Resuscitation Part 3: Circulation/Drugs

In circulation component of the resuscitation, we looked at the CPR, CPR mechanical devices, drugs, fluids and use of AED.

Firstly, we look at CPR based on AHA 2010 Guidelines. This video showed layman CPR. In the hospital context, ACLS guidelines will apply.

For better quality and consistent CPR, mechanical CPR devices had been implemented in pre hospital and hospital environment. Singapore National Resuscitation council discussed various CPR devices here.

In Khoo Teck Puat hospital, mechanical CPR Life Stat have been used.

The two rhythms shock-able are pulse less ventricular tachycardia and ventricular fibrillation. See notes here and below presentation

AED or automated external defibrillators are designed for layman to give life saving shocks to the patients who in cardiac arrests and are either in pulse-less ventricular tachycardia or ventricular fibrillation. 

In hospital, we use biphasic defibrillators who are capable to monitor, defibrillate and pace the patient's heart with extension of AED, known as Philips Code Master.

Advanced life support drugs are also given to assist in organ per fusion, facilitate defribillation, etc. Notes and video here.

There are other special situations who require additional steps to take during cardiac arrest scenarios such as drowning, poisoning and pregnancy. You may refer to the notes here

Post resuscitation care to maintain coronary per fusion cannot be neglected and the author in this presentation described this well.

Other resources: 

Resuscitation Part 2: Breathing (ventilation)

Here are some great videos on mechanical ventilation.

The basics of ventilation and care for patients on ventilator are discussed in the three videos. 

The first video discussed what is mechanical ventilation.

The second video discussed the nursing management of mechanical ventilation.

The third videos discussed how arterial blood gases can be interpreted easily

Once you understand the basics of blood gases and the basics of the mechanical ventilation, we can move on to understand the anatomy, connection and set up of transport ventilator used in Khoo Teck Puat Hospital, which is Oxylog 3000 plus. The first video demonstrate the oxylog 3000 which has similar features of oxylog 3000 plus.

Drager has a simulation trainer( in flash mode) to train users in the use of oxylog 3000. The screen shot is seen attached. Please click here to go to the link to begin training. (ads supported )

The next few videos demonstrated the oxylog 3000 plus by the vendor in the hospital.

Patient monitoring part 3: pain assessment

Pain is the five vital sign which we, emergency nurses monitor the patient before, intra and post treatment. 

PQRST Method Facilitates Accurate Pain Assessment

"Nurses can help patients more accurately report their pain by using these very specific “PQRST” assessment questions":

P = Provocation/Palliation 

What where you doing when the pain started? What caused it? What makes it better? Worse? What seems to trigger it? Stress? Position? Certain activities? 

What relieves it?  Medications, massage, heat/cold, changing position, being active, resting? 

What aggravates it?  Movement, bending, lying down, walking, standing?

Q = Quality/Quantity

 What does it feel like? Use words to describe the pain such as sharp, dull, stabbing, burning, crushing, throbbing, nauseating, shooting, twisting or stretching.

R = Region/Radiation

Where is the pain located? Does the pain radiate? Where? Does it feel like it travels/moves around?  Did it start elsewhere and is now localized to one spot?

S = Severity Scale

How severe is the pain on a scale of 0 to 10, with zero being no pain and 10 being the worst pain ever? Does it interfere with activities? How bad is it at its worst? Does it force you to sit down, lie down, slow down? How long does an episode last?

T – Timing

When/at what time did the pain start? How long did it last? How often does it occur: hourly? daily? weekly? monthly? Is it sudden or gradual? What were you doing when you first experienced it?  When do you usually experience it: daytime? night? early morning? Are you ever awakened by it? Does it lead to anything else? Is it accompanied by other signs and symptoms? Does it ever occur before, during or after meals? Does it occur seasonally?

Documentation

In addition to the initial pain assessment, Curley emphasized the important of documenting:

• Patient’s understanding of the pain scale. Describe the patient’s ability to assess pain level using the 0-10 pain scale.
• Patient satisfaction with pain level with current treatment modality. Ask the patient what his or her pain level was prior to taking pain medication and after taking pain medication. If the patient’s pain level is not acceptable, what interventions were taken?
• Timely re-assessment following any intervention and response to treatment. Quote the patient’s response. 
• Communication with physician. Always report any change in condition.
• Patient education provided and patient’s response to learning.Don’t write “patient understands” without a supportive evaluation such as patient can verbalize, demonstrate, describe, etc.

(Reference: https://www.crozerkeystone.org/healthcare-professionals/nursing/crozer-keystone-nurses-in-the-news/eNewsletters/2010/february-march/best-practices-pqrst-method/)

The different scales used can be seen in Khoo Teck Phuat Hospital across used comprehensive chart which can be downloaded here



Another good pain related articles can be retrieved here:

• Nursing times (ads supported)

Resuscitation Part 1: Airway

In the life support course for nurses, which is in line with advanced life support guidelines from the National Resuscitation council. the airway management module covers the following objectives:

1. Determine cause of airway obstruction

2. Open of airway with correct simple maneuvers

3. Use airway adjuncts correctly

4. Administer supplemental oxygen with various devices

5. Assist in endotracheal intubation

The presentation slides can be downloaded here

In some hospitals, video assisted intubation are known.

In Khoo Teck Puat hospital, C-mac is used with bougie.

To confirm placement, end tidal carbon dioxide detector or esophageal detector(ODD) is used post intubation with auscultation and chest x-ray.

In some cases, patients may be intubated under rapid sequence intubation for emergent airway management. Drugs may be given to assist intubation. The nurse assisting the airway need to prepared for failed airway situations which require insertion of LMA, assist in jet ventilation, tracheotomy.

More information can be seen in this presentation

Other resources can be found on the emergency nursing world.

After airway is managed, we moved on looking at management of ventilation.

Patient monitoring part 1: vital signs

In the emergency department, there are protocols established to identify the types of patient assessment and monitoring in the A&E. The slides seek to explain the importance of performing patient assessment and monitoring.The presentation also outline steps in performing patient assessment and monitoring. 

Types of monitoring

• Level of Consciousness using GCS Scale 
• Blood Pressure 
• Pulse 
• Respiration  
• Sp02 
• Temperature 
• Pain Score 
• Skin Color and Condition

To download the presentation, download here.

Part 2 of patient monitoring is Combined Abnormality of Parameters Score (CAPS)

Patient monitoring part 2: Combined Abnormality of Parameters Score (CAPS)

The purpose of CAPS  is to improve patient outcomes by detecting and acting upon early signs of deterioration in patients. CAPS identifies trends in patient observations and ensures that timely patient review and appropriate treatment occurs; and improves the documentation of patient observations. Notification should also occur where clinical deterioration occurs other than that assessed by the CAPS criteria, or where sound clinical judgment would suggest that notification is in the best interests of patient care. To download the slides, click HERE.

Part 3 of the patient monitoring is pain assessment

ECG Part 3: Acute Myocardial Infraction

In this post, we look at  Acute Myocardial Infraction (STEMI), how to interpret them.


The first video showed how does STEMI happen:

The second and third videos showed ECG changes( ischemia, injury and infraction):

The third video showed various STEMI ( the most simplest way to remember how to interpret STEMI)

More resources:

Inferior Myocardial Infraction: read more and more (*ads supported)

Anterior Myocardial Infraction: read more and more(*ads supported)

Lateral Myocardial Infraction: read more (*ads supported)

Myocarditis: read more(*ads supported)

Posterior Myocardial Infraction: read more and more(*ads supported)

Right ventricular myocardial infraction: read more and more(*ads supported)

Notes available here

Knowing the danger of cardiac arrest from acute myocardial infraction, we moved on to talk about resuscitation

ECG Part 2: ECG interpretation

There are 3 part video of basic ECG reading. The videos covered them very well.

The first video covered detailed 11 steps of ECG interpretation:

Notes on finding of normal 12 lead ECG can be found here( *supported with ads)

The second video covered ECG interpretation, normal sinus and sinus bradycardia:

• Steps of reading lead II ECG
• Normal Sinus Rhythm 
• Sinus Bradycardia

Notes on finding of normal 12 lead ECG can be found here( *supported with ads)

Notes on finding of sinus bradycardia can be found here( *supported with ads)

The third video covered various tachycardia:

• Sinus tachycardia
• Atrial tachycardia
• Atrial fibrillation
• Atrial Flutter

Notes on finding of sinus tachycardia can be found here( *supported with ads)

Notes on finding of atrial fibrillation can be found here( *supported with ads)

Notes on finding of atrial flutter can be found here( *supported with ads)

The third video covered various tachycardia:

• Atrial fibrillation
• Atrial tachycardia
• Supra ventricular tachycardia
• Ventricular tachycardia
• Ventricular tachycardia ( polymorphic)

Notes on finding of supra ventricular tachycardia can be found here( *supported with ads)

Notes on finding of ventricular tachycardia can be found here( *supported with ads)

Notes on finding of polymorphic ventricular tachycardia can be found here( *supported with ads)

Notes available here

The next post looked at identification of acute myocardial infractions

ECG Part 1: Doing 12 Lead ECG

Before we discuss how to do ECG, the new novice nurse must understand the anatomy and physiology of the heart and what does it mean on a 12 lead ECG.

The anatomy and physiology of the heart is well discussed in the below videos.

Courtesy of ECG Academy (*supported by ads)

After looking at the basics of the heart, now we can look at the placement of the ECG leads for the purpose of recording

Courtesy of ECG Academy (*supported by ads)

Notes available here

We moved on to the next post to look at interpretation of basic ECG

Triage Part 3: Principle of SOAP

Triage S.O.A.P principle stands for 

S: Subjective Data - Collects data about what patient is telling you.

O: Objective Data - What are you actually seeing
                                 ( Parameters, Injuries)

A: Assess - Assess the objective for objective finding

P: Plan - Establish a plan for the patient.

A typical SOAP will cover

S: Subjective Data ( Chief complaint, Pain assessment, time of onset, duration, frequency, effects to other body systems and whether self treat is done)

O: Objective data( Vital signs, GCS level, patient general appearance, physical injuries)

A: Assess

P: Plan( Plan priority status and perform point of care testing actions such as ECG, capillary blood sugar, urinalysis, urine pregnancy test, visual acuity test, x-ray) and perform necessary first aid if necessary

Triage SOAP principles is not only applied in the emergency department, but also on telephone, mass casualty situations and also at pre hospital care level. The algorithms may differ between peace time, hospital level and field level, but the SOAP principles remain unchanged. (*supported with ads*)


Next, we shall look at doing ECG and the landmarks of doing ECG

Triage- Part 2

In Singapore restructured hospitals, the triage system is Patient acuity Category ( PAC) scale as recommended by Ministry of Health  from 1st April 1999.

PAC triage system is one of the most advanced system which involves 4 categories. There are written standards or protocols for the triage process include initiation of diagnostic test e.g. ECG, selection of treatment and re evaluation of patients.

PAC Scale

PAC Scale 1:

Patients are either already in a state of cardiovascular collapse or in imminent danger of collapse and would therefore be required to be attended to without a moment's delay.

They require maximum allocation of staff and equipment resources for initial management


PAC Scale 2:

Patients are ill, non ambulant, and in various forms of severe distress. They are in stable state on cardiovascular examination and are not in danger of imminent collapse. The severity of their symptoms required very early attention, failing which early deterioration of their medical condition is likely.


PAC Scale 3:

Patients are ambulant and have acute mild to moderate symptoms. Acute treatment will result in resolution of their symptoms over time.


PAC Scale 4:

There are non emergency patients who should more approriately be  managed in the primary health care setting. They do not require immediate treatment and there is no immediate threat to life or limb.

Patient acuity status is determined after triage assessment using the principles of SOAP. SOAP principles of triage will be discussed in further details in next post.


There are other triage models which are used in disaster situations which is  START(Simple Triage and Rapid Treatment) triage flow model. (*supported with ads*)

Triage - Part 1

Triage is a very important skill for emergency nurses to pick up during their course of their nursing career as an emergency nurse. It is because triage decision making is an every day practice in the emergency department and decision made may affect the patient's timely care and outcomes.

For novice emergency nurse, the blog will introduce you to the concept of triage and what's involves in doing triage.

Note:

You are not expected to do triage without supervision

To be able to triage in ambulatory areas, the triage nurse need to be experienced and undergone in house triage officer's course or external course.

Other self learning triage course modules are available here.

Triage is defined as " the categorization of patients to determine their priorities in medical attention, treatment and disposal"

There is other definitions of triage here.

In Australia, College of emergency nursing has a position statement for triage nurse to define their role( However their triage system slightly differ from us).

Principles of triage:

1. Should be immediate and timely
2. Assessment should be adequate and accurate
3. Decisions are made based on assessment
4. Provide intervention according to acuity of condition
5. Patient satisfactionis achieved through establishment of a good rapport and support of their emotional needs.

Triage process in summary: Right patient to the right place at the right time at the right care provider

Part 2, we shall discuss the triage system used in Singapore.

Emergency Department Journey Part 1

For novice emergency nurses, it is very important to know the patient process in the emergency department. The emergency department across all countries are generic: Triage, Consult/Resuscitation, Treatment/Investigation, Disposition.

In Khoo Teck Puat Hospital, the patient's process is mapped in the patient's journey for patients to have a clear visibility of the visit process. This keep the patient informed of the process during their visit in emergency department.



Triage will discussed in more detailed in here

What is it like to be an emergency nurse ?

What is it like to be an emergency nurse?

The best person to answer this question is from the emergency nurse himself or herself.

I quoted from one of the two newspaper featured experienced emergency nurse in Khoo Teck Puat Hospital, Ms Nurul Ashikin said that: " The Quick Thinker: Working in the A&E department can be physically and mentally demanding, we need to be knowledgeable, be able to multi-task and alert on our job, as it is fast-paced and unpredictable"

Another Khoo Teck Puat Hospital emergency nurse, Ms Mary Grace, spoke the same, but also shared the abuses the emergency nurse face and the appreciation from the community.

You can view other emergency nurses stories in Singapore 

KKH (*supported with ads*)

Let's start by looking at the emergency department's patient journey through the department.