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1 S00283886 – Mima Golias

PARA 104: Foundations of Paramedic Practice

Assessment Task 1b – Written Assignment Primary Survey Case study

Name: Mima Golias Student Number: S00283886

2 S00283886 – Mima Golias Assessment Task 1b – Written Assignment Primary Survey Case study

“A primary survey is defined as a component of the patient assessment to recognize and manage all immediate life-threatening decisions.” (Sanders, Lewis, Quick & McKenna, 2012). The primary order of assessment that Ambulance Victoria follows the mnemonic DRabCDABH. This stands for dangers, response, airway, breathing, circulation, defibrillation, airway, breathing, and haemorrhage. This essay is going to demonstrate a primary survey relating to the case study about a 50-year-old man who had a cardiac arrest while gardening.

"Danger" is the first step in clinical practice and a very important one too, you must “check for any dangers to yourself, partner, bystanders, and patient prior to, and upon entering the scene” (Paramedic Studyguide, 2019). The assessment for possible dangers should begin pre-arrival for a job thinking about possible hazards and putting on the appropriate PPE equipment. Once you arrive on the scene, paramedics look, listen and smell for any possible dangers following the mnemonic “POP” which stands for Person, Object, Place. You also need to remember the direction to the patient thinking about a plan of action in case of an emergency exit. All of these are important in this step as “Your safety is paramount; there is absolutely no point in putting your safety at risk.” (Curtis, Ramsden, Shaban, Considine & Fry, 2016). The dangers relating to this scenario may include the wet clothing of the patient which could interfere with compressions and defibrillation, any gardening equipment, if he collapsed onto any tools, or if any of those tools are electric if they are still on or running it could cause danger to anyone around. Any bystanders if there is anyone else other than the neighbour and also the neighbour who is giving compression is

3 S00283886 – Mima Golias considered a danger as the paramedics need to take over. To overcome these dangers simply, take of the patient’s shirt make sure skin is dry, turn off any power equipment, and politely tell the neighbour to stop CPR and allow the paramedics to take over.

The second step of the primary assessment is "Response". This step aims to “determine the patient’s level of consciousness by assessing their response to different stimuli as per the AVPU assessment” ((Paramedic Studyguide, 2019). AVPU stands for, alert, verbal stimuli, pain stimuli, and unconscious and corresponds to the Glasgow coma scale (GCS). After quickly assessing dangers you go through if the patient aware and attentive, if not, you ask him simple questions such as the ones represented by ‘cows” can you hear me? Open your eyes, what’s your name? squeeze my hands. If the patient fails this test, you give them a trap squeeze or shake and shout. If the patient fails all these tests such as Eric in this case study, he is deemed unresponsive and GCS of 3 so you move onto the next step in the clinical practice of primary survey.

The third letter of the mnemonic is lowercase ‘a’ standing for "airway". The guidance for this step is “is the airway obstructed” (Trauma Victoria, 2020). It is a quick look in the airway to see if anything is in there and to make sure the patient is supine and has a neutral head alignment meaning we consider the cervical spine and place 2-5cm padding under the head of the patient if needed. After aligning the patient, a head tilt is performed so the airway is open and allows paramedics to have a visual inspection of the airway. The importance of this step is to check if there is something that the patient is choking on and that is the reason why they stopped breathing or not. In this case there is mucous and vomit, and the patient Eric has cyanosis of the lips presenting that he has hypoxia or more likely apnea. However, as

4 S00283886 – Mima Golias this is only a visual inspection only you take notice of the vomit and mucous and move onto the next step. The next step is a quick assessment of breathing, this is done by paramedic 1 is looking for “chest rising and falling, listening for breathing and feeling for chest rise and fall as well as breathe on the cheek” (ANZCOR, 2016), simultaneously paramedic 2 checks for a pulse on the carotid artery as it is the strongest. This is done for no more than 10 seconds as if there is no pulse or respiration rate paramedics need to act quickly. In this case study he has no pulse and is not breathing, because of this we move to the next step.

Circulation comes next after breathing, and due to Eric not having any pulse nor breathing CPR must commence straight away by paramedic 1 as the patient is deemed unresponsive and “All rescuers should perform chest compressions for all those who are unresponsive and not breathing normally” (ANZCOR, 2016). CPR is commenced and follows the guidelines of “compression depth 1/3 of chest diameter” (Ambulance Victoria, 2019), “30 compressions followed by 2 breaths within a cycle of 2 mins meaning around 100 - 120 compressions per minute” (Australia, 2019). While compressions are happening by paramedic 1, the other paramedic is beginning the next stage. Compressions aim to keep the blood circling the patient’s body but can be tiring so should be alternated with each paramedic every 2-minute cycle.

The next step is defibrillation and is performed at the same time as paramedic 1 giving lifesaving CPR. Paramedic 2 sets up defibrillation by positioning the electrodes appropriately, from there you turn on the Zoll machine and charge the device up to the appropriate joule amount depending on age and weight. You then stop CPR, analyse the heart rate on the ECG, if shockable, allow a shock, and once the shock has been received, CPR is

5 S00283886 – Mima Golias continued while you move onto the next step. In this scenario Eric requires defibrillation of appropriate energy of 200 joules as he has ventricular fibrillation (VF) which is known as “a chaotic ventricular rhythm that results in pulselessness” (Sanders, Lewis, Quick & McKenna, 2012). We know that it is VF as there is a non-discernible rate, an irregularly, irregular rhythm, P waves, QRS complex, and PR interval are all absent. This rhythm is shockable so in this scenario paramedics would stay clear, apply the shock and continue CPR for another 2 minutes while breathing is being set up as well as analysing, and suitable shocking throughout treatment.

The next step after defibrillation stands for "Airway" again. This step is to clear the airway allowing the patient to get oxygen when managing to breathe in the next step. This step begins with a triple airway manoeuvre, “the triple airway manoeuvre is used to maintain a patent upper airway and combines head tilt, jaw thrust, and chin lift (QAS, 2018). this allows the mouth to open and the airway to be completely visible. This patient Eric has mucous and vomit obstructing his airway yet “If the patient has vomit, blood or excessive secretions on their airway, these should be removed with suction.” (Trauma Victoria, 2020) As if we ventilate without clearing these fluids, they can cause more damage as it has not yet been properly cleared. We intermittently suction in the airway for no more than 10 seconds, yet AV CWIs states for 5 seconds at a time until the airway is all clear and ventilation can begin.

After the airway has been cleared the next step is breathing. In this step paramedics insert an OPA which is “an adjunct extending from the lips to the pharynx preventing the tongue from occluding the airway” (QAS, 2018). Once this has been properly measured and

6 S00283886 – Mima Golias inserted, a BVM will be secured around the mouth allowing ventilation to occur after every 30 compressions or when appropriate. Once this is placed in the paramedic giving CPR will swap with the paramedic on ventilation and will swap every 2 minutes from then on. Since Eric had cyanosis of the lips this shows either hypoxia or apnoea both require oxygen, however, not during the primary survey, due to accessibility and urgency of the situation.

The next step is to check for a life-threatening haemorrhage and to control it with the use of, elevation, immobilisation, bandage, pressure, or the use of a tourniquet. This would be done by the paramedic on ventilation and would be done in between ventilations if it was seriously life-threatening. However, in this case study, Eric has no life-threatening haemorrhage, so this step is looked at but isn’t performed as it is unnecessary.

The primary survey is a range of steps performed systematically by paramedics prehospital to assess patients. This essay was depicting a primary survey concerning a cardiac arrest by a 50-year-old man named Eric. Paramedics follow the systematic approach known as DRabCDABH in order to prioritise patient care and safety, in order to assess and provide the most appropriate treatment and outcome.

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8 S00283886 – Mima Golias References ANZCOR Guideline 5 – Breathing. (2016). [PDF] (5th ed., p. 2). Retrieved from

https://www.nzrc.org.nz/assets/Guidelines/BLS/ANZCOR-Guideline-5-BreathingJan16.pdf

ANZCOR Guideline 8 – Cardiopulmonary Resuscitation (CPR). (2016). [PDF] (8th ed., p. 2). Retrieved from

https://www.hpw.qld.gov.au/__data/assets/pdf_file/0010/5203/anzcorguideline8cprjan 16.pdf

Australia, H. (2019). How to perform CPR. Retrieved 4 May 2020. Retrieved from https://www.healthdirect.gov.au/how-to-perform-cpr

Clinical practice procedures: Airway management/Triple Airway Manoeuvre. (2018). [PDF] (pp. 448-449). Queensland. Retrieved from https://www.ambulance.qld.gov.au/docs/clinical/cpp/CPP_Triple%20airway %20manoeuvre.pdf

Curtis, K., Ramsden, C., Shaban, R., Considine, J., & Fry, M. (2016). Emergency and Trauma Care for Nurses and Paramedics (2nd ed., p. 273).

Paramedic Studyguide. (2019). Primary Survey — Paramedic Study Guide | Ultimate study guide for paramedic students. Retrieved 4 May 2020. Retrieved from https://www.paramedicstudyguide.com.au/primary-survey

QAS, C. (2018). Clinical practice procedures: Airway Management/Oropharyngeal Airway Insertion [PDF] (pp. 419-420). Queensland. Retrieved from

9 S00283886 – Mima Golias https://www.ambulance.qld.gov.au/docs/clinical/cpp/CPP_Oropharyngeal %20airway%20insertion.pdf

Sanders, M., Lewis, L., Quick, G., & McKenna, K. (2012). Mosby's paramedic textbook (4th ed., p. 503). St. Louis, Mo.: Elsevier/Mosby Jems.

Sanders, M., Lewis, L., Quick, G., & McKenna, K. (2012). Mosby's paramedic textbook (4th ed., p. 644). St. Louis, Mo.: Elsevier/Mosby Jems.

Trauma Victoria. (2020). Early Trauma Care-Primary Survey | Trauma Victoria. Retrieved 5 May 2020. Retrieved from https://trauma.reach.vic.gov.au/guidelines/early-trauma-care/primary-survey

Ambulance Victoria. (2019). Clinical Practice Protocols: First Responders [PDF] (4th ed., p. 2). Victoria. Retrieved from https://www.ambulance.vic.gov.au/wp-content/uploads/2019/11/frcpg.pdf...