1. WONCA RURAL 2014
Rural Skills Workshop
Dr Jo Scott-Jones
MRCGP FRNZCGP MMsc
Dip Obs, Sports, Geriatric Medicine
2. Conflicts of Interest and Bio
Registration and travel has been paid by
conference organisers, NZRGPN, and RNZCGP.
GP in Opotiki
Chairperson of the NZRGPN
Faculty member of the Rural Chapter RNZCGP
Senior lecturer (rural health) Auckland Uni
PRIME doctor
3. Process
• Pre and post questionnaire
• Being a rural GP
• MCI – introduction / review of concept
• Our experiences
• Triage concepts
• Application of concepts in practical exercises
• Discussion of challenges
• Emergency medicine skill sharing
4.
5. What things affect YOUR MCI response?
• Typical staffing of your health service?
• How do you handle the following?
– 4 victims in a two car “head-on”
– 17 victims in a “team” van
– 43 victims on a school bus
– 350 victims on a train
6. Mass Casualty Incident Definition
“When your resources are
overwhelmed by events.”
Get to know someone you don’t know already -
Their name ?
Where are they from ?
What resources do they work with ?
Talk about an example of the experience of being overwhelmed by events ?
How do you cope ?
28. THE GOLDEN HOUR
“The critical trauma patient has only 60
minutes from the time of injury to reach
definitive surgical care, or the odds of
a successful recovery diminish
dramatically”.
Pre-Hospital Trauma Life Support, Second Edition,
Patient Assessment and Management, page 42. 1990.
TIME IS VERY IMPORTANT
33. Scene Management
• Command
Who is in Charge?
Who is in charge of what?
Who is going to do what?
Who else needs to be here?
• Safety
Is there a hazard or threat?
Should I be here?
Am I protected?
What should I worry about?
34. Scene Management
• Assessment
What is going on?
How big is this, how many
people?
What do I need?
How does what I do affect
others?
What are they doing that
can affect me?
• Communications
Who needs to know?
What do they need to
know?
Does Command & Ops
know?
Do the other players
know?
35. Scene Management
• Triage
Who is doing it?
Where are they doing it?
What are they finding?
• Treatment
What skills do your local
health providers have?
How to organize?
How much can we do?
36. Scene Management
Transport
• Who is doing it?
• From where are they doing it?
• Where are the patients going?
• How many patients going where?
37. TRIAGE
“You know you are a nurse if
…..you triage the laundry when at
home – this pile needs immediate
attention, this pile can wait, this
pile, with a little stain stick will be
OK until you get back to it”
( Donna Wilk Cardillo RN )
40. In this initial phase ..
Open airways using position
Compress life threatening bleeding
Move patients to clearing points
Use other people / bystanders to provide
interventions
41. THE FIRST STEP IN BALANCING RESOURCES
WITH CASUALTIES
YES
PRIMARY TRIAGE
43. PRIMARY TRIAGE
If breathing is it good enough or will something
need to be done soon ?
Delayed
BREATHING?
DIFFICULTY
BREATHING?
BREATHING?
Dead
Immediate
Open Airway
YES
YES YES
NO
NO
NO
44. PRIMARY TRIAGE
They have an airway, and are breathing.
Are they circulating blood sufficiently?
MOBILE? Delayed
BREATHING?
DIFFICULTY
BREATHING?
RADIAL PULSE
PRESENT?
BREATHING?
Dead
Immediate
Open Airway
YES
YES
YES YES
NO
NO
NO
NO
NO
48. Treatment
• Group patients of the same triage colour together
around a central equipment pool
• Experienced personnel make decisions – where
possible others implement them
• Patients with the greatest chance of survival and
the least drain on resources are treated first.
• If the treatment is not likely to work – don’t do it.
• Treatments that tie up resources ( e.g intubation
and ventilation) should be delayed unless there is
a very good reason and resources to support
them.
49. Patient Scenario #1
This patient states he cannot move or feel his legs
His respirations are 24
He has a radial pulse of 100
He is awake are oriented
How would you triage this patient?
50. Patient Scenario #1
This patient states he cannot move or feel his legs
His respirations are 24
He has a radial pulse of 100
He is awake are oriented
URGENT - (YELLOW)
51. Patient Scenario #2
This patient has a blood soaked shirt on
His respirations are 36
His capillary refill is less than 2 seconds
He is awake are oriented
How would you triage this patient?
52. Patient Scenario #2
This patient has a blood soaked shirt on
His respirations are 36
His capillary refill is less than 2 seconds
He is awake are oriented
IMMEDIATE (RED)
53. Patient Scenario #3
This patient has some minor abrasions on his forehead
His respirations are 16
His capillary refill is less than 2 seconds
He is very slow in recalling his name and whereabouts
How would you triage this patient?
54. Patient Scenario #3
This patient has some minor abrasions on his forehead
His respirations are 16
His capillary refill is less than 2 seconds
He is very slow in recalling his name and whereabouts
IMMEDIATE (RED)
55. Patient Scenario #4
This patient appears to have no injuries
Her respirations are 20
Her capillary refill is less than 2 seconds
She is unconscious
How would you triage this patient?
56. Patient Scenario #4
This patient appears to have no injuries
Her respirations are 20
Her capillary refill is less than 2 seconds
She is unconscious
IMMEDIATE (RED)
57. Patient Scenario #5
This patient is lying quietly on the floor
He is not breathing
His capillary refill is more than 2 seconds
He is unconscious
How would you triage this patient?
58. Patient Scenario #5
This patient is lying quietly on the floor
He is not breathing
His capillary refill is more than 2 seconds
He is unconscious
REPOSITION THE AIRWAY!
59. Patient Scenario #5
He gurgles a couple of times as you attempt to open
his airway but does not resume breathing on his own
His capillary refill is still more than 2 seconds
He is still unconscious
How would you triage this patient?
60. Patient Scenario #5
He gurgles a couple of times as you attempt to open
his airway but does not resume breathing on his own
His capillary refill is still more than 2 seconds
He is still unconscious
DECEASED (BLACK)
63. Answers
Victim TRIAGE
13 Red
14 Green
15 Yellow
16 Red
17 Green
18 Red
19 Green
20 Green
21 Green
22 Black
23 Yellow
24 Yellow
25 Green
26 Green
27 Red
67. Who should receive analgesics?
• Everyone in pain
• No reason to with hold pain relief
• Does not “mask” other symptoms
• Pain is not a vital sign
• No risk of addiction
68. How do you choose?
• Desirable characteristics for analgesic
– Quick acting (short onset and peak effect)
– Short duration
– Minimize side effects
• Hypotension, respiratory suppression, emesis, etc.
– Easy to administer
– Multiple administration routes available
– Reversible
– Inexpensive
69. How do I choose?
• What is available
• Take patient allergies into consideration
• Take patient condition into consideration
– Use the least hemodynamically active agent if
patient is unstable
– The analgesic ladder…
70. Non Pharmacological approach
• Safe and can be effective
– Ice or heat
– Elevation
– Splinting/positioning
– Emotional support
– Distraction (guided imagery, biofeedback, breathing
exercises)
71. Paracetamol and Ibuprofen in
combination
Paracetamol, ibuprofen,
tramadol in combination. Start
with an inhalation agent if
distressed.
Start with inhalation agent, add
if stabilising – eg straightening a
fracture. Opiates titrated to
effect. Ketamine if not
adequately controlled, consider
Midazolam.
Once controlled add in
paracetamol, ibuprofen and
tramadol.
Mild
Moderate
Severe
Non pharmaceutical methods are often effective, reassurance, positioning, splinting.
Combinations work better than single agents, choose the “step” in proportion to the
level of pain.
72. Paracetamol
• Indications – mild pain / adjunct to more
severe pain
• Contraindications – paracetamol overdose
• Dosage – 1gm < 80 kg > 1.5gm
• Comments
Higher than normal dose – safe in short term,
not for fever unless uncomfortable.
73. Ibuprofen
• Indications - mild pain / adjunct to more
sever pain
• Contraindications – 3rd trimester pregnancy
• Dosage - 400mg < 80kg > 600mg
• Comments
Contraindications listed normally are to long
term administration.
74. Tramadol
• Indications – moderate pain / adjunct to
severe pain
• Contraindications – confusion / dementia
(children <12)
• Dosage 50mg orally
• Comments
Anti-cholinergic effect can worsen confusion,
caution use in the elderly, nausea in the past not
an allergy usually associated with dose > 50 mg
75. Entonox
• Indications – moderate / severe pain
• Contraindications – unable to obey
commands, suspected pneumothorax, bowel
obstruction, diving in the past 24 hrs.
• Dosage - self administered
• Comments
N2O expands gas filled spaces in the body,
watch for worsening of symptoms and stop.
76. Methoxyflurane
• Indications – moderate / severe pain
• Contraindications – unable to obey commands,
FHx malignant hyperthermia, renal impairment,
already used in the past week.
• Dosage 1 dose (3ml) < 12 > 2 doses (6ml)
• Comments
Not contraindicated for acute renal pain, or if on
dialysis, single use inhalation device, caution in
toxaemia / labour with foetal distress.
77.
78. Morphine
• Indications - severe pain
• Contraindications – respiratory depression, premature
labour
• Dosage
1-5 mg IV every 3-5 minutes for adults or
5-10 mg IM every 10 mins
0.1 mg / kg IV children
• Comments – takes up to 20 minutes to have maximal effect
in the elderly, dilute to 1 mg/ ml and titrate to effect,
duration of effect IV 2-3 hrs , nausea and itch are side
effects not allergies.
79. Fentanyl
• Indications – severe pain esp if no IV access,
haemodynamically unstable.
• Contraindications – respiratory depression, prem
labour
• Dosage – every 10 mins if needed
10-50mcg IV every 3-5 mins adults
100mcg IN < 80kg > 200mcg IN
2mcg/kg IN children
• Comments dilute 100mcg in 10 ml – contains 10
mcg/ml, IN use 1 ml syringe and MAD - onset 1-2
minutes, peak 15 minutes, duration 20- 60 minutes +
80. Fentanyl
• Generally minimal effect on blood pressure,
heart rate and ventilatory drive
• Helps to blunt HR and BP associated with
intubation
• Chest wall rigidity or muscle twitching can occur
– Should be reversible with Narcan
• Most side effects result from pushing the
medication too quickly
81. Ketamine
• Indications - severe pain
• Contraindications – unable to obey commands,
MI, psychosis
• Dosage – rpt once after 10 mins
10-50mg IV every 3-5 mins
1mg/kg IM, IN, Oral max 100mg
• Comment – adjunct to opiate – hallucinations
usually indicate sub therapeutic dose – rx with
more ketamine ! Duration up to 2 hrs.
82. Midazolam
• Indications - muscle spasm, if other analgesics have
not worked
• Contraindications - benzodiazepine allergy
• Dosage
1- 2 mg IV - wait 10 mins and a further 1 mg max of 5 mg
0.2 mg / kg IN
• Comment – ‘conscious sedation’ – cause of retrograde
amnesia not an analgesic. Combine with ketamine in
infusion for sedation and analgesia.
