Ambulance Equipment

Volunteer/PTS Ambulance Equipment HLT41115 Certificate IV in Health Care Clinical Education

Ambulance Equipment

Health Training Package HLT The learning material provided in this Study Guide has been developed to meet the requirements of the Health Training Package HLT. Training packages are a key feature of vocational education and training in Australia. They are developed nationally by industry, for industry. Qualifications are recognised nationally.

Ambulance Equipment Study Guide relates to the following national competencies: HLTAMB007 Assess and deliver basic clinical care HLTAAP002 Confirm physical health status

Every effort has been made to trace and acknowledge copyright material. occurred accidentally the authors and publishers tender their apologies.

Should any infringement have

Copying Except as permitted under the Act (for example a fair dealing for the purpose of study, research, criticism or review) no part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means without prior written permission. All enquiries should be made to the publisher at the address below.

Chief Executive Officer SA Ambulance Service GPO Box 3 Adelaide SA 5001

Published by SA Ambulance Service Clinical Education Version: 1.0 170407

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Ambulance Equipment

Contents Ambulance Familiarisation Exterior of the Ambulance

5

Interior of the Ambulance

6

Ambulance Kits Red Trauma Kit

21

Blue Airway Kit

22

Green Oxygen Sock

23

MRx

25

PTS Green FAB Kit

26

Ambulance Equipment Suction Equipment

29

Airway Devices

33

Supplemental Oxygen Delivery

47

Oxygen Cylinders

52

Electrocardiogram (ECG)

57

Taking a Blood Pressure

63

Glucometer

64

Motorcycle Helmets

66

Cervical Collar

68

Spinal Board

71

Oregon Spine Splint

73

Vacuum Mattress

77

Cardboard Splint

81

CT-6 Femoral Splint

82

Pelvic Binder

85

Improvised Splints

88

Arterial Tourniquet

89

Posey™ Restraint Net

91

Burn Dressings

93

Glossary Glossary

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Ambulance Equipment

Ambulance Familiarisation It is a basic requirement for an Ambulance Officer to be able to locate, recognise and maintain equipment that will be used for basic patient care and assessment. It is the responsibility of the crew on shift to ensure that they have thoroughly checked, restocked and prepared the Ambulance that they are using. It is also a requirement to leave the Ambulance and its equipment in a fully operational state. It is therefore essential to be familiar with the equipment, layout, contents and maintenance/cleaning of the Ambulance and any other vehicle that you are required to operate from.

This section will outline the interior and exterior layout of both Volunteer and PTS Ambulances, including the contents of all response kits.

Exterior of the Ambulance Within SAAS there two main types of Ambulance vehicles, the first (as shown to the right) is primarily used for Patient Transport Services (PTS). This vehicle has 'Ambulance' written on the outside and the internal layout and contents differ slightly to the Emergency Ambulance.

The Emergency Ambulance (pictured to the right), is used for Emergency Support Services (ESS) and country and metropolitan Emergency Crews (carer and volunteer). This vehicle has 'Emergency Ambulance' written on the side.

There are many other types of Ambulances and first response vehicles in SAAS. For example, managers and Team Leaders use light fleet, the Special Operations Team and some regional managers have 4WD vehicles, and there are specialised bariatric response, extended care response and command or incident unit vehicles.

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Interior of the Ambulance The interiors of Ambulances do differ slightly. Shown below is the interior front cabin of an Emergency Ambulance. Country Ambulance vehicles have a satellite phone and a UHF radio in addition to the standard communication equipment. It is important that you familiarise yourself with the Ambulance in your local area.

Ambulance controls, lights, beacons and sirens

GPS

MDT

Mobile Phone/Satellite Phone

Handheld GRN radio and Maglite torch Vehicle Radio

MDT Keyboard

Handheld GRN radio Maglite

Handhled GRN radio batteries in chargers

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Front Cabin The front cabin is where the majority of the communication equipment is located, the diagram below shows the standard equipment found in an Emergency Ambulance.

Sun visors The sun visor contains the following equipment: •

Safety glasses and safety glass holders

•

'Command' velcro panel (for Major Incidents, refer to the Major Incident Management study guide for more information)

•

SMART Triage Tag Pac (for use in Major Incidents, refer to the Major Incident Management Study Guide for more information)

Also on the inside of the sun visor is a copy of the Infection Control Precautions and Cleaning sticker.

Centre of dash compartment The compartment in the centre of the dash board contains the following: •

Vehicle operating manual

•

Vehicle check sheet

•

Vehicle defect book

•

Country street directory

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Ambulance Equipment

Glove box The glove box should contain the following: •

A packet of Panadol

•

Sunscreen (tube)

•

RID insect repellent

•

Fuel cards

•

Call Direct brochures

•

Call Direct referral pads

•

Earplugs

•

'Out of Service' tags.

Passenger door The pocket in the passenger door contains: •

Hand towel

•

Aqium hand gel

•

Patient Clinical Record folder

•

Patient Clinical Record pads

•

Metropolitan street directory

Driver's door The driver's door contains: •

Hand towel

•

Aqium gel

•

Refusal of transport forms

•

Treat no transport forms

Centre console The centre console contains: •

Boxes of gloves (Small, Medium, Large and Extra Large)

•

Bin Liners

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Rear compartment The following images provide an overview of the layout of the back of the Ambulance.

The following pages detail lists of what can be found in each locker and kit.

Rear interior (passenger side sliding door view) Locker 18

Locker 19

Locker 20

Grab and Go Locker Locker 1

Locker 25

Rear interior (drivers side view) Locker 17

Locker 16

Locker 15

Oxygen supply Blood pressure sphygmomanometer

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Rear interior (passenger side view) Locker 8 Locker 7

Locker 3 Locker 9 Locker 2 Locker 10

MRx Stand

Locker 4

Compact Carry Chair

Lockers 23 and 24

Commander/ Clinician pack

Locker 22 Locker 21

Suction

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Rear interior (rear door view)

Locker 14

Light controls

Locker 13

Locker 12

Locker 11

Driver's side sliding door view

Safety switch

D size oxygen cylinders

Jumper leads

Fire extinguisher

Light rescue/ access pack Battery charger

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Pocket between front seats The pocket between the seats contains the Commander/Clinician pack as well as the Blood and Body Fluid Exposure Kit. 'Grab and Go Locker' The compartment on top of the locker contains the helmet holder The storage locker at the top of the top contains: •

Cervical collars (4 adult and 2 paediatric)

•

Oxygen spares (adult and paediatric masks, non re-breathing bags, nasal specs, nebuliser chambers, O2 tubing)

The upper section of the 'Grab and Go' locker contains: •

Portable suction unit with hose and handle

The centre shelf of the 'Grab and Go' locker contains: •

Trauma Kit (red)

•

Oxygen Sock (green)

The bottom shelf of the 'Grab and Go' locker contains: •

Airway Kit (blue)

•

MRx

•

Fire extinguisher

Locker 1 Locker 1 is the Inhalo oxygen cylinder storage locker contains the 'C' size oxygen cylinders.

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Locker 2 In Locker 2 you can find: •

Tissues

•

Defibrillation pads

•

MRx paper rolls

•

ECG dots

•

P2 Masks (small and medium)

•

3M Masks (one size fits all)

•

Surgical masks

Locker 3 Locker 3 is where you can find boxes of gloves in the following sizes: •

Extra small

•

Small

•

Medium

•

Large

•

Extra Large

Locker 4 Locker 4 has a tray and three drawers which contain equipment that may be required to treat a patient during transport.

Fixed on the top of the console is a wire frames rack with restraint strap to safely secure a cardiac monitor when it is being used during transport of a patient.

The tray of Locker 4 is where medication can be prepared, it also contains a copy of the paediatric drug dose chart.

The first drawer of the units contains: •

Tourniquet

•

Razors

•

Alcohol wipes

•

Penlight torch

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•

Transpore tape (25mm)

•

Eye dressings

•

Tegaderm (small and large)

•

IV cannulas (Protectiv IV 14g, 16g, 18g, 20g, 22g, 24g)

•

Injection ports (bungs) and lever lock connectors

•

Glucometer

•

Lancets

•

Universal shears.

The middle drawer contains: •

Drawing up needles (18g)

•

Giving needles (23g)

•

Syringes (1mL, 2mL, 5mL, 10mL)

•

Saline (10mL)

•

Ventolin spacer

•

Oral glucose

•

Cophenylcaine nozzle

The middle drawer also contains the following drugs which are placed into a foam insert: •

GTN spray

•

Pack of aspirin

•

Adrenaline

•

Co-phenylcaine Forte

•

Methoxyflurane (complete pack)

•

Naloxone

•

Glucagon (ampoule only)

•

Midazolam

•

Benzylpenicillin (1.2g)

•

Salbutamol

•

Ipratropium.

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The bottom drawer of the workstation contains: •

Burnaid dressings (large and small and facial dressing)

•

Infusion sets

•

Saline (500mL)

•

Burette

•

Syringe (50mL)

Locker 5 Locker 5 is where the bin and a sharps container can be found.

Locker 6 The following equipment can be found in locker 6: •

Stethoscope

•

Sphygmomanometer

•

Large adult and infant BP cuffs

•

Bottled water

•

Emesis bags

•

Adult and child 3 in 1 masks

•

NRM bags

•

Nebuliser chambers

•

Blue incontinence sheets

•

Bin liners

•

Nasal specs.

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Locker 7 The following can be found in Locker 7: •

Roller bandages (10cm and 15cm)

•

Saline (30mL)

•

Transpore tape (25mm)

•

Elastoplast

•

Triangular bandages

•

Arterial tourniquet

Locker 8 The following can be found in Locker 8 •

Universal dressings

•

20x20 dressings

•

9x20 dressings

•

9x10 dressings

•

Eye dressings

•

Bandaids

•

Universal shears

•

Rescue blankets (foil)

Locker 9 Locker 9 contains the following: •

Pillow cases

•

SAM Pelvic Splint (Standard)

Locker 10 Locker 10 is where spare sheets can be found.

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Locker 11 Locker 11 contains: •

Pedi Mate harness

•

Body bag

•

Blue slide sheet

•

Plastics sheets

•

Biohazard bags

•

Contamination bags

•

7 foot lifting straps

•

Aquim hand gel

•

Clinell wipes

•

ISO wipes

Locker 12 The spinal board straps can be found in this locker.

Locker 13 Locker 13 contains the spinal board and step.

Locker 14 The following equipment can be found in Locker 14: •

Oregon spine splint

•

CT-6 traction splint

•

Pat slides

•

Cardboard splints (small and large)

•

Sally tubes for stretcher transfer

•

Sally tubes for seat transfer

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Locker 15 Blankets and saline (500mL) can be found in Locker 15.

Locker 16 Locker 16 also contains blankets as well as bath towels, trauma teddies, gowns (regular and extra large) and Snake Bite Kit. Locker 17 Locker 17 contains the following equipment: •

Roll of cling film

•

Maternity kit bag (maternity kit, resus bag with valve regulator, paediatric resus masks, oral airways, pall filter, 'Y' suction catheters, Res-Q-Vac neonatal/ paediatric kit, universal dressings)

Locker 18 Locker 18 contains the following: •

Oral airways (sizes 00, 1, 2, 3, 4)

•

Sphygmomanometer (complete set)

•

Cotton ties

•

Bite block

•

KY jelly sachets

•

Pall filters

•

Syringes (50mL)

Locker 19 Licker 19 contains: •

Adult resuscitation masks (sizes 3, 4 and 5)

•

Paediatric resuscitation masks (sizes 0, 1 and 2)

•

Adult and paediatric resuscitation bags (with extension trunk and valve)

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Locker 20 Locker 20 contains: •

Y suction catheters

•

Laryngeal mask airways (sizes 2, 3, 4, 5)

•

Nasopharyngeal airways (sizes 6, 7, 8)

•

Suction handles

Locker 21 Locker 21 contains the following PPE equipment: •

Tyvek overalls (medium, large and extra large)

•

Overboots (large and extra large)

•

Neoprene gloves (Small, medium, large and extra large)

•

Nitrile gloves

•

Texta

Locker 22 Locker 22 contains the Posey restraint net. This is also where crew bags and where patient luggage can be safely stored.

Lockers 23 and 24 These lockers are where Schedule 8 drugs can be stored.

Locker 25 Locker 25 contains: •

Bedpan, urinal and a roll of toilet paper

•

Suction tubes

•

Suction bags

•

Spare adult resuscitation bags

•

Assistance dog control lead

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Locker 26 Locker 26 is where you can find the following: •

D-size oxygen cylinders

•

Set of jumper leads

•

Fire extinguisher

•

Light rescue/access pack.

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Ambulance Kits Red Trauma Kit Top section (contains Drug Kit) Main compartment, contains top section and base section

Top Section

Tensofix Bandages (3x10cm and 2x15cm)

Universal shears Gloves, 1 pair of each size (Sml, Med, Lg and X-Lg)

1 x Penlight torch 1 x Transpore tape 25mm Spacer respiratory e-chamber

Base section 6x 30mL Saline 2x Triangular bandages 1x Bandaids (packet) 2x Eye pads

BP cuff and stethoscope

Aqium Gel (70mL)

2x 500mL saline 1x Giving set

Sharps container Glucometer and accessories

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1x blanket rescue (foil) 2x Embags

3x 75cm x 20cm universal dressings 3x 20cm x 20cm dressings 3x 9cm x 10cm dressings

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Drug Kit Drug side

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IV Side

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Blue Airway Kit Top section

3x KY gel sachets 4x LMA (sizes 2, 3, 4, and 5)

2x Tie off tape

Bottom section Co-phenylcaine nasal spray and 2 nozzles

Oropharyngeal airways, 1 of each size (00, 1, 2, 3 and 4) 1x Bite block 1x Disposable bag and mask, plus pal filter 1x Pair of shears

2x Safety glasses Right side pocket 2x 14g and 1x 6g suction catheters Nasopharyngeal airways, 1 of each size (6, 7, and 8mm)

Left side pocket 1x Biohazard bag 2x 3M masks 2 of each N95 (Sml and Med) 2x Surgical masks

1 set of resus masks (sizes 0, 1, 2, 3, 4 and 5) 1x 50mL syringe

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Green Oxygen Sock •

'C' size oxygen cylinder

•

2x Nebulisers

•

2x Adult 3-in-1 masks

•

2x Non re-breathing bags

•

1x Paediatric 3-in-1 mask

•

1x Nasal specs/cannula

•

1x O2 tubing.

MRx

2x spare paper Paediatric SpO2 probe Ear probe and ECG dots

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2x Defib pads Thermometer Test loader

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PTS Green FAB Kit Front pocket

2x Conforming bandages 15cm 2x Conforming bandages 10cm 2x 20cm x 9cm Dressings 2x 10cm x 9cm Dressings

2x 20cm x 20cm dressings 2x Universal dressings

2x Blankets rescue (foil) 2x Bandages triangular 4x Eye pads

Stethoscope and BP cuff

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Back pocket

1x Aqium gel 70mL 1x Penlight

1x Biohazard bag

1x Glucometer complete 10x Lancets in plastic bag

1x Bag-valve-mask Masks (large adult, large child and large paediatric)

2x 30mL Saline 1x Universal shears

Gloves 1 pair of each size (Sml, Med, Lg and X-Lg) 1x 1.2cm tape

1x Packet of bandaids 1x Embag

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Oropharyngeal Airways, 1 or each size (00, 1, 2, 3 and 4)

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Drug Kit 2x Drawing-up needles 2x Giving needles

Tegaderm/Opsite 2x 10cm x 12cm 2x 6cm x 7cm

Syringes 2x 2mL 2x 5mL

1x Packet of salbutamol

1x IM Glucagon

1x GTN 1x Ventolin puffer 1x spacer (loose) 1x Packet of Disprin

1x Glutose 15mL oral

2x Saline 10mL 2x Water for injection

2x Adrenaline (epinephrine) 2x Naloxone 2x Atrovent

Penthrox complete

2x Midazolam

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Ambulance Equipment Suction Equipment Manual and powered suction devices are designed to create a vacuum pressure to remove fluids, secretions and debris from the airway and oral cavity.

All Ambulances carry manual foot Ambu Maxi Suction Pump and are fitted with powered suction units. There is also a manual hand pump suction unit suitable for neonates and newborns in the Emergency Childbirth kit. The foot pump suction unit has a valve on the side which can reduce the vacuum pressure so that it is more suitable for use with paediatric patients.

AMBU-pump manual foot pump suction and paediatric valve

Res-Q-Vac newborn hand pump suction

Vehicle powered suction

The manual foot and vehicle suction units are connected to a suction catheter by a disposable suction tube. In the case of the manual hand suction, the catheter is connected directly to the catheter port on the device. There are two types of suction catheters found in an Ambulance, the ‘Y’ and the Yankauer.

‘Y’ Suction catheters ‘Y’ suction catheters are a soft plastic tube with a control port on the connector that are available in a range of sizes. ‘Y’ suction catheters: •

Are commonly used to remove liquid and secretions whilst minimising damage to soft tissues

•

Can pass down airway devices to clear secretions further down the respiratory passages

•

Largest size is generally used to maximise suction potential

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Soft tipped catheter showing suction port.

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•

Smaller size may be used for a patient who has trismus or for paediatric patients

•

Comes with a control port on the top that must be blocked with the operator’s finger in order for the suction to work.

Yankauer suction catheters The rigid Yankauer suction catheter is easier to direct than the soft tipped ‘Y’ suction catheters.

The Yankauer suction catheters: •

Are rigid and must be used very carefully so as not to cause any trauma to the soft tissue in the oral cavity

•

Come with a control port on the top that must be blocked with the operator’s finger in order for the suction to work.

Rigid Yankauer suction catheter

Note: In cases where material found in the mouth or pharynx is too large or viscous for the catheters to remove, consider using the end of the suction tube itself. Consider also rolling the patient onto their side to assist with manually clearing the material.

Suction technique Suction of the unconscious patient is best achieved with the patient in the supine position. It can also be performed in a patient who is postured laterally or sitting, for instance, trapped in a car seat. As this process involves inserting a foreign object into the airway, significant care should always be taken not to cause a gag reflex or tissue damage. An episode of vomiting or haemorrhage may exacerbate the airway obstruction. Suctioning should only be performed on the parts of the airway that can be directly visualised by the Ambulance Officer. Suction catheters should not be passed any further into the airway than this.

All catheters are supplied in sealed individual packages and should not be opened or attached to any suction tubing until required for use. Keeping these devices sterile for as long as possible prior to use minimises the infection risk to the patient.

Points to consider: 1. Ensure the availability and operability of the suction device to be used 2. Connect a length of suction tubing to the suction device and then to the connector on the suction catheter

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3. Measure the length of the suction catheter to be inserted into the airway. This is approximately the same measurement used when selecting the size of an oropharyngeal airway (i.e. from the lips to the angle of the jaw)

4. Once the correct length has been identified, this should be noted by placing the operator’s fingers on the catheter at this location (as per image on previous page) 5. With the suction catheter control port in the open position, insert the suction catheter into the patient’s airway −− The catheter suction port is open when left uncovered and closed when you put your finger over the port - this allows the operator control of suction 6. Insert the suction catheter until the tip is where it is required, but must still be visible

Port open (uncovered)

Port closed (covered)

7. Cover (close) the control port of the suction catheter to begin suctioning. Using the Yankauer suction handle you can easily direct the tip of the catheter to areas of the airway that require suction 8. The above process can be repeated until the airway is cleared of fluid or obstructions

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9. If the tip of the suction catheter becomes ‘stuck’ to the tissue of the mouth, tongue or airway, the Ambulance Officer should immediately open the suction port by removing their finger to discontinue the suction before relocating the catheter. If the suction catheter is simply pulled away from the tissues of the mouth/airway with the suction still operating, this will result in trauma and haemorrhage.

Newborn, neonate and paediatric considerations When using the manual suction in paediatrics, neonates or newborns this should be preceded by the release of the ‘paediatric valve’ which is a small grommet fitted to the large black plug on the side of the storage container (Please Note: this is not present on all units). This will decrease the force of the suction able to be achieved and limit the potential for mouth and airway trauma during suctioning.

The hand suction pump (Res-Q-Vac) should be used in cases of neonate or newborn suction.

Extreme care must be used when performing suction in a newborn, neonate and small paediatrics due to the delicate nature of the tissues in their airway. Rigid suction catheters (i.e. Yankauer) should not be used, as this will increase the chance of causing trauma.

A small sized soft tipped suction catheter is usually sufficient for suctioning patients in this age group.

If there is a requirement to suction the airway of a newborn or neonate, remember to suction the mouth first, then the nose. Suctioning the nasal passages first may cause the newborn to gasp. If the mouth (oropharynx) hasn’t already been cleared, the secretions may be inhaled.

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Airway Devices Oropharyngeal Airway (OPA) Once the patient’s airway is clear, an oropharyngeal airway (OPA) should be inserted for the unconscious patient. An OPA (also known as an oral airway) is a clinical device used to assist in maintaining a patent airway. It does this by creating a semi‑rigid plastic passage between the tongue and the roof of the mouth/back of the throat and prevents the tongue from falling back against the pharynx obstructing the passage of air. It also has a reinforced flange on one end to help it stay in place and stop a patient biting through it if they experience trismus. It is an airway device that is simple to insert and can be used in conjunction with a jaw thrust during the primary survey.

The OPAs used by SAAS are single patient use only, they should never be reused on another patient.

OPAs come in a number of sizes suitable for adults or paediatrics (colours may vary depending on the supplier). OPAs can be found in the bottom section of the blue airway kit and in the airway locker of the Ambulance. Size 00 airways are also located in the maternity kit.

The OPA does not protect the patient’s airway if they vomit or regurgitate.

The correct size OPA is chosen by measuring it alongside the patient’s head. The flange (coloured end) is aligned with the level of the patient’s incisor teeth and the correct size is achieved when the other end of the airway is level with the angle of the patient’s jaw. The correct sizing of this device is very important as an OPA that is too large or too small may be worse than no OPA at all.

Level with incisor teeth

Level with jaw angle

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OPA insertion technique The OPA is placed into the patient’s mouth by holding the flange and inserting it the opposite way around to the resting position.

Pass the tip of the OPA into the patient’s mouth between the patient’s tongue and hard palate (roof of the mouth) until about half of its length is in the mouth.

At this point rotate the OPA 180° whilst continuing to insert it until the flange rests against the patient’s lips. This ensures that the device is between the tongue and the palate/throat and has not pushed the tongue back against the pharynx.

If the patient gags at any time, the OPA should be removed immediately as continuing stimulation that results in gagging can cause vomiting and add further complications to airway management.

Newborn, neonate and paediatric considerations OPA insertion in newborns, neonates, infants and paediatrics is achieved by inserting the OPA in the same orientation as it will end up, meaning the OPA will not need to be rotated 180° once partially inserted as described for an adult. This is due to the softness and shape of the oral cavity and relatively large tongue in this age group.

Care should also be taken in extremely small newborns or neonates as the smallest OPA carried by SAAS (i.e. 00) may be too large and inappropriate. In this situation the Ambulance Officer should use manual techniques until the arrival of clinical support.

Laryngeal mask airway (LMA) The LMA is inserted into the patient's pharynx through the mouth and directs air or oxygen towards the trachea. This feature results in less chance of ventilations causing stomach inflation than is seen with the OPA.

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The tip of the device sits over the opening to the oesophagus and can provide improved protection from regurgitation entering the airway (aspiration) than the OPA, however there are still some risks if the mask does not seal adequately.

If inserted correctly, the LMA reduces the requirement for Ambulance Officers to have both hands constantly on the patient's airway (e.g. as occurs with manual airway manoeuvres and the OPA) and therefore allows other tasks to be completed concurrently.

Whilst this is usually a very effective and safe device, the LMA can block the airway if not positioned properly. If it becomes dislodged during patient movement, or the patient bites down on the tubing the Ambulance Officer must be in a position to regularly assess the efficiency and adequacy of the LMA and patient's ventilations.

The LMAs used by SAAS are 'single patient use only' and should never be reused on another patient (some of the LMAs used in hospitals are able to be reused). Like most consumable clinical equipment, each LMA also has an expiry date. These dates should be checked regularly to ensure the expiry date has not passed prior to use. LMAs can be found in the blue airway kit and in locker 20 of the Ambulance.

LMA size selection SAAS currently uses the Ultimate LMA in four different sizes 2, 3, 4 and 5. The appropriate sized LMA will depend on the size of the patient, refer to the chart below.

During clinical use, the weight range for each LMA size can be found printed on the packaging and also printed on the side of the LMA tubing.

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LMA size selection should follow the following guidelines: •

Size 5 - Adult 70-100kg (usually male adults)

•

Size 4 - Adult 50-70kg (usually female adults)

•

Size 3 - Child 30-50kg

•

Size 2 - Infant 10-20kg

Equipment requirements The first step when preparing to insert an LMA is to gather all the equipment required to facilitate insertion. It is important to remember that during the preparation period someone must be constantly attending to the patient's airway and supporting ventilation if required, if this cannot be satisfactorily achieved then the LMA should not be inserted until sufficient resources are available on scene. The Ambulance Officer will need to gather and prepare the following items: •

Select the appropriate sized LMA, it should be kept in its packaging until ready for preparation/use to maximise it sterility/cleanliness prior to insertion

•

Lubrication gel is used to lubricate the surface of the LMA so that it slides easily along the top of the patient's oral cavity during insertion

•

A 50ml syringe is used to inflate the cuff of the LMA which creates the seal

•

A bite block is used as a precaution in the event that a patient regains some level of consciousness and reflexively bites on the tube. The bite block will ensure that this action will not damage or obstruct the LMA tube which is supplying the patient with oxygen

•

Cotton tie tape (1M long) is used to secure the LMA after insertion to help minimise the risk of it becoming dislodged.

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LMA preparation 1. Ensure that the patient's airway and ventilation are being effectively managed at all times during this procedure 2. Position the length of cotton tie tape under the patient's neck, ready for securing the LMA in place 3. Remove the LMA from its packaging and retain the packaging to use as a clean work area 4. Check the integrity of the LMA by inflating a small volume of air (~20mls should be enough) using the 50ml syringe. Remove the syringe to prevent automatic deflation and observe that the LMA stays inflated. If the LMA leaks or does not remain inflated, discard it and select a replacement or alternative LMA. Any failure should be reported to the State Duty Manage at the conclusion of the case 5. Prepare the LMA for insertion by reinserting the 50ml syringe and withdrawing air from the LMA until it forms a flat, smooth, spoon shape with no wrinkles and the rim facing away from the opening (see image below)

6. Open the lubricant sachet and place lubricant gel around the outer edge of the LMA. Lubricant gel should not be placed on the side of the LMA that has the opening

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7. Prepare the 50ml syringe with the required amount of air for the size of the LMA being used 8. Open the bite block packaging and use the packet to store the device to ensure it stays clean until use 9. Ensure that all required equipment is ready to go and is easily accessible 10. Immediately prior to insertion of the LMA the Ambulance Officer should ensure that the patient is satisfactorily pre-oxygenated as during the period of insertion, ventilation will not be possible. This will generally be with the bag and mask and an OPA in situ.

LMA insertion technique 1. The easiest position to insert an LMA is from behind the patient's head. The Ambulance Officer should attempt where possible to position themselves in an optimal location to achieve a successful insertion 2. Hold the LMA with the index finger placed at the junction of the cuff and the tube 3. Tilt the patient's head back slightly (unless there is suspicion of a spinal injury) and request that an assistant opens the patient's mouth (this can be performed by the operator themselves if required)

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4. Insert the LMA into the patient's open mouth between the patient's tongue and hard palate. The tip and lubricated side of the LMA should be against the patient's hard palate (roof of mouth). The correct orientation can be confirmed using the black line on the LMA tube being orientated towards the patient's nose

5. Whilst inserting the LMA, maintain a moderate amount of pressure with the Ambulance Officer's index finger on the tube and advance the LMA until resistance is felt (and only a small portion of the tube remains visible)

6. Remove the grip on the LMA and inflate the cuff with the starting volume (as per the table below) using the preprepared 50ml syringe −− Letting go of the LMA allows it to adjust to the correct position in the patient's pharynx −− This may be seen as the LMA tube moves up and out slightly during inflation

LMA size

Starting Volume

2 3 4 5

5-10mL 15mL 25mL 35mL

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Increase volume to a maximum of: (Not determined) 25mL 35mL 45mL

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Confirming placement of the LMA 1. Attach the resuscitation bag (with bacterial filter attached) to the LMA while carefully holding onto the LMA tube (to ensure it is not moved or dislodged) and provide two ventilations 2. Observe for the rise and fall of the patient's chest during these two ventilations and listen for any excessive air leakage from the oral cavity 3. If there appears to be a large amount of air leakage from the oral cavity during ventilations, detach the resuscitation bag and inflate the LMA to the maximum volume (this is an extra 10ml of air) using the 50ml syringe. Never exceed the maximum volume of air when inflating the LMA 4. Re-attach the resuscitation bag and re-attempt the two trial ventilations 5. If the air entry is still not adequate (as determined by the lack of rise and fall of the patient's chest during ventilation or excessive air leaking from the mouth) immediately deflate all air from the LMA cuff and remove it. Re-insert an OPA and manual airway manoeuvres +/- bag and mask ventilation 6. If required, another attempt at inserting the LMA may be made after the patient is given sufficient oxygen using basic airway/ventilation management and all equipment is re‑prepared 7. An effective LMA seal is noted by good rise and fall of the chest during ventilation, no air leaks/noises coming from the mouth and the patient's SpO2 improves or remains stable (in the non-cardiac arrest patient).

Securing the LMA 1. Once the Ambulance Officer has confirmed the correct position of the LMA, remove the resuscitation bag and insert the bite block so that it is positioned between the top and bottom lateral row of teeth (on either side) especially at the rear (molars)

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2. Secure the LMA using the cotton tie tape so that it is positioned behind the patient's head. There are a variety of methods that can be used, to secure the LMA, the preferred method used in SAAS is as follows: −− Knot the tie tape firmly in the patient's mouth - this creates an anchor to the patient −− Wrap the tie around the LMA tube (not the bite block) and tie a firm knot so that the LMA tube is between the two knots. The second knot should be tied so as to be reversible (e.g. in a bow) should the LMA need to be removed

3. Re-attach the resuscitation bag and ensure adequate ventilation or oxygenation is achieved/maintained.

Precautions when using a LMA It is important to remember that a patient who is not self-ventilating is not going to be ventilated (and at risk of hypoxia) for the length of time it takes to insert a LMA. It should be a swift insertion process, practise will enable this.

Any movement of the patient (e.g. extrication) increases the risk of the LMA moving or becoming dislodged, especially if it is not secured firmly. It is important to regularly check that the LMA is still effective by observing the rise and fall of the patient's chest during ventilations, the patient's SpO2 and any changes in their general skin colour. If there is any doubt, remove the LMA re-oxygenate using manual airway manoeuvres and replace when next appropriate.

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Inadvertent rotation of the LMA during insertion may result in a complete airway obstruction. Make sure the device is inserted with the black line on the tube facing the upper lip/nose of the patient.

If you notice that the patient regurgitate, immediately deflate the LMA and remove it.

Standard airway clearance procedures (manual clearance, posture, suction) should be implemented. In an emergency situation it is okay to remove the LMA whilst it is still inflated if deflating the cuff (using the 50ml syringe) will cause a delay.

LMA insertion with a possible spinal injury If spinal injuries are suspected in the unconscious patient a cervical collar should be applied and LMA insertion should be performed, provided that ongoing attention is given to maintaining adequate spinal immobilisation.

When fitted correctly the cervical collar reduces the ability to hold the patient's mouth open to insert the LMA and therefore the cervical collar will usually need to be temporarily removed to facilitate insertion. In this circumstance a second Ambulance Officer will need to provide manual spinal immobilisation for the duration of LMA insertion while the collar is removed. Insertion of the LMA in this setting is a 2 to 3 person task, as someone must always be maintaining neutral alignment of the head.

1. The patient should first be ventilated using the bag and mask and an OPA with the cervical collar in situ as per normal procedures until such time that the LMA is prepared and ready for insertion

2. The person at the head end (who will be inserting the LMA) takes over manual immobilisation of the patient's head while the person at the patient's side (assistant) removes the collar

3. Once the collar is removed, the assistant takes over control of the patient's head and spinal immobilisation so that the attendant can insert the LMA using the normal method

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4. Once the LMA is inserted, there is adequate rise and fall of the chest and the LMA is secured (as per normal process), the attendant re-established the head control so that the assistant can reapply the cervical collar 5. If at any stage of the process the patient's heart rate is noticed to dramatically decrease, the LMA should immediately be deflated and removed and manual/ventilation techniques reinstated.

Nasopharyngeal airway (NPA) The NPA is a 'rescue' option for those patients who are unconscious, need airway support, have clenched teeth or are unable to tolerate an oral airway (OPA and LMA).

The NPA is considered an advanced airway and therefore should only be inserted after compressions and defibrillation have begun in the event of cardiac arrest.

The NPA does not stop the jaw or tongue from dropping back and potentially obstructing the airway through muscle relaxation. Therefore the NPA does not replace other airway management strategies such as posture, jaw thrust, chin lift and head tilt. The NPA doesn't prevent aspiration of secretions and vomit into the lungs, however it can be very useful for suctioning through if the patient has clenched teeth.

Note: The NPA cannot be used in patients with a suspected fracture of the base of the skull.

Co-phenylcaine is often used before inserting a NPA. This drug is a mixture of anaesthetic and vasoconstrictor, which minimises discomfort of NPA insertion and shrinks the tissue lining the nose to make more space for the NPA. It also helps reduce any bleeding that may occur during insertion. This bleeding is rare, but usually caused by disruption of polyps in the nasal cavity. This is not related to your NPA insertion technique.

For more information on cophenylcaine refer to the Pharmacology Study Guide.

The following is a checklist for the insertion of the nasopharyngeal airway: •

Safety −− Ensure to wear gloves and safety glasses to avoid the risk of exposure to body fluids

•

Right patient −− If unable to use an oropharyngeal airway/laryngeal mask airway due to trismus or presence of the gag reflex

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−− If there is no evidence of base of skull injury or caution with patients who have head or facial injuries −− The ideal patient is one who is experiencing persistent unconsciousness from a medical cause (e.g. stroke) or a seizure with trismus.

•

Equipment −− Co-phenylcaine and nozzle applicator −− Nasopharyngeal airway wither size 6, 7, or 8 −− Safety pin (packed with the NPA) −− KY lubricant

•

Patient history −− No known allergy

•

Select largest clear nostril −− Check which nostril to use and apply 2 sprays of cophenylcaine −− Vasoconstriction of the nasal mucosa should take a couple of minutes −− Literature indicates the mucosa becomes pale.

•

Put safety pin through the end of the NPA −− This is really important, the safety pin stops the NPA sliding into the large nasal cavity and keeps the tube sitting in the right position, flush with the nostril

•

Lubricate the tube −− Adequate lubrication minimises the trauma to the nasal mucosa

•

Insert the tube pointing towards the back of the head −− Insert the NPA tube back along the base of the nose. If you come across any resistance gently rotate the tube and do not force the tube in

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•

Avoid pushing the airway in an upward direction −− If you insert the NPA tube upwards you are likely to strike the vascular mucosal lining increasing the risk of bleeding and not situating the tube in the right position

•

The image below shows the Nasopharyngeal tube correctly inserted.

Advantages and disadvantages of using the NPA Advantages •

Great for seizure patients or other patients with medical cause of persistent unconsciousness

•

Great for patients with trismus

•

Rapidly inserted

•

Rarely causes vomiting

•

Can be suctioned through.

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Disadvantages •

Smaller than the oropharyngeal airway

•

Needs Co-phenylcaine which take a while to take effect

•

May cause haemorrhage

•

Doesn't prevent the tongue occluding the airway

•

May cause pressure necrosis on the nasal mucosa

•

If the nasal septum is deformed it may be difficult to insert.

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Supplemental Oxygen Delivery When managing some clinical conditions, it is important to increase the concentration of oxygen above that which we can get from air. To assist with this, various types of oxygen delivery equipment can be used to increase oxygen levels, including: •

Nasal cannula

•

Face mask

•

Non re-breather face mask

•

Bag and mask.

Each has the ability to deliver a different concentration of oxygen to support the patient’s requirements. Refer to the Cardiac Arrest Management study guide and Respiratory Conditions section of the Medical Conditions study guide for more information.

The pictures below outline the oxygen concentration delivered through each form of oxygen delivery equipment:

Nasal specs

Face mask

Non re-breather face mask

Bag and mask

≈ 30% inspired O2

≈ 40 - 45% inspired O2

≈ 80 - 85% inspired O2

≈ 100% inspired O2

Bag and mask Supporting ventilation is achieved in the Ambulance setting via the use of a resuscitation bag and mask which is designed to push air into the patient’s airway and lungs. This process of forcing air into the lungs is called intermittent positive pressure ventilation (IPPV). High flow oxygen can be attached to the bag and mask so the air that is pushed into the patient’s lungs will contain 100% oxygen.

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The resuscitation bag and masks used in SAAS are disposable and therefore intended for single patient use only. The role of the resuscitation bag is to provide a reservoir of air that can be squeezed by the Ambulance Officer into the patient’s lungs.

SAAS kits contain a range of face mask sizes from adult to newborn size, therefore the appropriate sized mask for the patient needs to be selected. The mask should cover both the patient’s mouth and nose.

A bacterial filter is attached between the face mask and the rest of the resuscitator to help reduce bacterial and viral contamination. It also helps decrease the chance of valves within the resuscitation bag occluding or not functioning correctly due to vomiting or secretions.

An extension tube is found attached to the resuscitation bag between the bag and patient valve. This is fitted to make bag and mask ventilation easier to achieve.

Oxygen tubing should be connected to the port on the bottom of the resuscitation bag and to an oxygen supply in cases where supplemental oxygen is required during ventilation.

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IPPV To ventilate effectively using the bag and mask, there needs to be an airtight seal between the mask and the patient’s face.

One hand is holding the mask and maintaining jaw thrust, while the other hand is free to ventilate.

•

Ventilation using the bag and mask is best achieved from the ‘head end’ of the patient, with the operator sitting behind the patient’s head in the rear cabin of the Ambulance (sitting in the ‘airway seat’)

•

Place the appropriate sized mask on the patient’s face starting by placing the tip of the mask (nose end) over the bridge of the patient’s nose, then rolling the mask down to cover the mouth. The bottom edge should be resting on the patient’s chin

•

Grip the mask with a thumb over the narrow (nose) portion of the face mask and the index finger around the chin end of the face mask, so that the thumb and index finger make a ‘C’ shape

•

Gently push the mask downward onto the patient’s face using these two fingers

•

Using all remaining fingers on the same hand, place these along the patient’s jaw and use these to initiate a jaw thrust by gently pulling the jaw into the face mask

•

If there are no concerns regarding the potential for a spinal injury, a head tilt may also be performed

•

If an adequate seal around the face mask has been achieved, there should be no air leaking from around the patient’s face and a gentle compression of the resuscitation bag should be enough to cause a rise in the patient’s chest.

Adequacy of ventilation is usually measured by looking at the rise and fall of the patient’s chest. The Ambulance Officer should squeeze the resuscitation bag sufficiently to observe a normal amount of ventilatory movement and no more.

Excessive ventilation volumes will markedly increase the chance of air entering the stomach causing regurgitation.

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In most situations the frequency of ventilation should be at a ‘normal’ respiratory rate (12-16 breaths per minute in adults). During CPR the ratio is 2 ventilations to every 30 chest compressions.

Once a good seal between the face and mask has been achieved, try to keep the mask in place as much as possible. Unless there is a pressing need to, do not remove the mask between ventilations otherwise the mask will need to be re-sealed each time there is a need to ventilate. This wastes time and may result in missed ventilation opportunities and partial loss of airway control.

IPPV and the LMA The resuscitation bag can be used to provide ventilations for a patient who has an LMA inserted by simply attaching the device to the end of the LMA tube.

Ventilations are then achieved in the same manner as the bag and mask, however there is no requirement to manually maintain the seal, freeing the operator’s hands to complete other tasks.

You may need to disconnect the badg and mask from the LMA when moving the patient. Keep these periods as short as possible.

Newborn, neonate and paediatric considerations A newborn/neonate version of the bag and mask unit is located in the Emergency Childbirth (maternity) kit. This version is smaller in size and volume.

The paediatric valves are set to reduce any excess ventilation pressure inadvertently being used on paediatric patients. Whilst these devices can be reasonably effective, they do not replace the need to take care when ventilating paediatrics. These valves should not be used when ventilating adults as they may cause ventilation to fail. Make sure these valves are routinely checked during equipment inspections.

Children and infants have smaller lung sizes than adults and therefore require less volume to be pushed in during IPPV. Excessive force or volumes can cause trauma to the lungs or force air into the child’s stomach. This may result in regurgitation of stomach contents making airway management very difficult. Ventilation volumes should be adjusted according to the patient’s size so that there is an adequate chest rise and fall.

A child’s face is generally flatter than an adult’s, so the smallest three sizes of face masks carried by SAAS are round in shape to enable them to fit with a better seal to a child’s face. The technique for gaining a seal is the same as for adults, but the

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operator should be aware of how much force they use to maintain the seal and manual airway manoeuvres so that they do not cause trauma.

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Oxygen Cylinders The Inhalo oxygen system is used for portable oxygen supply. All Ambulance also carry the D-size oxygen cylinders to provide the oxygen supply within the vehicle.

It is important that the Ambulance Officer is able to recognise the different types of oxygen cylinders and gauges as used by SAAS and be able to safely change over an empty cylinder and replace it with a full one.

When the contents gauge on an oxygen cylinder is showing that it is less than 1/4 full (i.e. the gauge has the indicator needle in the red area) the cylinder should be changed over for a full one as soon as operationally possible. The contents/pressure gauge on the gas cylinders used by SAAS may be either attached or inbuilt into the oxygen cylinders. They are designed to provide an indication of how much gas remains in a cylinder.

Preparing and using the Inhalo cylinder 1. Check the product label to ensure that you have the correct product (i.e. medical oxygen), this is no different to performing the standard medication check!

2. Check that the new cylinder is full by ensuring the content gauge indicated this.

If the cylinder is not full, select another cylinder for use and return the non-full cylinder to the station exchange point 3. Check that both the grey plastic covers are attached and intact 4. Ensure the flow selector is turned to zero

Note: The empty Inhalo should be placed in the appropriate location at your station or in a SAAS oxygen swap location (some metropolitan hospitals).

Alternatively, secure the empty Inhalo in the locker of the Ambulance until you return to station.

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5. Open or remove the two light grey covers to access the connection points and the ON/OFF hand wheel 6. Rotate the ON/OFF hand-wheel in a counter-clockwise direction as far as possible, then rotate in the opposite clockwise 1/4 of one turn

7. Connect one end of the oxygen tubing to the delivery equipment (i.e. face mask, nasal cannula or resuscitation bag) and the other end of the tubing to the Inhalo flow outlet 8. Rotate the gas flow selector knob to the desired flow rate of your application.

D-size oxygen cylinder changeover D-size oxygen cylinders have a gauge attached to the top oxygen. Valve spindle and flow outlet is directly attached to the vehicle oxygen supply. The gauge must be removed from the D-size cylinder oxygen valve spindle in order to remove the cylinder from the vehicle.

These gauges are regularly serviced to ensure their reliability and have a tag attached which indicates the date the next service is due. If you find a gauge that is past its service date, arrange for it to be returned to Communications Engineering department and obtain a changeover set.

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1. Ensure the cylinder selector control inside the vehicle has the full/other cylinder selected

2. Turn the empty cylinder valve OFF/CLOSED by rotating the hand wheel at the top of the cylinder completely clockwise

3. Remove the gauge from the empty cylinder by twisting the 'T' shaped handle to the right of the gauge until it becomes loose (a small amount of gas may escape from the gauge during this process)

4. Lift the gauge from the empty cylinder

5. Remove the cylinder from the vehicle bracket and place in the appropriate location at your station

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6. Obtain a full D-size oxygen cylinder, which is indicated by the sealed plastic covering over the oxygen valve and ON/OFF hand-wheel. Ensure it is the correct product (medical oxygen) and remove the plastic coverings 7. Place the new D-size cylinder in the Ambulance bracket, ensuring the two indentations for the metal pins on the gauge are on the left side 8. Secure the cylinder in the appropriate bracket in the Ambulance

9. Place the gauge over the spindle of the cylinder, ensuring the metal pins on the gauge align with the holes in the cylinder spindle 10. Tighten the 'T' shaped handle to secure the gauge to the cylinder 11. Turn the cylinder valve ON/OPEN by rotating the hand-wheel at the top of the cylinder counter-clockwise (the contents gauge should then indicate a full cylinder).

After completing the above steps, listen for any leaks (hissing sounds) from the gauge attachment points. If there is a leak, turn the cylinder off and re-tighten the 'T' shaped handle or re-locate the gauge on the spindle to get a better seal. If there is still a leak, the washer in the gauge may need to be replaced and the gauges should not be used further.

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Using the D-size cylinder (in the Ambulance) •

Connect one end of the oxygen tubing to the delivery equipment (i.e. face mask, nasal cannula or resuscitation bag) and the other end of the tubing to an oxygen flow outlet in the vehicle

•

Rotate the flow selector knob to the desired flow rate for your application.

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Electrocardiogram (ECG) A cardiac monitor can measure the electrical activity of the heart through electrodes placed on the skin. The monitor measures the electrical activity relative to the placement of the electrodes. A three lead ECG requires the placement of three electrodes, or dots, and provides the clinician with a 'view' of the heart's electrical activity from three different perspectives (Lead I, Lead II, and Lead III). For more information on cardiac electrophysiology refer to the Cardiovascular System section of the Anatomy and Physiology study guide.

How to record an ECG Placing the electrodes 1. Attach three electrodes to the ECG cables which are labelled and colour coded (which will help you to remember where to place them on the patient) 2. Remove the clear protective cover from the gel/adhesive surface of the electrode and place these on the patient's skin as follows: −− Right arm (RA): White - this should be placed just under the clavicle on the patient's right side −− Left arm (LA): Black - this should be placed just under the clavicle on the patient's left side −− Left leg (LL): Red - whilst this would infer that the electrode is to be placed on the patient's left leg, for the purposes of monitoring in the Ambulance setting, this position is modified and the electrode is placed under the ribs on the left side of the patient's abdomen.

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Acquiring an ECG Once the ECG electrodes have been placed on the patient, the MRx therapy knob is then turned to the 'On Monitor' position as shown in the picture below and the monitor will automatically begin to display the electrical activity of the heart (ECG) in Lead II.

The standard MRx has the capability to record three different views of the electrical activity of the heart or a '3 Lead ECG'. You may be requested to print Lead I and III to provide assistance to a Paramedic or ICP during a case. To print an ECG do as follows: •

Select the desired lead/view by using the small soft lead selection key to the left of the MRx screen

•

Each time the soft key is pressed the ECG view/display will scroll through the leads in the following order: Lead II, Lead III, Pads, Lead I Note: Lead II is usually the best view

•

Once the desired lead has been selected, the print button (which is located above the printer door) can be pressed to commence a recording of the ECG associated with that lead. To stop the printing process simply push the print button again.

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Other features of the MRx The printer Printer paper should be changed whenever empty or at the conclusion of a case if the red ink marks have become visible on the paper.

To replace the paper follow these steps: 1. Open the printer cover by depressing the small lever button at the bottom right of the printer. The cover will pop open and it will be easy to remove the empty roll 2. Prepare the new printer roll (ensuring that it is the correct paper for the MRx it is being installed into), by removing the small sticker and tearing a small length (about 10cm) of the paper off the roll. This will remove the sticky section that can cause the paper to jam in the printer 3. Insert the roll as indicated in the diagram on the inside of the printer cover (i.e. with the paper emerging fro under the roll) 4. Close the printer cover leaving a small section of paper hanging out of the cover 5. Tear off the small tag of paper protruding from the printer.

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Mark an event The MRx has the capability to record key events during a patient's managing in addition to the heart rate, ECG and SpO2 which can later be recalled to support case documentation on the PCR. It can be useful to mark certain events while monitoring (or resuscitating) a patient (e.g. drug administration). Activating this function will result in a recording of the treatment administered and when it was administered. There are a range of medications pre-programmed into the event pick list with one option being 'OTHER' which can be used as a generic/multi-purpose marker.

To mark an event while in monitor or AED mode follow these steps: 1. Press the soft grey â–ş button located on the top left of the monitor next to the words 'Mark Event' on the MRx screen

2. A list of treatment events will now be displayed at the bottom right area of the screen 3. Use the up/down menu selection soft keys as shown below to highlight the appropriate event 4. Press the 'tick' button to select the event. The event and time will then automatically be recorded by the MRx and the screen will return to its normal view.

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Printing an event summary After completing a case, it is possible to print a summary of all the events recorded by the MRx including a re-print of any ECG strips that were printed during the case.

This function is typically used to provide an overview of a case, particularly a cardiac arrest, to hospital staff after the patient has been handed over. The MRx creates an event (case) every time it is switched on and the last 30 events (cases) are stored in the unit's memory. To print an event summary follow these steps: 1. Turn the MRx on to monitor mode 2. Press the 'tick' button at the bottom of the screen which is located under the 'Menu' prompt 3. A series of menu options will appear 4. Scroll the highlighted area, using the up/down menu selection keys to 'Other' and select this option using the tick button 5. Another series of menu options will appear 6. Scroll the highlighted area using the up/down menu selection keys to 'Data Management' and select this option using the tick button 7. A warning message will appear on the screen 'Leaving normal operational mode...'

8. Press the tick button to acknowledge the warning and enter the case database

9. A different screen layout will appear which is a list of events (or cases) 10. Using the 'Prev item' or 'Next item' keys at the bottom of the screen, scroll the highlighted area to the event ID and date that is to be printed (this is usually the most recent one). Once the event required is highlighted, press the tick button 11. A small menu will then appear above the 'tick' button 12. Using the up/down menu selection key scroll the highlighted area to 'Print' and press the 'tick' button. Printing will begin automatically. Allow the entire summary to print (it may be quite long)

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13. Once the printing is complete, press the soft key under the 'Exit Data Mgmt' at the bottom left of the screen. This will return the MRx to monitoring mode.

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Taking a Blood Pressure •

To begin blood pressure measurement, use a properly sized blood pressure cuff. The length of the cuff's bladder should be at least equal to 80% of the circumference of the upper arm.

•

Wrap the cuff around the upper arm with the cuff's lower edge one inch above the antecubital fossa.

•

Lightly press the stethoscope over the brachial artery just below the cuff's edge.

•

Rapidly inflate the cuff to 180mmHg. Release air from the cuff at a moderate rate (3mm/sec).

•

Listen with the stethoscope and simultaneously observe the sphygmomanometer.

The first knocking sound is the subject's systolic pressure. When the knocking sound disappears, that is the diastolic pressure (such as 120/80).

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Glucometer The patient's blood glucose level (BGL) should be assessed for all emergency patients, but particularly for any patient who has an alteration in body function or conscious state. Ideal levels range between 4.0 - 8.0 millimole/L (mmol/L). to measure a BGL: For information on how to measure a BGL refer to the Ambulance Equipment study guide.

1. Gather the required equipment −− Glucometer −− Test strips −− Lancet −− Sharps container −− Tissue or Band-Aid 2. The glucometer should have been calibrated to the batch of test strips currently in use during the vehicle check 3. Ensure the test strips have not passed their expiry date; they will not work in the glucometer if they have expired 4. Tear the foil packed open using the easy tear point to remove the thin test strip 5. Insert the 'chip' end of the test strip (has a barcode appearance) into the small opening on the bottom of the glucometer, this will cause the device to automatically turn on 6. The glucometer will indicate when it is ready for use when an image of a drop of blood appears on the display screen. From this point there is a window of 30 seconds to acquire a drop of blood and place it onto the test strip 7. Choose a clean, dry finger. If the finger is dirty it can be cleaned with an antiseptic wipe. You will need to allow the finger to dry for 30 seconds so that there is no interference from the chemical on the swab with the function of the glucometer. Cleaning with an antiseptic wipe should not be performed routinely.

The fingers are usually chosen for this process as they are easy to access and usually have a good blood supply, however any clean area of skin that has good blood flow (e.g. warm and pink) can be used for this purpose (e.g. bottom of the heel in an infant).

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8. Prepare the lancet by removing the needle's protective cover by gently twisting it

9. Hold the lancet between the first two fingers as shown in the image below 10. Push the lancet firmly against the side of the finger (or site chosen) and depress the plunger mechanism on the top of the lancet to release the sharp, this process results in a small disruption to the skin that produces a small amount of blood 11. For safety, the needle in the lancet is designed to automatically retract after activation. However, all used lancets must be immediately disposed of in a sharps container 12. Holding the glucometer in an upright position so that the test strip is underneath the device, place the exposed top of the test strip into the drop of blood and hold it there until the glucometer beeps (a few seconds): this is to allow enough blood to be taken into the test strip for the reading to be performed 13. The device will then perform a count down and beep again when it displays the measurement.

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Motorcycle Helmets Removal of a motorcyclist's helmet enables access to their airway and enhances the ability to more completely assess the patient and manage spinal immobilisation.

On occasion, helmets may be removed prior to your arrival on scene. It is worthwhile establishing who removed the helmet and when, as this could provide indicators of the patient's initial Glasgow Coma Score (GCS), or if the helmet was worn correctly in the first place.

If not already done, the helmet should be removed in a controlled manner to prevent further injury or pain to the patient, whether they are conscious or not.

Always take the rider's helmet and any other protective clothing with you in the Ambulance to the hospital. Inspection by medical and nursing staff may assist with indications of mechanism of injury and therefore enable rapid diagnosis and treatment.

Types of helmet The removal of clip on visors may enable early access to the airway and give you an important visual connection with your patient. Patients wearing a full face helmet will need to have their whole helmet removes to enable an assessment of airway and respiratory state, whereas other types can allow for some level of assessment. All helmets will need to be removed to enable good cervical spine immobilisation.

Helmet removal Removal of a helmet requires coordination and communication between Ambulance Officers. Each circumstance will provide unique challenges, but the general process is as follows: •

Attendant 1 immobilises the helmet and head in alignment by placing their forearms alongside the helmet and their palms behind the patient's shoulders, as for cervical spine immobilisation without a helmet

•

Attendant 2 examines the helmet and removes any removable face shields or goggles and assesses the patient's airway and respiratory status

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•

Attendant 2 takes over the cervical spine immobilisation in one of two ways: −− They can grasp the patient's mandible (lower jaw) with one hand by placing the thumb at the angle of the mandible on one side and two fingers at the angle on the other side, and place their other hand under the patient's neck at the base of the skull −− They can also place their hands on either side of the head by grasping the maxilla with the thumbs on either side and curling their fingers under the occipital bone

•

Attendant 1 begins to remove the helmet by carefully spreading the sides of the helmet away from the ears of the patient and then rotates the helmet from the back of the patient's head forwards to clear the patient's nose

•

Attendant 1 then follows the curvature of the patient's head and draws the helmet towards themselves in a straight line

•

Care must be take to ensure the head does not drop when the helmet is removed.

If required, Attendant 2 can re-position their hands at any time through the helmet removal, but this requires communication with Attendant 1 to ensure cervical spine immobilisation is maintained at all times

•

Once the helmet is off, Attendant 1 can resume cervical spine immobilisation whilst Attendant 2 applies a rigid cervical spinal collar.

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Cervical Collar The cervical collar should be used for any patient involved in trauma where there is a suspicion of a potential spinal injury. Application of the cervical collar is a two person procedure.

SAAS has adult and paediatric cervical collars. The adult collar has 4 adjustable sizes, whereas the paediatric collar has three adjustable sizes. The collars are for single patient use only (not washed and recycled).

Sizing One member of the crew should maintain manual head immobilisation throughout patient care, while the other prepares and applies the collar. •

With the patient's head in a neutral alignment, measure the length of the patient's neck to determine the size to adjust the cervical collar

•

Measure how many of your fingers fill the space between the patient's shoulder and the level of their chin

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•

Take the collar out of its plastic cover and adjust to the required size

•

Place the same amount of fingers, as determined in the previous step, at the lower plastic edge of the collar, the size is determined by the oval window nearest the upper edge of your fingers

•

Pull the chin support section of the collar upward until the selected oval window is coloured red

•

Lock into position by pushing the two locking mechanisms until a 'click' is felt and heard, check it is locked in by confirming that the chin section can no longer be adjusted up or down.

Application - supine patient Method 1 •

Bend the collar to pre-form it so that it will conform around the patient's neck with more ease

•

Slide the rear panel behind the right side of the patient's neck, until the Velcro part of the collar protrudes from the other (left) side

•

Fold the front of the collar over the front of the patient's neck so that the yellow chin support panel is centred under the patient's chin

•

Fix the rear Velcro strap to the front of the collar on the left side of the patient

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Method 2 •

Bend the collar to pre-form it so that it will conform around the patient's neck with more ease

•

Place the front of the collar over the patient's neck so that the yellow chin support panel is centred under the patient's chin

•

Fold the rear panel and gently feed it under the patient's head, while the other officer maintains good head and spinal control

•

Fix the rear Velcro strap to the front of the collar on the left side of the patient.

Application - sitting patient •

Bend the collar to pre-form it so that it will conform around the patient's neck with more ease

•

Place the front of the collar over the patient's neck so that the yellow chin support panel is centred under the patient's chin

•

Fold the rear panel behind the patient's head, while the other officer maintains good head and spinal control

•

Fix the rear Velcro strap to the front of the collar on the left side of the patient.

Note: Head and neck movement need to be kept to a minimum. Therefore the patient requires manual immobilisation when applying the cervical collar.

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Spinal Board The spinal board has multiple uses including as a patient lifting device, a transfer platform, as patient protection during vehicle cutting, spinal immobilisation and as a 'sled and extrication tool.

Use of the spinal board should be done using safe Manual Tasks processes. For more information on safe Manual Tasks processes, refer to the Manual Tasks study guide.

The spinal board is not a spinal splint, it is a movement or extrication device only.

The log roll technique is used to move a patient onto a spinal board whilst maintaining spinal alignment.

A cervical collar should be applied before conducting a log roll.

Log roll •

A log roll requires a minimum of four people - one to maintain head alignment, one at the chest, one at the hips and one to manage the spinal board

•

The patient's arms should be fully extended alongside the body with palms facing in (preferred) or across the chest

•

The clinician who is maintaining head alignment must control and coordinate all patient movements

•

The chest person grasps the patient's far side, shoulder and waist

•

The hip person grasps the patient's far side hip and leg

•

Only on the direction of the person who is managing the head (usually on the count of three) is the patient rolled away from the board and toward the Ambulance Officer in one motion to a 45 degree angle

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•

A secondary survey of the back should be conducted before the patient is placed on the spinal board

•

The spinal board person then places the board against the patient's back

•

Only at the direction of the clinician who is managing the head (again, usually on the count of three), the patient and board are lowered to the ground in one motion

•

If the patient needs to be moved sideways in order to be centred on the spinal board this can be done with a gentle push while maintaining spinal alignment but only at the direction of the clinician who is managing the head

The patient needs to be secured to the spinal board using spinal board straps and placed on the stretcher for transport as per Manual Tasks instructions. The lead clinician should stay with the patient at all times and continue manual head and spinal immobilisation.

Transport Patients are not to be transported on the spinal board.

It needs to be removed from under the patient once they are on the stretcher using a log roll (as previously described).

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Oregon Spine Splint The Oregon Spine Splint is used in conjunction with a cervical collar and manual support to immobilise the cervical and thoracic sections of the spine. Particularly when a patient needs to be extricated from an awkward space, such as a vehicle at the scene of a crash.

Once the Oregon splint is secured correctly on a patient, the device should remain in place during the transport of the patient.

The splint can be x-rayed through, however, some hospital staff may choose to remove it during their physical examination of the patient.

•

All splint components are packed in the thin long orange bag labelled 'Oregon Spine Splint

•

The splint is a rigid orange board with 12 colour coded straps sewn into the back and a head support

•

Extra padding is supplied to fill gaps created by the natural alignment of the head and individual variations between patients

•

The head immobilisation is fixed with the two loose straps, the forehead restrain strap and the chin restraint strap.

Preparation There is little preparation required for applying the Oregon splint. Unpack the components of the splint and unravel the 12 attached straps so that they are easily accessible

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It is important that everyone involved in applying the splint to the patient is aware of how it will be done. It is a coordinated exercise which is best achieved with one lead clinician directing others.

Application The following is a guide on how to apply the Oregon splint. It is most often used to extricate patients from a car, so each situation will vary depending on the amount of damage to the vehicle, the type of vehicle and what access remains. If you want to access a patient or extricate them in a certain way, inform the rescue service (MFS, CFS, SES) of what you want to do and they will facilitate this or suggest a safer alternative.

•

Apply the cervical collar

•

While supporting the patient, so there is minimal body movement, slide the Oregon splint behind the patient with the smooth surface of the splint (no straps) in contact with the patient's back

•

Slide the splint down until the 'T' shaped head support of the Oregon is behind the patient head

•

Ensure the patient's spine is aligned with the centre of the splint

•

Pull the large black groin straps to the side so they are out of the way, but accessible for later application

•

Apply and adjust the diagonal chest straps until firm - be careful not to push or pull the patient −− Orange straps go over the left shoulder and under the right arm −− Green straps go over the right shoulder and under the left arm

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−− Buckles should be positioned just underneath the left and right clavicles.

•

Apply the lower chest and abdominal straps −− Grey straps with white buckles are for the lower chest - tension firmly but not as to restrict comfortable breathing −− Grey straps with black buckles are for the abdomen tension firmly but not as to put too much pressure on the abdominal organs

•

Apply the groin straps - these are 'shimmied' under the patient's legs, as high up into the groin as comfortably possible −− Long black strap (with white buckle) on the patient's left goes from the patient's left side under their left leg and pulled tight - this aligns the strap well under the gluteal muscle −− The long strap can then come back and up between the legs, over the left groin and upper leg. It is fastened into the corresponding white buckle in front of the left pelvis and tensioned firmly

•

The same process is completed from the other side for the long black strap (with black buckle) on the patient's right.

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Secure the 'T' shaped head support to the patient's head: •

Depending on the patient, you may need to place some padding behind the patient's head (not the neck) to keep them in an anatomically neutral position

•

Maintain manual cervical spine alignment ready for inline extrication. This manual head alignment is maintained during the extrication to avoid potential displacement of the head position should the splint move during extrication

•

Once the patient is placed in a horizontal position the head straps can be applied.

The groin straps can be released. The patient is now lying flat

•

The non-slip pad of the forehead restraint strap is placed against the patient's forehead and the lengths are then secured to the Velcro panels of the left and right head flaps

•

The chin strap is centred over the patient's chin and the lengths are secured to the Velcro panels on the left and right head flaps

•

Tighten all straps to make them as firm as possible, but not so that they severely restrict breathing or circulation

•

Slightly life the splint using the two loops on the back of the splint and the patient can be pulled in a vertical alignment (using correct Manual Tasks postures) out of the rear of the vehicle, using the spinal board as a platform

•

Extra lateral support around the torso, pelvis and limbs will assist in a smooth vertical inline extrication

•

Once the patient has been extricated and is on the stretcher in a supine position it will be necessary to loosen the two black groin straps and possibly slightly loosen the chest and abdomen straps as they may otherwise restrict circulation.

Note: For in-line extrication head straps should not be applied until after the patient is extricated, to minimise hyperextension of the cervical spine. For other extrication (i.e. out of car door) head straps should be applied before extrication to minimise lateral movement of the cervical spine.

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Vacuum Mattress The Vacuum Mattress ('Vac Mat') can be used when a difficult extrication is not required and you suspect the patient has a spinal injury.

The Vacuum Mattress can be used for immobilisation of a patient with non-spinal injuries, such as pelvis fractures or limb fractures, however, it is most often used for spinal immobilisation. When applied correctly it can maintain alignment for the full length of the spine.

If the Oregon splint has been used for extrication, it should be removed from the patient if you intent to transport them in the Vacuum Mattress Basic spinal care in the form of manual immobilisation, cervical collar and full sensory and motor assessment should be completed prior to moving the patient.

The Vacuum Mattress is too thick to be rolled directly under a patient without compromising spinal alignment, therefore the patient needs to be moved onto the mattress using the spinal board and log roll techniques.

The Vacuum Mattress can be x-rayed through, however some hospital staff may choose to remove it during their physical examination of the patient.

•

The Vacuum Mattress is rolled and packed a large bag and stored behind the forward facing attendant seat of emergency Ambulances

•

The Vac Mat has 7 pairs of restrain straps and 8 lifting handles sewn into the back (red side) and one loose head restrains strap

•

The blue side of the Vac Mat has a red line marked at the head end to indicate the level of the patient's shoulders in the supine position

•

There is a valve at the foot end of the Vac Mat which twists to open and close.

This connects to the Ambu foot pump suction tubing for removal of air.

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Preparation Prepare the Vacuum Mattress for use by unrolling and laying it out on a flat surface. If you can prepare the mattress on the stretcher it will save extra manual handling of the patient.

•

Ensure all the internal beads are spread evenly across the mattress

•

There are 7 coloured straps and 4 handles on each side, make sure all these straps are free and not caught under the mattress

•

Place a sheet onto the mattress. This will provide a layer between the patient and the mattress for comfort and for ease of further manual handling if required

•

Use the spinal board to move the patient onto the stretcher. Ensure all movements maintain spinal alignment with a controlled log roll onto the spinal board

•

Once the patient and spinal board are on the stretcher, maintain spinal alignment with a controlled log roll to get the patient off the spinal board and onto the mattress

•

If the patient is not lying in the centre of the mattress, use the sheet and a coordinated movement while maintaining spinal alignment to re-position the patient to the centre of the mattress

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Application Once member of the crew should maintain manual head immobilisation throughout patient care, keeping the patient informed and ensuring that no twisting of the patient occurs.

Begin securing the patient in the mattress by buckling the colour coded straps and tighten using a 'feed into and pull out of the buckle' method to prevent twisting and jerking of the patient.

If there is another clinician available, they can push laterally inwards on the sides of the mattress as this will greatly east the tightening of the straps.

In the following order connect the straps across the body and tighten: •

Green pelvis strap

•

Upper yellow leg strap

•

Lower yellow leg strap

•

Red foot strap - apply a 'figure of eight' around the patient's ankle. This provides some support if the patient is to be moved up or down an incline

•

Blue shoulder straps - apply diagonally across the chest

•

Black arm strap - apply over the patient's arms if you want to keep them from moving, these straps can go under the arms if you want to allow the patient freedom to move their arms

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•

Wrap the head section around the patients head and apply the forehead strap, remember to continue with manual head support

•

Ensure the mattress valve is close so that air can be effectively suctioned out

•

Attach the Ambu foot pump suction tubing to the mattress valve

•

While one person uses the foot pump to remove air from the mattress, extra clinicians can squeeze the sides of the mattress inward against the patient with even pressure to ensure the mattress conforms to the patient's body

•

Keep pumping the suction unit until the mattress if firm around the patient

•

Detach the suction tubing from the valve once the mattress if firm and appropriately conformed. Ensure the valve is fully closed

•

Secure the patient and mattress to the Ambulance stretcher using all stretcher harness straps.

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Cardboard Splint Cardboard splints can be shaped to suit the injury and are generally used for forearm, wrist and hand injuries or for ankle, foot and lower leg injuries. These splints come in two sizes (small and large) and can be manipulated by cutting to fit adults or children.

Be sure to use padding such as a combine dressing or small hand towel between the cardboard and the patient's injured limb. Padding provides better comfort and more contact around the injury so that there is less room for movement within the splint.

Secure the cardboard splint around the limb using tape or bandages.

Arm injuries •

Prepare the cardboard splint with padding so that it is ready to put on the patient without causing them any unnecessary movement

•

Secure the splint.

•

Arm injuries can also be supported on a pillow or a sling

Leg and foot injuries •

Prepare the cardboard splint by cutting the end to allow for immobilisation of foot movement and line with appropriate padding

•

For injuries near the ankle a splint up to the knee is usually sufficient, but for lower leg injuries near the knee, a full length splint is more beneficial for immobilisation

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CT-6 Femoral Splint The femur is one of the largest and strongest bones in the body and takes considerable force to break in a healthy person. When it breaks, the large muscles of the thigh often contract causing the two bone fragments to become misaligned.

Mechanical traction pulls the bones back into alignment and lengthens the large thigh muscle. This has a number of benefits for the patient: •

Reduces pain

•

Minimises haemorrhage (an individual can lose over a litre of blood into the thigh)

•

Reduces change of further injury to nerves and blood vessels from the jagged bone fragments/edges.

The CT-6 splint can be used on open and closed femur fractures. The CT-6 is NOT to be used for neck of femur (NOF) fractures.

CT-6 femoral splint is contra-indicated when you suspect: •

Fractured pelvis

•

Significant knee injury

•

Fractured lower leg in conjunction with the fractured femur

•

Significant ankle or foot injury.

Application 1. Remove the CT-6 from the pouch

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2. Connect all tubing sections and straighten all the straps. The sections fit together like poles of a tent

3. Place the splint alongside the uninjured leg to adjust for an adequate length. Adjust by removing the hip cap and adding or subtracting tubing length so that the overall length extends from just above the hip crest to about 20cm below the foot heading

4. Place the splint alongside the injured leg. First apply the hip strap, slip the long strap and buckle under the leg and slide (shimmy) upward and positioned high in the groin area. Engage the buckle and tighten. The top of the traction pole should be positioned at the belt line or hip crest.

5. Apply the ankle hitch, wrapping the padded strap around the foot with the two thin side straps running along each side of the ankle. Tighten the foot strap to fit snugly at the base of the foot.

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6. Apply moderate tension by pulling the cord exiting the pulley system below the foot

7. Apply the Velcro straps around the leg, starting with the strap above the fracture, then above the knee, then below the knee, then above the ankle. Secure the end of the tension cord under the fourth (ankle) strap.

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Pelvic Binder Indications for use Mechanisms of injury which suggest a pelvic fracture can be the result of: •

High energy transfer (e.g. motor vehicle collision/bike/car etc.)

•

Fall from height

•

Crush injury

•

Clinical suspicion of pelvic bleeding causing hypotension in the absence of other causes.

It should not be used for suspected isolated neck of femur fractures or suspected traumatic hip dislocations.

Application The pelvic binder must be applied to the skin (all clothing removed prior to application); it must not be released to remove clothing once applied as it may cause significant deterioration.

1. Select the appropriate size SAM Pelvic Sling™ II for the patient: −− Standard: 81-127cm (Standard size fits 90% of the population) −− Extra Small: 69-119cm (located in the Vac Matt bag) −− Extra Large: 91-152cm (located in the Vac Matt bag) 2. Remove clothing and sharp objects before applying the SAM Pelvic Sling™ II (the sling should not be removed to facilitate the removal of clothing) 3. Unfold the SAM Pelvic Sling™ II on a prepared stretcher with the white surface facing up

4. Place the patient on to the SAM Pelvic Sling™ II using any of the following three methods:

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−− Place the patient on the prepared stretcher (as per step 3) following extrication, avoid log rolling the patient if possible OR −− Slide the SAM Pelvic Sling™ II behind the knees and slide up into position

OR −− Log roll the patient 20° and place the folded SAM Pelvic Sling™ II

5. Once the white side of the SAM Pelvic Sling™ II is positioned beneath the patient's buttocks (refer to the illustrated instructions located on the SAM Pelvic Sling™ II), wrap the non-buckle side of the SAM Pelvic Sling™ II around the patient

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6. Firmly wrap the buckle side of the SAM Pelvic Sling™ II around the patient, positioning the buckle over the pubis symphysis

7. Two operators then pull slowly, smoothly and firmly in opposite directions, firmly applying traction to the black strap and counter traction to the orange strap simultaneously until you feel or hear the buckle click - at this point maintain tension and press the straps down into the blue surface of the sling ensuring that adhesion between the surfaces is achieved. Another click will be heard 8. Tie the patient's knees together using a broad triangular bandage, and bring the feet together using another triangular bandage applied in a figure of eight to secure

If the SAM Pelvic Sling™ II has been correctly applied then: •

There should be two clicks heard while applying tension

•

The pelvic binder is tolerated well by the patient after application

•

The patient's observations remain stable or improve after application of the pelvic binder

•

The patient's experience or pain remains stable or improves after the application of the pelvic binder.

Due to the mechanisms associated with pelvic fractures, and the high potential for other significant injury, request clinical support early.

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Improvised Splints Sometimes the location of an injury or the angulation of an injury means that a traditional splint (i.e. cardboard splint) is not appropriate.

If the patient's pain is under control and the limb distal to the injury has adequate circulation, sensation and movement (can wiggle toes or fingers) there is no need to realign the injury if you can manage the patient without doing so.

The exception to this would be a fractured femur which has the potential for a large amount of bleeding.

Pillow or blankets •

A pillow or blanket can be used to wrap around and conform to the angulations of the injured body part

•

The pillow or blanket can support a limb in a comfortable position

•

Pillows or blankets can be used in conjunction with other splints or techniques.

Slings and bandages •

For minor injuries, a bandage can be used to strap a joint or limb

•

The triangular bandage can be used to immobilise an injured arm.

This method of applying a sling illustrated below is used to support a forearm injury. It can be used in conjunction with a cardboard splint for more rigid immobilisation.

The collar and cuff sling is useful for a humerus fracture or an upper arm injury. To apply a collar and cuff sling: 1. Fold the triangular bandage into a narrow length and make into two loops, one away from you and one towards you 2. Gather the two loops and place them carefully around the wrist of the injured arm 3. Pull the two loose ends around the patient's neck and tie to secure.

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Arterial Tourniquet 1. Place the tourniquet proximal to the injury site. Tourniquet should be as close as possible to the bleeding site while still achieving haemorrhage control

2. Click the buckle into place

3. Pull strap down tight

4. Rotate windlass to tighten until haemorrhage is controlled (distal pulses should no longer be palpable)

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5. Secure the windlass in the locking buckle

6. Record time of application on trap label and on PCR.

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Posey™ Restraint Net This device provides the maximum safety for Ambulance crews and the patient during transport. The net covers the patient's body and secures their arms and legs to the net allowing for minimal movement without placing any significant obstructive force on the head, neck, thorax or abdomen. These nets are used by the RFDS for all transfers of mental health patients.

Some Ambulance crews will have been provided with, or have access to restraint nets or other restraint equipment. Some Team Leaders, RFDS and Mental Health Escort Officers also carry this equipment.

Applying the restraint net •

With the patient on the stretcher, and the blue safety harness straps applied, position the net over the patient, placing their arms through the two arm holes. The net should have the tie down strap webbing and Velcro arm straps on the outside surface (facing up)

•

With the fleece padding around the patient's collar and shoulders, secure the top most straps around the head end of the stretcher. These straps should loop through the stretcher headrest not the stretcher railing so that the head end can be adjusted (supine or semi-recumbent) as required during transport.

•

Secure the middle leg strap to the foot end of the stretcher, by running the webbing strap between the stretcher end and the padded rail and loop back to the top of the stretcher to fasten

•

Secure the four torso straps to each side of the stretcher.

The webbing straps should loop

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through the inside of the stretcher rails, under the lower rail and loop back around the outside of the rail to fasten. All loose ends should be tied up so they do not get caught in the stretcher undercarriage •

Once all of the webbing straps are secure, the arms and feet can be restrained to the net.

Place the upper arm Velcro strap around the patient's upper arm, ensuring the Velcro is fixed.

•

Place the wrist Velcro strap around the patient's wrist or forearm and secure. Note: Ensure that care is taken to not dislodge any IV access when applying the arm restraints.

•

If required, the feet can also be secured to the net using the ankle Velcro straps, applied in the same manner as the upper arm straps.

The patient is often quite well restrained without these ankle straps, however they can be applied if indicated by a risk assessment.

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Burn Dressings Use of cling wrap Once cooling has occurred, cover the burn area with a wet dressing, wet sheet or cling wrap, this minimises the exposure to infection and reduces irritation to the exposed nerves Note: Cling wrap should be applied lengthways, not circumferentially as tight wrapping may cut off circulation when the area of the body swells (oedema)

Strips of cling wrap should be applied along the length of a limb or body part then held in place with a loose roller bandage which will allow heat to dissipate Cooling can continue over wet dressings or cling wrap if required

Use of hydrogel dressings The following steps outline the use of hydrogel or gel-impregnated dressings: •

Apply the most appropriate size dressing to cover the burn area (SAAS carries large dressings that can cover a torso and a face mask dressing complete with eye and mouth openings)

•

If there is a need to hold a dressing in place on limbs, use an open weave bandage loosely applied to allow heat to dissipate

•

It is not necessary to continue cooling when hydrogel or gel-impregnated dressings have been applied.

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•

Hydrogel dressings have maximum application times that must be adhered to: −− Neonates: use of a maximum of 10 minutes −− Young children and the elderly: use for a maximum of 20 minutes −− Burns to >15% body surface area: use of a maximum of 20 minutes.

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Ambulance Equipment

Glossary Term Antecubital fossa

Definition Or elbow pit, is the triangular area on the anterior view of the elbow.

Š SA Ambulance Service - April 2017

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