medication, but cannot recall the medication's name. He had a heart attack 2 years ago that felt very much like the pain he was having today. His last meal was 6 hours ago. The pain started while he was walking home carrying several heavy bags, though he now has no pain. His vital signs, ABCDE survey, and head-to-toe examination are normal. You have given aspirin and started an IV line and will now handover to an inpatient provider. 

# GLOSSARY

# ABCDE
The initial steps of any patient assessment, which includes assessing and treating Airway, Breathing, Circulation, Disability and Exposure.

# Accessory muscle use
Use of muscles other than the diaphragm to assist in breathing (commonly the neck, chest wall, and abdominal muscles). May appear as indrawing/retractions between the ribs, or in the neck muscles.

# Altered mental status (AMS)
Term used for a range of presentations from changes in behaviour or memory, to disorientation, confusion and coma.

# AMS
See altered mental status.

# Anaemia
Decreased concentration of red blood cells, leading to a decreased ability to carry oxygen.

# Anaphylaxis
A severe allergic reaction that can cause shock.

# Asthma
A condition causing mucus production and intermittent spasm in the bronchial airways, resulting in narrowing that causes wheezing.

# AVPU
A system to assess level of consciousness: Alert, Verbal, Pain, and Unresponsive.

# Bag-valve-mask (BVM) device
A manual handheld device consisting of an air-filled bag connected to a mask. The bag is compressed by hand to deliver a breath as the mask is held to the patient's face.

# Bolus
A defined volume of fluid or other substance given rapidly, usually intravenously.

# Bradycardia
Heart rate lower than normal range.

# BVM
See "bag-valve-mask device".

# Capillary refill
A marker of perfusion, checked by pushing on the fingernail, palms or soles and releasing to see long it takes for the colour to come back to the skin (blood flow to return). The normal range is less than 3 seconds.

# Cardiopulmonary resuscitation (CPR)
Performing chest compressions and ventilation with the goal of resuscitating a patient with no pulse.

# Cervical spine (C-spine)
The part of the spine in the neck, containing the first seven vertebrae.

# Circumferential burn
Burns that extend around a body part can act like a rigid band and may limit blood supply (to a limb) or breathing (burn around the chest or abdomen).

# Cholera
Bacterial infection causing a profound watery diarrhoea, often described as rice-water stools.

# Chronic obstructive pulmonary disease (COPD)
Term describing breakdown of lung structure (emphysema) and chronic inflammation causing spasm of the lower airways and wheezing.

# Coma
Prolonged state of unconsciousness.

# Compartment syndrome
A condition of increased pressure from swelling in an area of the body that cannot expand, such as compartments in the forearm or lower leg. Compartment syndrome reduces blood flow to the area and may result in severe pain as well as damage to nerves and other tissues.

# Confusion
Problems with clarity, recall and organization of thought.

# Convulsion
See Seizure.

# CPR
See cardiopulmonary resuscitation.

# Crackles
High pitched sound, like crumpling of a paper bag, heard with a stethoscope. Crackles are caused by fluid in the airspaces of the lungs. Also called rales or crepitations (creps). 

# SKILLS

# Crepitations
See "Crackles".

# Crepitus
Crackling or popping when pressing on the skin or bones.

# Cyanosis
Blue colouring to the skin or lips, resulting from low blood oxygen levels.

# Decontamination
Removing a dangerous substance, such as chemicals, toxins or infectious materials, from a person's skin or clothes. Depending on the substance, this is done by brushing off the substance or irrigating with water.

# Deep wound packing
Tight packing of a large or gaping wound with clean, compact gauze to ensure that external pressure can effectively compress an area of bleeding that is too large or too deep to compress otherwise.

# Defibrillator
Machine that delivers high-energy electrical current to convert abnormal heart rhythms.

# Dehydration
Decreased fluid in the body.

# Delirium
Rapidly changing state of confusion, characterized by agitation, loss of focus and inability to interact appropriately.

# Dementia
Chronic condition characterized by abnormal mental state, including loss of memory and problems with thinking. There is often no change in ability to focus on the present.

# Destination planning
Planning the choice of destination facility for transport or transfer in order to best match transport time and the level of services available at the receiving facility to the patient's clinical needs.

# Diabetic ketoacidosis (DKA)
A condition occurring in diabetics in which lack of insulin causes elevated blood sugar, leading to severe dehydration and build-up of acid in the blood.

# Diaphoresis
Sweating.

# DIB
See difficulty in breathing.

# DKA
See Diabetic Ketoacidosis.

# Dilation (of blood vessels)
The enlargement or stretching of a part of the body (e.g. blood vessels).

# Difficulty in breathing (DIB)
The feeling of difficulty in breathing (sometimes also called shortness of breath, or SOB) can result from many causes, including problems with the lungs, problems with oxygen, airway blockage, fast breathing, weak respiratory muscles.

# Direct pressure
A way to control external bleeding (haemorrhage) from a wound by applying firm pressure with two or three fingers at the site of bleeding.

# Disposition
The next step in care of a patient -this may be handover of care to another provider through admission or transfer, or discharge to home.

# Drowning
Compromise of breathing from water in the lungs, usually resulting from prolonged time under water.

# Eclampsia
A condition when a pregnant or newly delivered woman has seizures, high blood pressure, and protein in the urine. It can progress to coma and is life-threatening. ("Pre-eclampsia" is diagnosed based on specific criteria and identifies a woman at high-risk of progression to eclampsia.)

# Ectopic pregnancy
A pregnancy outside of the uterus, most often in the fallopian tubes. As an ectopic embryo grows, it may damage the surrounding structures, causing sudden severe bleeding. Ruptured ectopic pregnancy is a surgical emergency.

# Envenomation
The process by which venom is injected by the bite (or sting) of a venomous animal.

# Escharotomy
A surgical procedure to cut and release burned tissue that may restrict breathing or blood supply to a limb.

# Flail chest
When multiple rib fractures in more than one place cause a segment of the rib cage to be separated from the rest of the chest wall and prevent normal breathing movement. 

# Inflammation
Redness and swelling that may result from trauma, infection, allergy or other causes.

# Ingestion
Swallowing a substance -generally used for dangerous substances or doses.

# Inhalation injury
Inflammation or oedema of the airways or lungs resulting from breathing hot gases or irritating chemicals (most commonly smoke inhalation in the setting of fire).

# Intubation
Placing a breathing tube through the mouth, down the throat, and through the vocal cords to allow ventilation of the lungs by bag device or ventilator.

# Ischaemia
Inadequate oxygen and blood supply to tissues that can lead to tissue death (myocardial ischaemia, or lack of oxygen to the heart muscle, is an example).

# IV (abbreviation for intravenous)
Often used to refer to an intravenous catheter, or for the intravenous route of administration of a medication or fluid.

# Kangaroo care
Using skin to skin contact between a newborn infant and mother and covering the child's head and exposed body, to prevent hypothermia and promote bonding.

# Laceration
A cut or slice to the tissues.

# Large-bore IV
A large IV catheter is needed for rapid volume resuscitation. Ideally, these catheters should be placed in larger blood vessels (that tend to be closer to the heart, like the antecubital fossa in the arms or large veins in the neck). In adults, this is usually defined as 14-or 16-gauge, though in some settings, 18 may be the largest available gauge.

# Level of consciousness
Describes the level of responsiveness or alertness to the environment.

# Lethargy
Excessive drowsiness and slowness to respond.

# Log roll
A method of rolling a person to the side while preventing the spine from bending. Usually performed when spinal injury is suspected to prevent additional damage.

# Nasal flaring
The widening of nostrils during breathing -it results from increased effort, and is a sign of difficulty in breathing.

# Nasopharyngeal airway (NPA)
A rubber tube inserted through the nostril that reaches to the opening of the throat to allow air to pass.

# Needle decompression
Insertion of a needle into the chest wall to relieve the pressure of a tension pneumothorax.

# Oedema
Abnormal swelling or fluid build-up in the body tissues, outside the vascular space.

# Oral rehydration solution (ORS)
A water, glucose, and salt mixture given by mouth or nasogastric tube to dehydrated patients to replace fluid losses.

# Orientation
Describes a person's relationship to the surrounding world, including the ability to accurately identify one's own name and location, as well as the current time and date.

# Oropharyngeal airway (OPA)
A plastic device inserted through the mouth that reaches to the opening of the throat to prevent the tongue from blocking the airway and allows air to pass.

# ORS
See "Oral rehydration solution".

# Oxygen (O2) saturation
Percent of oxygen in the blood.

# Parkland Formula
A formula used to estimate the amount of IV fluid needed for resuscitation of a burn patient over the first 24 hours after the burn. It is: 4 ml fluid X weight in kilograms X total burn surface area. Half should be given over the first 8 hours, and half over the next 16 hours.

# Percussion
Tapping on the chest wall to assess the lungs. The quality of the sound on tapping may indicate fluid or air in the lungs.

# Perfusion
The delivery of blood to body tissues.

# Pericardial effusion
Fluid in the sac around the heart (the pericardium). 

# SKILLS

# Pericardial tamponade
A critical build-up of fluid in the sac around the heart (the pericardium) that compresses the heart and interferes with normal pumping of blood to the body, leading to shock.

# Personal protective equipment (PPE)
Equipment meant to be worn by a person to protect from infection or injury. This can include gloves, goggles, and protective clothing such as aprons or fluid resistant gowns.

# Pleural effusion
Abnormal fluid collection around the lung that can cause difficulty in breathing and even lung collapse. Common causes include tuberculosis and other infections, heart failure and cancer.

# Pleuritic pain
Pain that is worse with breathing, usually caused by inflammation.

# Pneumonia
Infection of the lungs.

# Pneumothorax
Air in the space between the lungs and the chest wall (pleural space) that causes the lung to collapse.

# Pre-eclampsia
See Eclampsia.

# Priapism
Persistent, abnormal erection of the penis.

# Psychosis
Broadly defined as loss of contact with reality.

# Pulmonary embolism
Blood clot travelling to and blocking the vessels of the lungs. The most common source is the legs.

# Pulse oximeter
Device that detects oxygen saturation (the percentage of red blood cells saturated with oxygen).

# Rabies
A virus that is transmitted through animal bites that affects the brain and nerves and can cause altered mental status.

# Rebound tenderness
Pain that occurs when releasing pressure on the abdomen (as opposed to when pressing on the abdomen).

# Resuscitation
Time-sensitive interventions performed in an attempt to manage life-threatening conditions.
Retractions (sometimes also called "in-drawing" or "recessions")
The visible pulling in of tissues between the ribs or around the collarbones with strained inspiration. Retractions are a sign of serious difficulty in breathing.

# SAMPLE history
An approach to asking key history findings for all patients. SAMPLE stands for: S -Signs and Symptoms, A -Allergies, M -Medications, P -Past history, L -Last oral intake, E -Events surrounding the illness or injury.

# Seizure
Also called convulsions or fits. Abnormal electrical activity in the brain, often seen as altered mental status with abnormal repetitive movements. Seizures may be a primary condition or may be caused by infection, injury, toxins or chemical balance problems.

# Shock
A state where organs do not get enough blood and oxygen (poor perfusion), leading to organs not working properly.

# Skin pinch testing
An easy way to check hydration status in children by pinching the skin, usually on the abdomen. Well-hydrated skin should return to normal in less than 2 seconds.

# Sprain
A stretched, pulled, or torn ligament.

# Stridor
A high pitched sound on breathing in that is caused by swelling or a physical obstruction of the upper airway.

# Stroke
Death of brain tissue due to ischaemia from either blood clot or haemorrhage.

# Sucking chest wound
A wound in the chest wall that allows air in and out of the chest cavity, indicating an open pneumothorax.

# Tachycardia
Heart rate faster than normal range.

# Tachypnoea
Rapid breathing. 

# SKILLS

# Tension pneumothorax
Occurs when a pneumothorax causes sufficient pressure inside the chest cavity that blood vessels collapse (reducing the amount of blood that can return to the heart, and the heart cannot fill or pump enough blood to maintain perfusion of the organs).

# Tracheal shift
Describes a change in the position of the trachea to either side of midline, a finding sometimes associated with tension pneumothorax.

# Trauma primary survey
The trauma primary survey is another term for the ABCDE approach in injured patients. It includes initial assessment of an injured person and management of all immediately lifethreatening injuries, in order of priority. The primary survey consists of the ABCDE: Airway, Breathing, Circulation, Disability and Exposure.

# Trauma secondary survey
The head-to-toe (front and back) examination of the trauma patient that includes taking a SAMPLE history. The purpose of this survey is to identify and treat all injuries, with priority given to any hidden life-threatening conditions that were missed by the primary survey.

# Tripod position
Sitting upright with neck extended but leaning slightly forward with hands on knees. People with severe difficulty in breathing will often sit in this position.

# Wheezing
A whistling sound made when breathing out due to inflammation in the lungs, suggestive of lower airway swelling. 

# SKILLS

# SKILLS
SKILL STATIONS are designed to allow you to practise new skills and demonstrate lifesaving techniques.

# REMEMBER...ALWAYS WEAR PROPER PPE PRIOR TO CARING FOR A PATIENT AND PERFORMING ANY SKILL.

# AIRWAY SKILL STATIONS

# AIRWAY SKILL STATION: BASIC AIRWAY MANOEUVRES

# Opening the airway: adult head-tilt and chin-lift
To be used for patients with altered mental status who may not be able to protect the airway, with NO history of trauma:
- Place person face up on flat, firm surface.
- Tilt the head back with one hand and lift the chin with your fingers.
-To do this, place one hand on the patient's forehead and then place two fingers of the other hand on the chin. Rotate your hands, tilting the chin up away from the chest. - Remove foreign bodies if visible.
- Use suction to remove any liquids or secretions from the airway if needed. - Hold the airway open -do not let the head drop back as this will close the airway.

# Opening the airway: paediatric head-tilt and chin-lift
To be used with patients with altered mental status who may not be able to protect the airway, with NO history of trauma:
- Remember, children's heads are bigger than adults' heads compared to body size, and their airways are softer and easier to block when the neck is bent. In older children, the airway can be opened by tilting the head backwards slightly (see figure). - Babies have the largest heads relative to their body size. Their heads should be placed in neutral (sniffing) position (see figure). - Inspect the mouth and remove visible foreign bodies. Take care not to push the foreign body deeper into the airway.
Adult head-tilt and chin-lift

# Adult head-tilt and chin lift

# Deep wound packing for external bleeding
If the wound is deep or gaping and simple pressure does not stop the bleeding, deep wound packing may help. However, deep wound packing is a temporary procedure to stop the bleeding since it can lead to infection if left for more than 24 hours.
- Put on gloves.
- Always assess pulses, capillary refill and sensation before and after dressing or splinting any wound.
- Thoroughly wash out the wound by flushing with at least a litre of clean water (under pressure when possible; see next section). - Use gauze or another clean, compact material to completely fill the space within the wound.
- Use additional gauze on top of the wound surface and apply direct pressure with your gloved hand or a bandage wrapped firmly around the wound/limb. - For limb wounds requiring packing, apply a splint to reduce the risk of re-bleeding.
- A deep wound pack should not be left in place for more than 24 hours because of the risk of infection. - If bleeding does not stop, consider tourniquet (see next section).

# Tourniquet technique for uncontrolled external bleeding
You will not be expected to perform the tourniquet technique BUT you will be expected to know what life-threatening conditions it can be used for, the special considerations around use of a tourniquet and the ongoing care of the patient.
Use this technique ONLY if all other bleeding control measures have failed AND haemorrhage is life-threatening. If you place a tourniquet, there is a possibility that tissues below the tourniquet will be permanently damaged and even require amputation. If you are considering using a tourniquet, CALL FOR HELP IMMEDIATELY and plan for handover/transfer to a unit where surgery is possible.
- If available, use a pneumatic tourniquet (like a blood pressure cuff ) over padded skin and inflate until bleeding stops. If not, use a thick band or piece of cloth or belt (the wider, the better), over padded skin. - Apply as close to wound as possible, but do not place over a wound or a fracture.
- Apply enough pressure to make distal pulses disappear and re-assess bleeding.
- If bleeding stops, leave dressing in place if already present or dress the wound and prepare for handover/transfer to a surgical care unit. - If the bleeding does not stop, increase tourniquet pressure until major bleeding ceases.
- Record the exact time the tourniquet was applied in the notes AND write it on the patient's skin or the tourniquet itself. - Consult advanced provider as soon as possible (and never more than 2 hours) after placing a tourniquet. - The tourniquet should be released every 2 hours for at least 10 minutes. Hold direct pressure to the bleeding area during this time. Do not re-apply the tourniquet unless evidence of continued active bleeding. - Location of the tourniquet: tourniquets should only be placed on extremities and should be placed above the level of the bleeding. Because of the relationship between the bones and blood vessels, tourniquets on the upper arm or leg are often more effective than tourniquets placed below the elbow or knee. - Make sure the tourniquet is clearly visible.
- Remember tourniquet should be placed as a last resort. If you place a tourniquet, you are cutting off blood supply to the limb, so only do this for life-threatening bleeding. When tourniquet use is absolutely necessary, use a wide, yet constrictive, band.

# FRACTURE IMMOBILIZATION: OPEN
Consider an open fracture if there is a wound near a fracture site. Open fracture sites can often be contaminated and will require cleaning and potentially surgical debridement before the fracture can be fixed. If an open fracture is suspected, plan for handover/transfer to a surgical or orthopaedic unit after splinting.
- Give pain relief prior to splinting.
- Control haemorrhage with direct pressure. In limb amputation, if bleeding is uncontrolled apply tourniquet (see above), commence fluid resuscitation and plan for rapid handover/transfer. - Straighten (reduce) the limb if there are signs of poor perfusion or absent pulses in the limb.
- Remove any dirt, grass, obvious glass or other debris from the wound and irrigate the wound with 2 litres of normal saline. - Cover the wound with saline-soaked gauze. - Splint as above, but leave a window so you can continue to monitor the wound.
- In amputation, cover wound with sterile, saline-soaked gauze or towel.
- Give tetanus vaccination.
- Begin IV antibiotics.

# IMMOBILIZATION SKILL STATION: APPLYING A PELVIC BINDER
Pelvic fractures can cause life-threatening haemorrhage by damaging blood vessels adjacent to the fractures. If a person has been injured and has pain in and around the pelvis, apply a binder (see figures). As the pelvis is shaped in a ring, the binder will bring together the displaced bones and help limit internal bleeding. Signs of pelvic fractures include pain or abnormal movement of the pelvis on exam; bruising around the hips, at the top of legs, or to the genitals; and signs and symptoms of shock.
- Place bed sheet or similar under the pelvis. If the bed sheet is wide, fold it over so that it spans from the lower back to the end of the buttocks. - You may need to log roll the patient in order to get the binder in position.
- The sheet should be centered over the greater trochanters (hip bones, as demonstrated by the instructor) and firmly cross-over at the front. - Pull firmly and tie, but do not cause the person undue pain. It should feel firm but not overly painful.
- Document what time the pelvic binder was applied.
- Check the binder each hour. Confirm that the binder is still applying pressure around the pelvis.
Ensure that that skin is intact where the binder has been applied and around the genitals.

# Normal pelvis
Open pelvic fracture page 27

# Normal pelvis
Open pelvic fracture

# ADULT BURN MANAGEMENT: DETERMINE TOTAL BODY SURFACE AREA (TBSA)
This is used to calculate the fluids needed using the Parkland Formula. Use the Rule of Nines body chart for adults and modified chart for children and infants (see figure).
The body is divided into portions that each make up 9% of the total body surface. Children have different percentages due to the different body proportions, such as a larger head and smaller limbs (see figures).
- Assess the person using the diagram below.
- Note the areas of burn and shade them in on the diagram.
- - Full or partial thickness burns greater than or equal to 15% total burn surface area in adults.
- Full or partial thickness burns greater than or equal to 10% total burn surface area in children.

# BURN MANAGEMENT: PARKLAND FORMULA CALCULATION FOR THE FIRST 24 HOURS
4 ml IV fluid X weight in kilograms X % total burn surface area- *% total burn surface area = % partial thickness burn area + % full thickness burn area (% superficial burn area is NOT used in the calculation)
The Parkland Formula is a fluid resuscitation management strategy for the initial 24 hours following a burn. Patients presenting beyond 24 hours after the initial burn will also need fluid resuscitation, but the Parkland Formula is not used beyond 24 hours.
- The first half of the fluid should be given within the first 8 hours after the burn (NOT after arrival to care). - The second half is to be given over the subsequent 16 hours.
- For adults, give normal saline or Ringer's Lactate.
- For children, use a dextrose-containing fluid (Ringer's Lactate with 5% dextrose or normal saline with 5% dextrose for initial resuscitation). If no dextrose-containing fluids are available, give an additional dose of dextrose (either IV or orally) with IV fluids (see MEDICATIONS). REMEMBER: Patients with serious burns to >15% of their body, burns involving the hand, face, groin area, joints, or burns that go completely around the body or a body part need to be transferred/ handed over for specialized care.

# Drug indication Dosage Adverse effects
Antibiotics Specific drugs in this category will be determined by local treatment protocols and availability. These should include a broad-spectrum regimen for life-threatening infections that can be used empirically (before the infectious source is definitively identified) in very ill patients.
- Allergic reactions Tablet: 2 mg, 5 mg Solution: 5 mg/1 ml ampoule Adults: First dose: 10 mg slow IV push OR 20 mg rectally Second dose after 10 minutes: 5 mg slow IV push or 10 mg rectally Maximum IV dose: 30 mg

# Children:
First dose: 0.2 mg/kg slow IV push or 0.5 mg/kg rectally. Can repeat half of first dose after 10 minutes if seizures/convulsions continue.
Maximum IV dose: 20 mg Do not give second dose if respiratory rate is less than 10 breaths per minute.

# Do not give diazepam intramuscularly (unpredictable absorption).

# How to give rectal diazepam:
- Draw up the dose from an ampoule of diazepam into a small syringe (tuberculin if available). Base the dose on the weight of the child, when possible. - Remove the needle.
- Insert the syringe 4-5 cm into the rectum, and inject the diazepam solution. - Hold the buttocks together for a few minutes.  

# IF unable to give IV, give 10 g IM injection only (as above, 5 g in each buttock).
If seizures/convulsions recur: after 15 minutes give an additional 2 g (10 ml of 20%) IV over 20 minutes.
If transport delayed, continue treatment: Give 5 g of 50% solution IM with 1 ml of 2% lidocaine every four hours in alternate buttocks.
- Remember: child must be able to seal mouth around spacer opening. Babies will likely require spacer mask or nebulizer.
Nebulizer: (ADULT) 5mg in 5 ml sterile saline.
(CHILD) 2.5mg in 3 ml sterile saline.
For severe wheezing, above doses can be given several times in an hour. 

# Tetanus vaccination

# Fluid status
The level of fluid in the body. It can be low (dehydration), normal, or high (fluid overload and/ or oedema).

# Fontanelle
A gap (soft spot) between the developing bones of the skull in babies -changes in the volume of fontanelles may reflect fluid status. Fontanelles normally close between 12 and 18 months of age.

# Foreign body
An object from outside the body (e.g. a foreign body in the airway).

# Fracture
A broken or cracked bone.

# GCS
See Glasgow Coma Scale.

# Gastroenteritis
Infection or inflammation of the stomach and intestine that can cause vomiting, diarrhoea and abdominal pain.

# Glasgow Coma Scale (GCS)
A system of assessing the neurologic function of a trauma patient. It is a score ranging from 3 (unresponsive) to 15 (normal) that assesses responsiveness based on eye movement, verbal response and motor response.

# Guarding
Voluntary or involuntary contraction of the abdominal wall muscles when pressing on the abdomen.

# Handover
A brief summary of critical patient information given by the current provider any time a patient is transferred to a new provider. Handover summarizes the clinical presentation, the care the patient has received, and alerts the new provider of any potential complications. Handover should always be given to transport providers, in addition to receiving-facility providers. Handover should also be given even when care is transferred to a new provider within the same facility.

# Haemorrhage
Large volume bleeding. It may occur externally or within the body.

# Haemorrhagic shock
A state of poor perfusion due to substantial blood loss.

# Haematoma
Bleeding or a collection of blood within the tissues, outside of the vascular space. Also called bruising.

# Haemothorax
Blood in the space between the chest wall and the lungs.

# Heart attack
(Also called myocardial infarction). Death of heart muscle due to a lack of oxygen-rich blood getting to the heart.

# Heart failure
When the heart fails to pump enough blood to perfuse the organs, usually resulting in oedema in the lungs or extremities.

# Hives
Multiple itchy, red and raised areas on the skin suggestive of an allergic reaction.

# Human Immunodeficiency Virus (HIV)
A virus that weakens the immune system and can lead to AIDS, a syndrome of multiple infections.

# Hyperthermia
High body temperature.

# Hyperventilation
Increased (fast) rate of breathing.

# Hyperresonance
Hollow sounds with percussion.

# Hypoglycaemia
Low blood sugar.

# Hypothermia
Low body temperature.

# Hypotension
Blood pressure lower than the normal range.

# Hypovolaemic shock
Poor perfusion due to low blood volume, which may result from decreased fluid intake or severe fluid or blood loss.

# Hypoxia
Low levels of oxygen in the blood. 

# D
- Always check AVPU - Hypoglycaemia is common in ill children.
- Check for tone and response to stimulus.
- Look for lethargy or irritability.

# E INFANTS AND CHILDREN HAVE DIFFICULTY MAINTAINING TEMPERATURE
- Remove wet clothing and dry skin thoroughly. Place infants skin-to-skin when possible.
- For hypothermia, cover the head (but be sure mouth and nose are clear).
- For hyperthermia, unbundle tightly wrapped babies.

# DANGER SIGNS IN CHILDREN
- Signs of airway obstruction (unable to swallow saliva/ drooling or stridor) - Increased breathing e ort (fast breathing, nasal aring , grunting, chest indrawing or retractions) - Cyanosis (blue colour of the skin, especially at the lips and ngertips) - Altered mental status (including lethargy or unusual sleepiness, confusion, disorientation)
- Moves only when stimulated or no movement at all (AVPU other than "A") Penetrating eye injury Avoid pressure on the eye, stabilize but do not remove foreign objects, give antibiotics and tetanus, elevate head of bed.
Open abdominal wound Give IV uids, nothing by mouth. Cover visible bowel with sterile gauze soaked in sterile saline, give antibiotics.

# Pelvic fracture
Give IV uids, stabilize with sheet or pelvic binder.

# Fracture with poor limb perfusion
Reduce fracture, splint.
Open fracture Irrigate well, dress wound, splint, give antibiotics, rapid handover for operative management.

# Penetrating object
Leave object in place and stabilize it to prevent further injury.

# Crush injury
Give IV uids, monitor urine output, monitor for compartment syndrome.

# Burn injury
Assess size and calculate uid needs, give IV uids and oxygen, monitor for airway oedema.

# Blast injury
Give oxygen, treat burns as below, give IV uids, monitor closely for delayed e ects of internal injury.

# REMEMBER: INJURED PATIENTS WITH WOUNDS, INCLUDING BURNS AND OPEN FRACTURES, NEED TETANUS VACCINATION.

# HIGH-RISK MECHANISMS AND INJURIES

# High-Risk Mechanisms High-Risk Injuries
- Pedestrian or cyclist hit by a vehicle - Motorcycle crash or any vehicle crash with unrestrained occupants - Falls from heights greater than 3 metres (or twice a child's height) - Gunshot or stabbing - Explosion or re in an enclosed space.
- Penetrating injuries to head, neck or torso - Blast or crush injuries - Flail chest - Two or more large bone fractures, or pelvic fracture - Spinal injury - Limb paralysis - Amputation above wrist or ankle

# SPECIAL CONSIDERATIONS IN CHILDREN
- Children can look well but then deteriorate quickly.
- Children have more exible bones than adults and can have serious internal injuries with few external signs.
- Use caution when calculating uid and medication dosages. Use exact weight whenever possible.
- Watch carefully for hypothermia and hypoglycaemia.

# DISPOSITION
Conditions that require handover or transfer to a specialist unit include: Wheezing in children is often caused by an object inhaled into the airway, viral infection or asthma.
Stridor in children is often caused by an object stuck in the airway or airway swelling from infection.
Fast or deep breathing can indicate diabetic crisis (DKA), which may be the rst sign of diabetes in a child.

# FAST BREATHING MAY BE THE ONLY SIGN OF A SERIOUS BREATHING PROBLEM IN A CHILD.

# DISPOSITION
Salbutamol and IM adrenaline e ects last for about 3 hours, and life-threatening symptoms may recur. Monitor closely, always have repeat dose available during transport and caution new providers at handover.
Naloxone lasts approximately 1 hour, and most opioids last longer. Monitor closely, always have repeat dose available during transport and caution new providers.
Following immersion in water (drowning), a person may develop delayed breathing problems after several hours. Monitor closely and caution new providers.
Never leave patients with di culty in breathing unmonitored during handover/transfer.
Make transfer arrangements as early as possible for any patient who may require intubation or assisted ventilation. Monitor uid status closely Paediatric patients are more susceptible to both uid losses and uid overload.

# SPECIAL CONSIDERATIONS IN CHILDREN

# DISPOSITION CONSIDERATIONS
Patients with AMS who may not be able to protect the airway should never be left alone. Monitor closely and give direct handover to new provider.
Naloxone lasts approximately 1 hour. Most opioids last longer--always alert new providers that patients may need repeat doses.
Hypoglycaemia often recurs. Alert new providers to monitor blood glucose frequently in any patient who has been treated for hypoglycaemia. 

# MEDICATIONS

# Magnesium Sulphate
Solution: 1 g in 2 ml ampoule (50% or 500 mg/ml), 5 g in 10 ml ampoule (50% or 500 mg/ml) Give 4 g IV (dilute to a 20% solution and give 20ml) slowly over 20 minutes AND give 10 g IM: 5 g (10 ml of 50% solution) with 1 ml of 2% lidocaine in each buttock.
If unable to give IV, give 10 g IM injection only (as above, 5 g in each buttock).
If seizures/convulsions recur: after 15 minutes give additional 2 g (10 ml of 20%) IV over 20 minutes.
If transport delayed continue: Give 5 g of 50% solution IM with 1 ml of 2% lidocaine every 4h in alternate buttocks.  Nebulizer: (ADULT) 5 mg in 5 ml sterile saline. (CHILD) 2.5 mg in 3 ml sterile saline.
For severe wheezing, above doses can be given several times in an hour.

# Severe wheezing
Tetanus Vaccine IM Injection: 0.5 ml (Give for children not up to date; adults with none in 5 years; or status unknown)

# Wounds (including burns and open fractures)
TRANSFER AND HANDOVER

# Arrange transfer
- Check that patient needs match the available services at the destination facility (eg, operating theatre open, blood available)
- Communicate directly with an accepting provider at the receiving facility prior to departure
- Ensure that destination facility can be reached in time given patient condition
- Ensure that patient and family are aware of reasons, plan, and destination for transport
- Record family contact name and number in sending facility chart and in paperwork sent with patient
- Secure patient valuables for transport (whenever possible, leave with family)
- A brief written record (including name, date of birth, clinical presentation and all interventions) should ALWAYS accompany the patient.

# Prepare for needs during transport
- PPE for sta
- Airway equipment and suction (check if working before departure)
- Adequate oxygen (with replacement tank if needed) and bag valve mask (BVM)
- IV access: Check that IV is secured prior to transport; consider second IV or backup supply
- Medications: Bring additional doses of medications and uids, and consider other medications that may be needed
- Prepare for new or recurrent symptoms.
- Seizure/convulsion patients: place pads/pillows around patient to limit injury from a seizure during transport.
- Watch for vomiting and ensure that airway remains clear, particularly for those with cervical spine immobilization.
- Check that there is adequate fuel for transport.
- Ensure that telephone or radio is present in vehicle and working

# Patient positioning
- Position patient for best airway opening and breathing.
- Use recovery position if no trauma.
- If >20 weeks pregnant and NO spine injury: Place pillows along the length of her right back to tilt patient onto her left side. This avoids compression of the large blood vessels by the pregnant uterus.
- Check that cervical spine has been immobilized if indicated.
- Possible spine injury: use backboard and log-roll manoeuvre to move patients. Check for pressure spots every 2 hours; pad areas with soft material as needed. If >20-weeks pregnant: Tip backboard slightly to the left using a wedge or other materials.
- Splint or immobilize fractures to protect soft tissues and decrease pain and bleeding.

# On-going care during transport
- Re-assess the ABCDE approach at least every 15 minutes, including repeat vital signs and glucose checks if patient has been hypoglycaemic
- Control bleeding prior to transport and monitor site for new bleeding
- Perform regular re-assessment of any splinted extremity
- Continue necessary treatments (e.g. oxygen, IV uids, oxytocin, glucose)
- Keep the patient from getting too hot or too cold during transport.

# Paediatric Considerations
- Prepare appropriate size equipment and weight-adjusted dosages of critical medications.
- Bring a family member or friend, and tell the receiving facility who is accompanying the child.
- Remember that critically ill or injured children can look well initially and then worsen quickly. Monitor closely.
- Hypothermia and hypoglycaemia are common in children. Monitor closely.

# SBAR handover
- Situation: Basic patient information (e.g. age, sex); chief complaint (the patient's initial description of the problem, such as di culty in breathing for 3 days, or arm pain after a fall)
- Background: 2-4 most important and relevant aspects of patient's case and/or condition; important ABCDE ndings/ interventions.
- Assessment: What you think is wrong with the patient; reason for the handover/transfer.
- Recommendations: next steps in treatment plan; potential worsening of the patient's condition (e.g. need for close airway observation if inhalation burn is suspected); cautions regarding prior therapies or interventions (e.g. time of last adrenaline dose to anticipate return symptoms, need to monitor mental status if sedating medications have been given, need to monitor 3-way dressing for clotting, etc.).