PARTICIPANT WORKBOOK

INTRO
Module 1: The ABCDE and
SAMPLE history approach

ABCDE
OBJECTIVES

TRAUMA
On completing this module you should be able to:
1. list the hazards that must be considered when approaching an ill or injured person;
2. list the elements to approaching an ill or injured person safely;
3. list the components of the systematic ABCDE approach to emergency patients;
4. assess an airway;

BREATHING
5. explain when to use airway devices;
6. explain when advanced airway management is needed;
7. assess breathing;
8. explain when to assist breathing;
9. assess fluid status (circulation);

SHOCK
10. provide appropriate fluid resuscitation;
11. describe the critical ABCDE actions;
12. list the elements of a SAMPLE history;
13. perform a relevant SAMPLE history.

AMS
Essential skills
• Assessing ABCDE • Glucose administration
• Cervical spine immobilization • Needle decompression for tension
• Full spine immobilization pneumothorax
• Head-tilt and chin-lift/jaw thrust • Three-sided dressing for chest wound
SKILLS

• Airway suctioning • Intravenous (IV) line placement

• Management of choking • IV fluid resuscitation
• Recovery position • Direct pressure for haemorrhage control,
including deep wound packing
• Nasopharyngeal and oropharyngeal airway
placement • Tourniquet for haemorrhage control
• Bag-valve-mask ventilation • Pelvic binding
• Wound management
GLOSSARY

• Oxygen administration
• Skin pinch test • Fracture immobilization
• AVPU (alert, voice, pain, unresponsive) • Snake bite management
assessment
REFS & QUICK CARDS

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Module 1: The ABCDE and SAMPLE history approach

KEY TERMS
Write the definition using the Glossary at the back of the workbook.

ABCDE:

Accessory muscle use:

Altered mental status (AMS):

Anaphylaxis:

AVPU:

Bag-valve-mask (BVM):

Capillary refill:

Cardiopulmonary resuscitation (CPR):

Cervical spine (c-spine):

Convulsion:

Crackles (crepitations):

Crepitus:

Deep wound packing:

Defibrillator:

Diaphoresis:

Difficulty in breathing (DIB):

Disposition:

Foreign body:

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INTRO
GCS (Glasgow Coma Scale):

ABCDE
Hives:

Haematoma:

Haemorrhage:

TRAUMA
Haemothorax:

Hyperresonance:

Hyperthermia:

BREATHING
Hypoglycaemia:

Hypothermia:

Hypotension:

SHOCK
Hypoxia:

Inhalation injury:

Intubation:

AMS
Large bore IV:

Nasal flaring:

Nasopharyngeal airway (NPA):

SKILLS

Needle decompression:

Oedema:
GLOSSARY

Oropharyngeal airway (OPA):

Oxygen saturation (O2 sat):

REFS & QUICK CARDS

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Module 1: The ABCDE and SAMPLE history approach

Percussion:

Perfusion:

Pericardial tamponade:

Personal protective equipment (PPE):

Pleural effusion:

Pneumothorax:

Pulse oximeter:

Retractions:

SAMPLE history:

Seizure:

Shock:

Stridor:

Sucking chest wound:

Tachypnoea:

Tension pneumothorax:

Wheezing:

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 PARTICIPANT WORKBOOK

INTRO
OVERVIEW
Approaching every patient in a systematic way ensures that life-threatening conditions are

ABCDE
recognized promptly and that the most critical interventions are done first. In a stable patient,
the initial ABCDE approach may only take seconds to a few minutes. The ABCDE should be
followed by a rapid history using the SAMPLE approach (Signs and Symptoms, Allergies,
Medications, Past medical history, Last oral intake and Events). The SAMPLE history categories
are described in general below, and essential questions for a specific presentation are listed in
the relevant module. Using the standard SAMPLE and ABCDE approach together ensures that

TRAUMA
different providers can easily communicate about acutely ill patients.

The goal of the ABCDE approach is to rapidly identify life-threatening conditions;

ensure the airway stays open; and ensure that breathing and circulation are adequate
to deliver oxygen to the body.
The goal of the SAMPLE approach is to rapidly gather history critical to the management

BREATHING
of the acutely ill patient.

This module will address:

ƒƒ Safety considerations
ƒƒ Elements of the ABCDE approach

SHOCK
ƒƒ In-depth: acute life-threatening conditions (signs, symptoms and management)
ƒƒ Paediatric considerations in the ABCDE approach
ƒƒ Elements of the SAMPLE history
ƒƒ Disposition considerations

AMS
SAFETY CONSIDERATIONS
A critical part of the approach to any ill or injured patient is keeping providers and others safe.
An ill or injured provider will be unable to help anyone, and instead becomes an extra patient
for other responders to treat. Safety consideration involves checking for:
ƒƒ scene hazards. Is there a fire, electrical wire or chemical spill that could injure providers or
SKILLS

bystanders? At a road traffic crash, is the scene closed to oncoming traffic? If a building has
collapsed, is it safe to enter? At the scene of an explosion, always consider the possibility of
further explosions. Remember that delayed building collapse may follow explosions, fires
and earthquakes.
ƒƒ violence. Is there a chance that providers may be harmed by the patient or by others? For
patients who are aggressive or agitated, request help as needed from security personnel or
GLOSSARY

police before beginning your assessment.

ƒƒ infectious disease risk. Is there a possibility for disease exposure (such as flu or haemorrhagic
fever)?
REFS & QUICK CARDS

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Module 1: The ABCDE and SAMPLE history approach

USE PERSONAL PROTECTIVE EQUIPMENT

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

CLEANING AND DECONTAMINATION

Infectious disease exposure is a significant risk. Use PPE and wash your hands before and after
every patient contact. At the scene, hand washing may not be immediately possible; carry an
alcohol gel cleanser if possible. Between patients, clean and disinfect all facility and vehicle
surfaces and all reusable equipment.

Decontamination may be required after exposure to pesticides or other chemicals (dry or wet)
and, depending on the chemical, may include washing or brushing to remove the substance.
Not all chemicals can be safely washed away, and some must be removed in specific ways to
avoid further injury. You must wear appropriate PPE for this. Refer to local decontamination
protocols for people and equipment.

ASK FOR MORE HELP IF NEEDED

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

Workbook question 1: Safety

A person walks into your health post vomiting, bleeding from the mouth, and
complaining of abdominal pain.
Using the workbook section above, describe what is needed to safely approach this
person:
________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

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 PARTICIPANT WORKBOOK

INTRO
ELEMENTS OF THE ABCDE APPROACH

ABCDE
The ABCDE approach
The ABCDE approach provides a framework for the systematic and organized evaluation of
acutely ill patients in order to rapidly identify and intervene for life-threatening conditions:

A – Airway: check for and correct any obstruction to movement of air into the lungs
B – Breathing: ensure adequate movement of air into the lungs

TRAUMA
C – Circulation: evaluate whether there is adequate perfusion to deliver oxygen to the tissues;
check for signs of life-threatening bleeding
D – Disability: assess and protect brain and spine functions
E – Exposure: identify all injuries and any environmental threats and avoid hypothermia

BREATHING
This stepwise approach is designed to ensure that life-threatening conditions can be
identified and treated early, in order of priority. If a problem is discovered in any of these
steps, it must be addressed immediately before moving on to the next step. The ABCDE
approach should be performed in the first 5 minutes and repeated whenever a patient’s
condition changes or worsens.

SHOCK
AMS
SKILLS
GLOSSARY
REFS & QUICK CARDS

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Module 1: The ABCDE and SAMPLE history approach

THE ABCDE ASSESSMENT AND MANAGEMENT

REMEMBER... Always check for signs of trauma in each of the ABCDE sections, and
reference the trauma module as needed. [see TRAUMA]

ASSESSMENT IMMEDIATE MANAGEMENT

Airway Can the patient talk normally? If

YES, the airway is open.
• If the patient is unconscious and
not breathing normally and:
If the patient cannot talk –– NO TRAUMA: open the airway

A normally:
• look to see if the chest wall
is moving and listen to see if
using the head-tilt and chin-lift
manoeuvre. [See SKILLS]
–– CONCERN FOR TRAUMA: maintain
there is air movement from the cervical spine immobilization and
mouth or nose. open the airway using the jaw
thrust manoeuvre. [See SKILLS]
• listen for abnormal sounds
(such as stridor, grunting, or –– Place an oropharyngeal or
snoring) or a hoarse or raspy nasopharyngeal airway to
voice that indicates a partially maintain the airway. [See SKILLS]
obstructed airway.
• If a foreign body is suspected:
–– Stridor plus swelling and/or
–– If the object is visible, remove it –
hives suggest a severe allergic
be careful not to push the object
reaction (anaphylaxis).
any deeper.
• Look and listen for fluid (such as –– If the patient is able to cough or
blood, vomit) in the airway. make noises, keep the patient
• Look for foreign body or calm and encourage coughing.
abnormal swelling around the –– If the patient is choking (unable
airway, and altered mental to cough, not making sounds) use
status. age-appropriate chest thrusts/
• Check if the patient is able to abdominal thrusts/back blows.
swallow saliva or is drooling. [See SKILLS]
–– If the patient becomes
unconscious while choking,
follow relevant CPR protocols.
• If secretions or vomit are present,
suction when available, or wipe
clean. Consider placing patient in
the recovery position if the rest of
the ABCDE is normal and no trauma
is suspected. [See SKILLS]
• If the patient has swelling, hives
or stridor, consider severe allergic
reaction (anaphylaxis), and give
intramuscular adrenaline. [See
SKILLS]
• Allow the patient to stay in a
position of comfort and prepare
for rapid handover/transfer to a
centre capable of advanced airway
management, if needed.
If the airway is open, move onto “Breathing”.

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 PARTICIPANT WORKBOOK

INTRO
ASSESSMENT IMMEDIATE MANAGEMENT

Breathing • Look, listen, and feel to see if • If unconscious with abnormal

ABCDE
the patient is breathing. breathing, start bag-valve-mask
• Assess if breathing is very fast, ventilation and follow relevant CPR

B very slow, or very shallow. protocols.

• Look for signs of increased work • If not breathing adequately (too
of breathing (such as accessory slow for age or too shallow), begin
muscle use, chest indrawing/ bag-valve-mask ventilation with
retractions, nasal flaring) or oxygen [See SKILLS]. If oxygen not
abnormal chest wall movement. immediately available, DO NOT

TRAUMA
DELAY ventilation. Start ventilation
• Listen for abnormal breath
while oxygen is being prepared.
sounds such as wheezing or
Plan for rapid handover/transfer.
crackles. [See DIFFICULTY IN
BREATHING] • If breathing fast or hypoxic, give
oxygen [See SKILLS]
• With severe wheezing, there
may be limited/no breath • If wheezing, give salbutamol.
sounds on examination because [See SKILLS] Repeat salbutamol as

BREATHING
narrowing of the airways may needed.
be so severe that breathing • If concern for severe allergic
cannot be heard. reaction (anaphylaxis), give
• Listen to see if breath sounds intramuscular adrenaline.
are equal on both sides. [See SKILLS]
• Check for the absence of • If concern for tension
breath sounds and dull sounds pneumothorax, perform needle
with percussion on one side decompression immediately and
(large pleural effusion or give IV fluids and oxygen. [See

SHOCK
haemothorax). [See SKILLS] SKILLS] Plan for rapid handover/
transfer.
• If there are no breath sounds
on one side, and hypotension, • If concern for large pleural effusion
check for distended neck veins or haemothorax, give oxygen and
or a shifted trachea (tension plan for rapid handover/transfer.
pneumothorax). • If cause unknown, remember the
• Check oxygen saturation with a possibility of trauma [See TRAUMA]
pulse oximeter when available.

AMS
If breathing is adequate, move onto “Circulation”.

Circulation • Look and feel for signs of

poor perfusion (cool, moist
• For cardiopulmonary arrest, follow
relevant CPR protocols.
extremities, delayed capillary • If signs of poor perfusion, give IV

C
refill greater than 3 seconds, low fluids and oxygen [See SKILLS] and:
blood pressure, tachypnoea,
–– For external bleeding, apply
tachycardia, absent pulses).
SKILLS

direct pressure or use other

• Look for both external AND technique to control. [See SKILLS]
internal bleeding, including
–– If internal bleeding or pericardial
bleeding:
tamponade are suspected, refer
–– into chest; rapidly to a centre with surgical
–– into abdomen; capabilities.
–– from stomach or intestine;
If cause unknown, remember the
–– from pelvic or femur fracture;
GLOSSARY

possibility of trauma: Bind pelvic

–– from wounds. fractures and splint femur fractures,
or any fracture with compromised
• Look for hypotension, distended blood flow. [See TRAUMA and SKILLS]
neck veins and muffled heart
sounds that might indicate
pericardial tamponade.
REFS & QUICK CARDS

If circulation is adequate, move onto “Disability”.

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Module 1: The ABCDE and SAMPLE history approach

ASSESSMENT IMMEDIATE MANAGEMENT

Disability • Assess level of consciousness

with the AVPU scale (Alert,
• If altered mental status and no
evidence of trauma, place in
Voice, Pain, Unresponsive) or recovery position. [See SKILLS]

D
in trauma cases, the Glasgow • If glucose low (<3.5 mmol/L) or
Coma Scale (GCS). [See SKILLS] glucose test not available and
• Always check glucose level in patient has altered mental status,
the confused or unconscious give glucose. [See SKILLS]
patient. • For active seizures, give a
• Check for pupil size, whether benzodiazepine. [See SKILLS]
the pupils are equal, and if • If pregnant and having seizures,
pupils are reactive to light. give magnesium sulphate. [See
SKILLS]
• If pupils are small and breathing
slow, consider opioid overdose and
give naloxone. [See SKILLS]
• If pupils are not equal, consider
increased pressure on the brain
and raise head of bed 30 degrees
• Check movement and sensation
if no concern for spinal injury.
in all four limbs.
Plan for rapid transfer to an
• Look for abnormal repetitive advanced provider or facility with
movements or shaking on neurosurgical care.
one or both sides of the body
(seizure/convulsion). If cause unknown, remember
possibility of trauma: Immobilize the
cervical spine if concern for trauma.
[See TRAUMA and SKILLS]

Exposure • Examine the entire body for

hidden injuries, rashes, bites or
• If snake bite is suspected,
immobilize the limb. [See SKILLS]
other lesions. Take a picture of the snake if

E • Rashes, such as hives, can possible from a distance and send

indicate allergic reaction, with patient. Do not risk additional
and other rashes can indicate bites to catch/kill snake.
serious infection. • Remove constricting clothing and
all jewelry.
• Cover the patient as soon as
possible to prevent hypothermia.
Acutely ill patients have difficulty
regulating body temperature.
• Remove any wet clothes and dry
patient thoroughly.
• Respect the patient and protect
modesty during exposure.
If cause unknown, remember the
possibility of trauma: Log roll if
suspected spinal injury [See TRAUMA
and SKILLS]

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 PARTICIPANT WORKBOOK

INTRO
ABCDE IN DEPTH: ACUTE, LIFE-THREATENING CONDITIONS
This section takes a deeper look at conditions that must be managed during the ABCDE approach.

ABCDE
AIRWAY conditions

TRAUMA
CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT
Obstruction • Visible secretions, vomit The airway can become obstructed by secretions,
due to foreign or foreign bodies in the vomit or foreign bodies.
body airway • Remove the foreign body if possible and suction
• Abnormal sounds from fluid. Be careful not to push a foreign body
the airway (such as

BREATHING
further into the airway. Do not try to remove a
stridor, snoring, gurgling) foreign body unless clearly visible.
• Mental status changes • Use age-appropriate chest thrusts/abdominal
leading to airway thrusts/back blows if the airway is completely
obstruction from the obstructed. [See SKILLS]
tongue • The tongue may obstruct the airway in patients
• Poor chest rise with a decreased level of consciousness.
–– Open the airway using a head-tilt and chin-
lift manoeuvre, or use jaw thrust (if there is

SHOCK
concern for trauma); and place an oral or
nasopharyngeal airway as needed. [See SKILLS]
–– These patients may also not be able to protect
their airway and need to be watched for
vomiting and aspiration.
• Plan for rapid handover/transfer to advanced
provider capable of advanced airway
management if the obstruction cannot be

AMS
removed.
Obstruction • Burns to head and neck Burns can cause airway swelling due to
due to burns • Burned nasal hairs or inhalational injuries.
soot around the nose or • Give oxygen to ALL patients with suspected
mouth airway burn even if they do not show signs of
• Abnormal sounds from hypoxia. [See SKILLS]
the airway (such as • Open the airway using appropriate manoeuvre
SKILLS

stridor) and place an oral or nasopharyngeal airway as

• Change in voice needed. [See SKILLS]
• Poor chest rise • Maintain cervical spine immobilization if there is
evidence of trauma. [See SKILLS]
• The airway can swell and close off very quickly in
burn patients. Plan for rapid handover/transfer
to a provider capable of advanced airway
GLOSSARY

management.
REFS & QUICK CARDS

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Module 1: The ABCDE and SAMPLE history approach

CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT

Obstruction • Mouth, lip, and tongue Severe allergic reactions can cause swelling of the
due to severe swelling airway that can lead to obstruction.
allergic • Difficulty breathing with • Give intramuscular adrenaline for airway
reaction stridor and/or wheezing obstruction, severe wheezing or shock. [See
(anaphylaxis) SKILLS]
• Rash or hives (patches of
pale or red, itchy, warm, –– Adrenaline can wear off in minutes so be
swollen skin) prepared to give additional doses.
• Tachycardia and
hypotension • Place an IV and give IV fluids. [See SKILLS]
• Abnormal sounds from • Reposition airway as needed (sit patient upright
the airway (such as if no trauma) and give oxygen. [See SKILLS]
stridor, snoring, gurgling) • If severe or not improving, prepare for rapid
• Poor chest rise handover/transfer for advanced airway
management.
Obstruction • Neck haematoma or Airway obstruction may result from injuries to the
due to trauma injuries to head and neck head or neck. Blood, bone or damaged tissue may
• Abnormal sounds from block the airway. Penetrating wounds to the neck
the airway (such as may also cause obstruction due to swelling or
stridor, snoring, gurgling) expanding haematoma.
• Change in voice • Suction to remove any blood that might block
• Poor chest rise the airway.
• Open the airway using jaw thrust only (do not
use head-tilt/chin-lift); and place an oral airway
as needed (do not use nasopharyngeal airways if
there is facial trauma). [See SKILLS}
• Maintain cervical spine immobilization if there is
evidence of trauma. [See SKILLS]
• Plan for rapid handover/transfer to advanced
provider capable of advanced airway
management or surgical intervention.
For any abnormal airway sounds, re-assess airway frequently as partial obstruction may worsen
rapidly and block airway.

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 PARTICIPANT WORKBOOK

INTRO
BREATHING conditions

ABCDE
B
CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT
Tension Hypotension WITH Any pneumothorax can become a tension
pneumothorax difficulty in breathing AND pneumothorax. Air in the cavity between the lungs

TRAUMA
any of the following: and the chest wall can collapse the lung (simple
• distended neck veins pneumothorax). Building pressure (tension) from
a large pneumothorax can displace and block flow
• absent breath sounds on from the main vessels back to the heart, causing
affected side shock (tension pneumothorax).
• hyperresonance with
• If tension pneumothorax is suspected, perform
percussion on affected
emergency needle decompression. [See SKILLS]
side [See SKILLS]

BREATHING
• Give oxygen. [See SKILLS]
• tracheal shift away from
affected side • Give IV fluids. [See SKILLS]
• Arrange for rapid handover/transfer to an
advanced provider capable of placing a chest
tube.
Suspected • Slow respiratory rate Opioid medications (such as morphine, pethidine,
opioid • Hypoxia and heroin) can decrease the body’s drive to
overdose breathe.
• Very small pupils

SHOCK
• Give naloxone to reverse the effects of opioids.
[See SKILLS]
–– Monitor closely as naloxone will wear off and
additional doses may be needed.
• Give oxygen. [See SKILLS]
Asthma/ • Wheezing Asthma and COPD are conditions causing spasm
COPD (chronic • Cough in the lower airways, resulting in narrowing that

AMS
obstructive causes difficulty in breathing and wheezing.
• Accessory muscle use
pulmonary • Administer salbutamol as soon as possible.
disease) • May have history of
asthma/COPD diagnosis, (Salbutamol helps to relieve the spasm in the air
allergies or smoking passages) [See SKILLS]
• Give oxygen if indicated. [See SKILLS]
Large pleural • Decreased breath sounds Pleural effusion occurs when fluid builds up in
effusion/ on affected side the space between the lung and the chest wall
SKILLS

haemothorax • Dull sounds with or diaphragm. As the fluid builds up, it limits
percussion on affected expansion of the lungs.
side [See SKILLS] • Give oxygen. [See SKILLS]
• If there is a large amount • Arrange for handover/transfer immediately
of fluid, may have shock (many of these patients will need a procedure to
drain fluid).
GLOSSARY

If cause unknown, remember the possibility of trauma [See TRAUMA]

REFS & QUICK CARDS

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Module 1: The ABCDE and SAMPLE history approach

CIRCULATION conditions

C
CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT
Pulselessness • No pulse Follow relevant cardiopulmonary resuscitation
• Unconscious (CPR) protocols.
• Not breathing
Shock • Rapid heart rate Poor perfusion is the failure to deliver enough
(tachycardia) oxygen-carrying blood to the vital organs. When
• Rapid breathing poor perfusion continues until organ function is
(tachypnoea) affected, this is called shock and can lead rapidly
to death.
• Pale and cool skin
• Capillary refill>3 seconds • Initial treatment for shock includes laying the
patient flat (if tolerated).
• Sweating (diaphoresis)
• Give oxygen. [See SKILLS]
• May have dizziness,
confusion, altered mental • Control bleeding. [See SKILLS]
status • Start an IV and give IV fluids. [See SKILLS]
• May have hypotension • If there are signs of infection, give antibiotics if
available.
• Prepare for rapid handover/transfer.
Severe • Bleeding wounds External bleeding that is not controlled can lead
bleeding • Bruising around the quickly to shock. A large quantity of blood can also
(haemorrhage) umbilicus (belly button) be lost into the chest, pelvis, thigh and abdomen
or over the flanks can be a before the bleeding is recognized.
sign of internal bleeding • Stop the bleeding. Depending on the source, use:
• Bleeding from the rectum –– direct pressure [See SKILLS]
or vagina or in vomit –– deep wound packing [See SKILLS]
• Pelvic fracture –– a tourniquet [See SKILLS]
• Femur fracture –– pelvic binder or femur splint. [See SKILLS]
• Decreased breath sounds
on one side of the chest • Give IV fluids. [See SKILLS]
(haemothorax)
• Refer for blood transfusion and ongoing surgical
• Signs of poor perfusion management if needed.
(such as hypotension,
tachycardia, pale skin, A tourniquet should be used only for life-
diaphoresis) threatening bleeding.
Pericardial • Signs of poor perfusion Pericardial tamponade occurs when fluid builds
tamponade (tachycardia, tachypnoea, up in the sac around the heart. The pressure from
hypotension, pale this fluid can collapse the chambers of the heart
and cool skin, cold and keep them from filling properly, limiting blood
extremities, capillary refill flow to the tissues and causing shock. Treatment is
>3 seconds) drainage by pericardiocentesis.
• Distended neck veins • In order to keep the patient alive until the fluid
• Muffled heart sounds around the heart can be drained, give IV fluids to
• May have dizziness, ensure that as much volume as possible enters
confusion, altered mental the heart. [See SKILLS]
status • Refer rapidly for surgical management.

If cause unknown, remember the possibility of trauma [See TRAUMA]

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INTRO
DISABILITY conditions

ABCDE
D
CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT
Hypoglycaemia • Sweating (diaphoresis) Patients with hypoglycaemia (low blood sugar)
need glucose immediately. [See SKILLS]

TRAUMA
• Altered mental
status (ranging • If the person can speak and swallow, give oral
from confusion to glucose.
unconsciousness) • If the person cannot speak or is unconscious, give
• Seizures/convulsions IV glucose if possible.
• Blood glucose • If IV glucose is not possible or available, give
<3.5 mmol/L buccal (inside of the cheek) glucose. [See SKILLS]
• History of diabetes,

BREATHING
malaria or severe
infection
• Responds quickly to
glucose
Increased • Headache Increased pressure on the brain can occur from
pressure on the • Seizures/convulsions trauma, tumours, increased fluid, bleeding or
brain infections. Because the skull is rigid, any swelling,
• Nausea, vomiting
fluid, or mass increases the pressure around the

SHOCK
• Altered mental status brain, limiting blood flow and possibly displacing
• Unequal pupils brain tissue, causing death.
• Weakness on one side • Raise the head of the bed to 30 degrees if
of the body there is no concern for trauma and there is no
hypotension.
• Check glucose. [See SKILLS]
• If there are seizures/convulsions, give a
benzodiazepine. [See SKILLS]

AMS
• The pressure must be reduced as quickly as
possible. Arrange for rapid handover/transfer to a
surgical centre.
Seizure/ Signs and symptoms of The goal in managing seizures/convulsions is to
convulsion active seizure: prevent hypoxia and injury.
• Repetitive movements, • Protect the seizing person from falls and from
gaze fixed to one any hard or sharp objects nearby.
SKILLS

side or alternating • Do not place anything in the mouth of a person

rhythmically and not with active seizure except to suction airway.
responsive. [See SKILLS]
Sign and symptoms of • Give oxygen. [See SKILLS]
recent seizure: • Check blood glucose. Give glucose if
• Bitten tongue <3.5 mmol/L. [See SKILLS]
• Treat with a benzodiazepine [See SKILLS] and
GLOSSARY

• Urinated on self
monitor closely for slowing or difficult breathing.
• Known history of
seizures/convulsions • Place patient in recovery position if there is no
trauma suspected. [See SKILLS]
• Confusion that
gradually improves • If the patient is pregnant, or recently gave birth,
over minutes to hours give magnesium sulphate. [See SKILLS]
REFS & QUICK CARDS

If cause unknown, remember the possibility of trauma [See TRAUMA]

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Module 1: The ABCDE and SAMPLE history approach

EXPOSURE conditions

E
CONDITION SIGNS AND SYMPTOMS IN-DEPTH DESCRIPTION AND MANAGEMENT
Snake bite • History of snake bite The goal of managing snake bites is to limit the
• Bite marks may be seen spread of the venom and the effects of venom on
the body.
• Oedema
• Blistering of the skin • Immobilize the extremity. [See SKILLS]
• Bruising • Take a picture of the snake when possible and
send with the patient (for example, with the
• Hypotension patient’s mobile phone).
• Paralysis • Give IV fluids if evidence of shock. [See SKILLS]
• Seizures • These patients may have delayed shock or airway
• Bleeding from wounds problems. Monitor closely and plan early for
rapid handover/transfer.

Vital signs should be checked at the end of the ABCDE

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

ABCDE SHOULD BE REPEATED FREQUENTLY

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

Workbook question 2: ABCDE approach

Using the workbook section above, list the management for airway blocked by a
foreign body.
________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

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 PARTICIPANT WORKBOOK

INTRO
PAEDIATRIC ABCDE CONSIDERATIONS
While the ABCDE approach is used in both adults and children, there are some aspects of

ABCDE
assessing and managing children that are different from adults. The “Paediatric considerations”
sections throughout the workbook highlight these differences.

Paediatric considerations

Pediatric airway conditions

TRAUMA
A
Excessive drooling, stridor, airway swelling and unwillingness to move the neck are all high-risk
signs in children. Look carefully in the airway for foreign bodies, burns or obstruction. Allow the
child to remain in a position of comfort. Position airway as needed below.
Compared to adults, children have: So you must do this:

BREATHING
Bigger tongues. • Place the child in the “sniffing” position (modified
head-tilt, chin-lift – like the slight upward and
forward tilt of the head when sniffing a flower).
Shorter necks with airways that are softer and • Avoid over-extending or flexing the neck.
more easily blocked.
A larger head compared to the rest of the • Watch closely for airway obstruction.
body.

SHOCK
• Use the jaw thrust if airway is not open. [See
SKILLS]
• Position head (using padding under shoulders
for very small children) to open airway if no
trauma. [See SKILLS]

AMS
SKILLS
GLOSSARY

For choking, use age-appropriate chest thrusts/abdominal thrusts/back blows. [See SKILLS]
REFS & QUICK CARDS

Neutral position in infants

27
Module 1: The ABCDE and SAMPLE history approach

Pediatric breathing conditions

B
• Nasal flaring, head bobbing, grunting and chest indrawing OR retractions, are signs of
respiratory distress in children.
page 33
• CYANOSIS – a blue/grey discoloration around the lips, mouth or fingertips – is the result of a lack
of oxygen and is a danger sign.
• CHEST INDRAWING is a common presentation of paediatric accessory muscle use.
–– Look at the lower chest wall (lower ribs). The child has chest indrawing if the lower chest wall
goes IN when the child breathes IN.
–– In normal breathing, the whole chest wall (upper and lower) and the abdomen move OUT when
the child breathes IN.

Chest indrawing

• A SILENT CHEST (no breath sounds when you listen to the chest) is a sign of severe respiratory
distress in a child. With severe spasm and narrowing of the airways, there may be limited air
movement and few breath sounds on exam. Chest
Giveindrawing
salbutamol and oxygen and re-assess frequently.
[See SKILLS]
• STRIDOR signals severe airway compromise, and there are many possible causes. Children
with stridor should be allowed to stay in a position of comfort and transferred immediately to
an advanced provider. Further treatment will often include nebulized adrenaline. If immediate
transfer is not possible, consider intramuscular adrenaline as per severe allergic reaction
treatment. [See SKILLS]

Pediatric circulation conditions

C
• MANAGEMENT OF POOR PERFUSION IN CHILDREN MAY CHANGE based on the cause and on the
condition of the child. [See SHOCK and SKILLS modules]
• LOW BLOOD PRESSURE IN A CHILD IS A SIGN OF SEVERE SHOCK. Children are able to maintain
normal blood pressure for longer than adults when in shock. Closely monitor other signs of poor
perfusion, such as decreased urine output and altered mental status.
• THE AMOUNT OF INTRAVENOUS FLUID GIVEN TO CHILDREN IS DIFFERENT FROM ADULTS. [See
SKILLS]
• IN MALNOURISHED CHILDREN, both the rate of fluid administration and the type of fluid are
different. [See SKILLS]
• SEVERE SIGNS: Sunken fontanelle, poor skin pinch [See SKILLS], lethargy, altered mental status.

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INTRO
Pediatric disability conditions

ABCDE
D
• LOW BLOOD GLUCOSE is a very common cause of altered mental status in sick children.
–– If possible, check blood glucose in children with altered mental status.
–– When it is not possible to check the blood glucose level, administer glucose.
• Always check for seizure/convulsions.

TRAUMA
• It is sometimes difficult to determine if infants are acting normally. Always ask the person caring
for the child.

Pediatric exposure conditions

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

PAEDIATRIC DANGER SIGNS IN ABCDE

SHOCK
In addition to performing a thorough ABCDE approach, all paediatric patients should be evaluated
for the presence of danger signs. Children with danger signs need URGENT attention and referral/
handover to a provider able to provide advanced paediatric care.
Paediatric danger signs include:
• Signs of airway obstruction (stridor or drooling/unable to swallow saliva)
• Increased breathing effort (fast breathing, nasal flaring, grunting, chest indrawing or retractions)

AMS
• Cyanosis (blue colour of the skin, especially at the lips and fingertips)
• Altered mental status (including lethargy or unusual sleepiness, confusion, disorientation)
• Moves only when stimulated or no movement at all (AVPU other than “A”)
• Not feeding well or cannot drink or breastfeed
• Vomiting everything
• Seizures/convulsions
• Low body temperature (hypothermia)
SKILLS
GLOSSARY
REFS & QUICK CARDS

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Module 1: The ABCDE and SAMPLE history approach

Workbook question 3: ABCDE approach

Using the workbook section above, list one of each of the following:

ƒƒ a paediatric airway consideration

_______________________________________________________________________

ƒƒ a paediatric breathing consideration

_______________________________________________________________________

ƒƒ a paediatric circulation consideration

_______________________________________________________________________

ƒƒ a paediatric disability consideration

_______________________________________________________________________

ƒƒ a paediatric exposure consideration

_______________________________________________________________________

Elements of the SAMPLE history

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

S: Signs and symptoms

The patient/family’s report of signs and symptoms is essential to assessment and management.

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

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

P: Past medical history

Knowing prior medical conditions may help in understanding the current illness and may
change management choices.

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INTRO
L: Last oral intake
Record the time of last oral intake and whether solid or liquid. A full stomach increases the risk

ABCDE
of vomiting and subsequent choking, especially with sedation or intubation that might be
required for surgical procedures.

E: Events surrounding the injury or illness

Knowing the circumstances around the injury or illness may be helpful in understanding the
cause, progression and severity.

TRAUMA
Workbook question 4: SAMPLE history
Using the workbook section above, list what the letters in SAMPLE stand for:

BREATHING
S: _______________________________________________________________________

A: ______________________________________________________________________

M: ______________________________________________________________________

P: _______________________________________________________________________

SHOCK
L: _______________________________________________________________________

E:_______________________________________________________________________

DISPOSITION CONSIDERATIONS

AMS
ƒƒ If you have to intervene in any of the ABCDE categories, immediately plan for handover/
transfer to a higher level of care.
ƒƒ Once you have completed the ABCDE approach, take a SAMPLE history and complete a
physical examination based on the specific condition (secondary examination).
ƒƒ A good handover summary [See SKILLS] to the next provider requires:
SKILLS

–– brief identification of the patient;

–– relevant elements of the SAMPLE history;
–– physical examination findings;
–– record of interventions given;
GLOSSARY

–– plans for care needed next and other concerns you may have.
REFS & QUICK CARDS

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Module 1: The ABCDE and SAMPLE history approach

FOR REFERENCE: NORMAL VITAL SIGNS

NORMAL ADULT VITAL SIGNS

ƒ Pulse rate: 60–100 beats per minute
ƒ Respiratory rate: 10–20 breaths per minute
– A respiratory rate of less than eight breaths per minute is a danger sign and may require
intervention.
ƒ Systolic blood pressure >90 mmHg
ƒ If you cannot take a blood pressure reading, you can use the pulse to estimate systolic blood
pressure. Feeling for a pulse at the locations below can provide an estimate of systolic blood
pressure in an adult (although this method may not work well in the elderly):
• Carotid (neck) pulse ≥ 60 mmHg
• Femoral (groin) pulse ≥ 70 mmHg
• Radial (wrist) pulse ≥ 80 mmHg

NORMAL PAEDIATRIC VITAL SIGNS pag

Vital signs are age-dependent in children. Normal heart rate and respiratory rate are higher
in younger children, and normal blood pressures are lower. The brachial (middle of the upper
arm) artery should be used to check the pulse in infants and small children.

Normal paediatric vital signs

AGE NORMAL HEART RATE
(in years) (beats per minute)
≤1 100–160
1–3 90–150
4–5 80–140

AGE RESPIRATORY RATE

(breaths per minute) Location of
≤2 months 40–60 brachial pulse
in a child
2–12 months 25–50
1–5 years 20–40
Location of brachial pulse in a child
* To estimate a child’s (1–10 years old) weight in kilograms use the formula:
[age in years + 4] x 2
or use weight-estimation tools such as PAWPER, Mercy TAPE, or Broselow tape.

ƒ Children are able to maintain normal blood pressure for longer than adults when they are
in shock. You must check closely for signs of poor perfusion.
ƒ The amount of IV fluid appropriate for children is different from that for adults. [See SKILLS]

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INTRO
FACILITATOR-LED CASE SCENARIOS
These case scenarios will be discussed in small groups. These cases in this module will NOT be

ABCDE
assessed and are for practice only. It is important that you practise with these scenarios since
you will be assessed on how you lead a case in later modules. To complete a case scenario,
the group must identify the critical findings and management needed and formulate a 1–2
line handover summary that includes assessment findings and interventions. You should
use the Quick Cards to manage these scenarios.

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

BREATHING
1. What do you need to do in your initial approach?

2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about
look, listen and feel findings; use the Quick Card for reference as needed.

ASSESSMENT FINDINGS INTERVENTION INTERVENTIONS TO

NEEDED? PERFORM:

SHOCK
AIRWAY YES NO

BREATHING YES NO

CIRCULATION YES NO

DISABILITY YES NO

AMS
EXPOSURE YES NO

3. Formulate 1–2 sentences to summarize this patient for handover.

SKILLS
GLOSSARY
REFS & QUICK CARDS

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Module 1: The ABCDE and SAMPLE history approach

CASE #2: PAEDIATRIC ABCDE

A mother brings in her 2-year-old son for difficulty in breathing. She reports that he has had a
fever for 3 days and has had worsening difficulty in breathing. He has been coughing a lot and
today will not eat or drink.

1. What is your initial approach to this patient?

2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator for specific
findings when you look, listen and feel; use the Quick Card for reference as needed.

ASSESSMENT FINDINGS INTERVENTION INTERVENTIONS TO

NEEDED? PERFORM:

AIRWAY YES NO

BREATHING YES NO

CIRCULATION YES NO

DISABILITY YES NO

EXPOSURE YES NO

3. Formulate a 1–2 sentence summary of this patient for handover.

MULTIPLE CHOICE QUESTIONS

Answer the questions below. Questions and answers will be discussed within the session.

1. A mother brings in her 3-year-old child because of difficulty in breathing. On assessment,

you hear loud, high-pitched sounds when the child breathes in. What is the most immediate
concern?
A. Severe infection
B. Shock
C. Asthma attack
D. Upper airway obstruction

2. An elderly woman fell at home. She had normal vital signs, but complained of neck and knee
pain prior to transport. During transport, she starts snoring and gurgling when taking a breath.
What is the most appropriate method to immediately manage this problem?
A. Placing her in the recovery position
B. Administering salbutamol
C. Jaw thrust
D. Head-tilt/chin-lift

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INTRO
3. A 50-year-old man has collapsed in a store and you are called to assist him. He is unconscious,
has a respiratory rate of four breaths per minute and a pulse of 100 beats per minute. The
collapse was witnessed and there is no trauma. What is the best next step?

ABCDE
A. Begin chest compressions
B. Open the airway
C. Begin bag-valve-mask ventilations
D. Check pupils

TRAUMA
4. A 2-year-old boy is brought to you for being more sleepy than normal. He is unconscious. You
open his airway, and insert an oropharyngeal airway. What is your next step?
A. Check blood pressure
B. Check AVPU scale
C. Check glucose

BREATHING
D. Check breathing

5. You are listening to the lungs of a 26-year-old man who has sudden onset chest pain and he
is taking 30 breaths a minute. Which lung-sound finding is most suggestive of pneumothorax?
A. Crackles on both sides
B. Absent lung sounds on one side
C. Stridor

SHOCK
D. Wheezing on both sides

AMS
SKILLS
GLOSSARY
REFS & QUICK CARDS

35
Notes
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 PARTICIPANT WORKBOOK

INTRO
Module 2: Approach to trauma

ABCDE
Objectives
On completing this module you should be able to:

TRAUMA
1. recognize key history findings suggestive of high-risk injuries;
2. recognize physical examination findings suggestive of high-risk injuries;
3. perform Trauma Primary Survey (the ABCDE approach to trauma patients);
4. perform Trauma Secondary Survey (the head-to-toe trauma exam);
5. recognize life-threatening injuries;

BREATHING
6. perform critical interventions for high-risk conditions.

Essential skills
• Cervical spine immobilization • Direct pressure for haemorrhage control,
• Spine immobilization and log-roll manoeuvre including deep wound packing
• Jaw-thrust manoeuvre • Tourniquet for haemorrhage control

SHOCK
• Airway suctioning • IV line insertion
• Insertion of oropharyngeal and • IV flluid resuscitation
nasopharyngeal airway • AVPU and GCS assessment
• Recovery Position • Pelvic binding
• Oxygen delivery • Basic fracture immobilization
• Bag-valve-mask ventilation • Trauma secondary survey
• Needle decompression for tension • Basic wound management, including irrigation

AMS
pneumothorax (washing)
• Three-sided dressing for a sucking chest wound • Burn management

KEY TERMS
Write the definition using the Glossary at the back of the workbook.
SKILLS

AVPU:

Bradycardia:

Circumferential burn:
GLOSSARY

Crepitus:

Compartment syndrome:
REFS & QUICK CARDS

37
Module 2: Approach to trauma

Cyanosis:

Decontamination:

Deep wound packing:

Diaphoresis:

Direct pressure:

Disposition:

Escharotomy:

Flail chest:

Fracture:

Glasgow Coma Scale:

Guarding:

Haemorrhage:

Haemorrhagic shock:

Haematoma:

Haemothorax:

Hyperresonance:

Hypothermia:

Hypovolaemic shock:

Hypoxia:

Laceration:

Large bore IV:

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 PARTICIPANT WORKBOOK

INTRO
Log-roll manoeuvre:

ABCDE
Needle decompression:

Parkland Formula:

Percussion:

TRAUMA
Pericardial tamponade:

Pneumothorax:

Priapism:

BREATHING
Rebound tenderness:

SAMPLE history:

Shock:

SHOCK
Sprain:

Sucking chest wound:

Tension pneumothorax:

AMS
Trauma primary survey:

Trauma secondary survey:

SKILLS
GLOSSARY
REFS & QUICK CARDS

39
Module 2: Approach to trauma

Overview

GENERAL PRINCIPLES OF TRAUMA CARE

Early priorities for an injured person include managing airway and breathing emergencies,
controlling bleeding, treating shock and immobilizing the spine if needed.

The goal of INITIAL ASSESSMENT is to identify life-threatening injuries.

The goal of ACUTE MANAGEMENT is to ensure oxygenation and perfusion, to control
pain and to plan ongoing care.

This module will guide you through the:

ƒƒ Approach to trauma
ƒƒ ABCDE: Trauma primary survey
ƒƒ DO: Important conditions to recognize and manage in the primary survey (signs, symptoms
and management)
ƒƒ ASK: Key history findings (SAMPLE history)
ƒƒ CHECK: Trauma secondary survey
ƒƒ DO: Important conditions to recognize and manage based on the history and secondary
survey (Signs, symptoms and management)
ƒƒ Special populations
–– Trauma in pregnancy
–– Special considerations in children
ƒƒ Disposition considerations

APPROACH TO TRAUMA
Approach to the trauma patient consists of three phases:
ƒƒ Trauma primary survey: The ABCDE approach for injured patients
ƒƒ SAMPLE history: Signs and Symptoms, Allergies, Medications, Past medical history, Last oral
intake, and Events surrounding the injury
ƒƒ Trauma secondary survey: A complete head-to-toe examination to look for injuries not
identified by the primary survey

During primary and secondary surveys, if life-threatening problems are identified, STOP
AND MANAGE them.

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 PARTICIPANT WORKBOOK

INTRO
ABCDE: TRAUMA PRIMARY SURVEY
The ABCDE approach in injured patients is often also called the trauma primary survey. As

ABCDE
for all patients this should be conducted within the first 5 minutes and repeated whenever
the patient’s condition worsens. This trauma-specific ABCDE approach includes the initial
assessment and management for all immediately life-threatening injuries. Always suspect
head and spine injury in a trauma patient with altered mental status.

ASSESSMENT IMMEDIATE MANAGEMENT

TRAUMA
Airway with Look for: • Stabilize the cervical spine.
[See SKILLS]
• blood, vomit, tongue or
cervical spine objects obstructing the airway • Open airway using jaw thrust, NOT
immobilization • burned nasal hairs or soot head-tilt chin-lift if suspected spine
around the nose or mouth injury. [See SKILLS]
• Suction airway secretions, blood and/

A
• head or neck trauma
or vomit. Remove any visible foreign
• neck haematoma (bleeding

BREATHING
objects from the airway. [See SKILLS]
under the skin)
• Place oral airway (avoid nasal airway if
• altered mental status, as
facial trauma). [See SKILLS]
this can affect the ability to
protect the airway • If the patient has an expanding
neck haematoma or evidence
Listen for abnormal airway of airway burns or trauma, plan
sounds (such as gurgling, for rapid handover/transfer to a
snoring, stridor, noisy provider capable of advanced airway
breathing). management.

SHOCK
If the airway is open, move onto
“Breathing”.

Breathing Look for: • Give oxygen. [See SKILLS]

• increased work of breathing • Perform needle decompression
• abnormal chest wall immediately and give oxygen and

B movement which may

indicate flail chest
IV fluids for tension pneumothorax.
[See SKILLS]

AMS
• tracheal shift • Place three-sided dressing for sucking
chest wound. [See SKILLS]
• sucking chest wound
• If breathing not adequate or patient
• cyanosis (blue-grey color of
remains hypoxic on oxygen, assist
the skin) around the lips and
breathing with bag-valve-mask
fingertips
ventilation. [See SKILLS]
• abrasion, bruising or other
• For chest or abdominal burns that
signs of injury to chest
SKILLS

restrict breathing, handover for

• circumferential burns (burns escharotomy (a surgical procedure
that go all the way around to cut and release burned tissue that
a body part) to chest or may restrict breathing or blood supply
abdomen to a limb).
• absent or decreased breath
sounds If breathing is adequate, move onto
“Circulation”.
GLOSSARY

Listen for dull sounds

or hyperresonance with
percussion.
Feel for crepitus (cracking and
popping when pressing on the
skin).
REFS & QUICK CARDS

41
Module 2: Approach to trauma

ASSESSMENT IMMEDIATE MANAGEMENT

Circulation Look for: • Apply direct pressure to control active

bleeding, or deep wound packing if
• capillary refill longer than
3 seconds large or gaping. [See SKILLS]

C • pale extremities
• distended neck veins
• If amputated limbs or any other
source of uncontrolled bleeding are
present, apply tourniquet (document
• external AND internal time of application), start IV fluids and
bleeding plan for urgent transfer to a surgical
unit. [See SKILLS]
Common sources of serious
bleeding are: • If ongoing blood loss or evidence of
poor perfusion, place two large bore
• chest injuries IVs, give IV fluids and re-assess. [See
• abdominal injuries SKILLS]
• pelvic fractures • If burn injury, start IV fluids according
• femur fractures to burn size.
• amputations or large external • Splint suspected femur fracture. [See
wounds SKILLS]
• burns, noting size and depth • Bind pelvic fracture. [See SKILLS]
• Leave any penetrating objects in place
Feel for: and stabilize object for transfer to a
• cold extremities surgical team.
• weak pulse or tachycardia • Position pregnant patients on their
left side while maintaining spinal
immobilization.
If circulation is adequate, move onto
“Disability”.

Disability Look for: • If GCS <9 (or for children, AVPU score
of P or U), plan for rapid handover/
• confusion, lethargy or
agitation transfer to a provider capable of

D
advanced airway management.
• seizures/convulsions
• If patient is lethargic or unconscious,
• unequal or poorly reactive re-assess the airway frequently as
pupils above.
• deformities of skull • Suspect spine injury or closed head
• blood or fluid from ear or nose injury with any trauma and altered
mental status.
Check:
• Give oxygen if concern for hypoxia
• AVPU or GCS as a cause of altered mental status.
• movement and sensation in [See SKILLS]
all extremities • Give glucose if altered mental status
• blood glucose level if and: measured low blood glucose,
confused or unconscious unable to check blood glucose, or
history of diabetes. [See SKILLS]
• If seizing, give a benzodiazepine.
[See SKILLS]

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 PARTICIPANT WORKBOOK

INTRO
ASSESSMENT IMMEDIATE MANAGEMENT

Exposure Remove all clothing. • If spinal injury is suspected, perform

ABCDE
Examine entire body for log-roll manoeuvre to examine the
evidence of injury (including back. [See SKILLS]

E the back, spine, groin and

underarms) using the log-roll
manoeuvre.
• Remove restrictive clothing and all
jewellery.
• Remove any wet clothes and dry
patient thoroughly.
• Cover the patient as soon as possible

TRAUMA
to prevent hypothermia. Acutely
injured patients have difficulty
regulating body temperature.
• Respect the patient and protect
modesty during exposure.

BREATHING
Workbook question 1: Approach to trauma
A middle-aged man is brought in after being hit by a car. Using the workbook section
above, list the immediate management for the assessment findings below.

PRIMARY SURVEY FINDINGS IMMEDIATE MANAGEMENT

On airway assessment:

SHOCK
• Gurgling airway sounds
1. ������������������������������������������������
• Obvious head trauma

2. ������������������������������������������������

3. ������������������������������������������������

AMS
4. ������������������������������������������������

On circulation assessment:
• Weak pulses
1. ������������������������������������������������
• Capillary refill of <3 seconds
• Unstable pelvis on exam
SKILLS

2. ������������������������������������������������

3. ������������������������������������������������
GLOSSARY
REFS & QUICK CARDS

43
Module 2: Approach to trauma

DO: IMPORTANT CONDITIONS TO RECOGNIZE AND MANAGE

IN THE PRIMARY SURVEY

A Airway conditions

CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT

Airway • Visible blood, secretions, Head and neck injuries may result in obstruction
obstruction vomit, tongue or foreign of the airway by blood, secretions, vomit, foreign
bodies in the airway bodies, or swelling. Penetrating wounds to
• Changes in voice the neck can cause expanding haematomas.
Inhalational injuries due to burns can cause
• Abnormal sounds
swelling.
from the airway (such
as stridor, snoring, • Patients with a decreased level of consciousness
gurgling) may not be able to protect their airways and
• Neck haematoma or need to be watched for vomiting and aspiration.
burns to head and neck –– Suction the airway and remove foreign bodies.
• Mental status changes –– Open the airway using a jaw thrust manoeuvre
leading to airway (NOT head-tilt/chin-lift) and place an oral
obstruction airway as needed. [See: SKILLS]
• Poor chest rise • Maintain cervical spine immobilization
• Injury causing swelling throughout, if needed.
of the airway (such as • Plan for rapid handover/transfer to a provider
anaphylaxis or airway capable of advanced airway management.
burn)

B Breathing conditions

CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT

Tension • Hypotension WITH: Any pneumothorax can become a tension
pneumothorax –– difficulty breathing pneumothorax. Air in the cavity between the
lungs and the chest wall can collapse the lung
–– distended neck veins
(simple pneumothorax). Building pressure
–– absent breath sounds (tension) from a large pneumothorax can
on affected side displace and block flow from the great vessels
–– hyperresonance with to the heart, causing shock as the heart cannot
percussion on affected receive and pump enough blood to the rest of
side the body (tension pneumothorax). In tension
–– may have tracheal pneumothorax, perfusion is compromised.
shift away from • Treat tension pneumothorax immediately with
affected side needle depression. [See: SKILLS]
• Give oxygen and IV fluids. [See: SKILLS]
• Plan for rapid handover/transfer to an advanced
provider capable of placing a chest tube.

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 PARTICIPANT WORKBOOK

INTRO
CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT
Sucking chest • Open wound in the Sucking chest wounds are important to recognize

ABCDE
wound (open chest wall with air because they can rapidly cause a tension
pneumothorax) passing through causing pneumothorax. Air enters the chest cavity (into
bubbling or “sucking” the space between the chest wall and the lungs)
noises through the wound in the chest wall when the
• Difficulty in breathing patient takes a breath. Pressure on the lung builds
if the air cannot escape.
• Chest pain
• Give oxygen. [See SKILLS]

TRAUMA
• Place a three-sided dressing that allows air to
leave with exhalation but prevents air from
entering when the person inhales. [See SKILLS]
–– There is a danger of the dressing becoming
stuck to the chest wall with clotted blood and
causing a tension pneumothorax.
–– After applying a three-sided dressing the
patient should be observed continuously.

BREATHING
–– Remove the dressing if worsening respiratory
status or evidence of worsening perfusion.
Plan for rapid handover/transfer to an advanced
provider capable of placing a chest tube.
Flail chest • Difficulty in breathing Flail chest segments occur when ribs are broken
• Chest pain in multiple places, freeing an entire section of ribs
from the chest wall. Without the connection to
• Part of chest wall
the chest wall, this section will move abnormally

SHOCK
moving in the opposite
with breathing and prevent part of the lung from
direction of the rest
expanding. Flail chest is also usually associated
of the chest when
with damage to underlying lung tissue.
breathing
• Give oxygen and pain control. [See SKILLS]
• There is a very high risk of developing difficulty
in breathing and hypoxia.
• Plan for rapid handover/transfer to a provider
capable of chest tube placement, advanced

AMS
airway placement and ventilation.
Haemothorax • Difficulty in breathing Haemothorax (blood in the space between
• Decreased breath the lungs and the chest wall) can present with
sounds on affected side decreased or absent breath sounds and dull
sounds with percussion on the affected side.
• Dull sounds with
percussion on affected • Give oxygen and IV fluids.
side • Plan for rapid handover/transfer to a centre with
SKILLS

• Large haemothorax may surgical capacity.

cause shock
GLOSSARY
REFS & QUICK CARDS

45
Module 2: Approach to trauma

C Circulation conditions

CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT

Hypovolaemic • Tachycardia, Hypovolaemic shock can result from rapid loss of
shock tachypnoea, pale skin, blood (haemorrhagic shock) or from the fluid loss
cold extremities, slow associated with burns. An adult patient in shock
capillary refill may have only tachycardia (elevated heart rate)
• May have dizziness, and/or tachypnoea (high respiratory rate) and may
confusion or altered not have low blood pressure until the condition is
mental status immediately life-threatening. Even with a systolic
blood pressure greater than 90 mmHg, suspect
• May have hypotension
hypovolaemic shock if there is severe bleeding or
• External bleeding or any sign of poor perfusion (such as cool, moist,
internal bleeding (chest, or pale skin, slow capillary refill, fast breathing,
abdomen, pelvis, femur, confusion, restlessness, anxiety).
blood vessels)
• Stop bleeding with direct pressure, deep wound
packing if wound is gaping, a tourniquet,
splinting of fractures and binding the pelvis as
needed. [See SKILLS]
• Start two large-bore IV lines and give IV fluids.
[See SKILLS]
• Patients with suspected large haemothorax
or other internal haemorrhage will need rapid
handover/transfer to a unit with surgical care
and blood transfusion capabilities.
REMEMBER... Children and young people are able to maintain a normal blood pressure until they
have lost up to a quarter of their blood. Always check for other signs of shock.
[See “Special considerations in children” section]
Pericardial • Signs of poor perfusion Pericardial tamponade occurs when fluid builds
tamponade (such as tachycardia, up in the sac around the heart. The pressure from
tachypnoea, this fluid can collapse the chambers of the heart
hypotension, pale and prevent them from filling, limiting the amount
skin, cold extremities, of blood the heart can pump.
capillary refill greater • Give IV fluid to improve heart filling. [See SKILLS]
than 3 seconds)
• Patients need immediate handover/transfer to
• Distended neck veins an advanced provider for drainage of the fluid.
• Muffled heart sounds
• May have dizziness,
confusion, altered
mental status

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INTRO
D

ABCDE
Disability conditions

CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT

Severe head • Visual changes, loss Brain injuries can range from mild bruising to

TRAUMA
injury of memory, seizures/ severe bleeding in or around the brain. Because
convulsions, vomiting, the skull is rigid, the bleeding cannot expand
headache and causes increased pressure on the brain. If the
pressure becomes too high, it will prevent blood
• Altered mental status or from entering into the skull and perfusing the
other neurologic deficit brain, and can squeeze part of the brain through
• Scalp wound and/or the base of the skull, causing death. Any trauma to
skull deformity the brain can cause significant impact on function.

BREATHING
• Bruising to head • Always remember that head injuries can be
(particularly around eyes associated with spinal injuries. Immobilize the
or behind ears) spine and use the log-roll technique to examine
the back of the body.
• Blood or fluid from the
ears or nose • Use the Glasgow Coma Scale (or AVPU in
children) to assess and monitor patients with
• Unequal pupils head injury.
• Weakness on one side of • Be sure to frequently re-assess ABCDE.
the body
• If concern for open skull fracture, give IV

SHOCK
antibiotics as per local protocol.
• Always check glucose and administer as needed.
• Do not give food or drink by mouth.
• Plan for early handover/transfer to a facility with
specialist care.

AMS
REMEMBER… People who initially appear well may have hidden life-threatening injuries,
such as internal bleeding. It is very important to re-assess trauma patients frequently
using the primary survey. Once you find a primary survey problem and manage it, go
back and repeat the primary survey to identify any new problems and make sure that
the management worked. Ideally, the ABCDE approach should be rechecked every 15
minutes and with any change in condition.
SKILLS

Vital signs should be checked at the end of the primary survey

A full set of vital signs (blood pressure, heart rate, respiratory rate and oxygen saturation if available)
should be performed after the primary survey. Do not delay primary survey interventions for
vital signs.
GLOSSARY
REFS & QUICK CARDS

47
Module 2: Approach to trauma

Workbook question 2: Approach to trauma

Using the workbook section above, list five important conditions to recognize in the
primary survey
1._______________________________________________________________________

2._______________________________________________________________________

3._______________________________________________________________________

4._______________________________________________________________________

5._______________________________________________________________________

ASK: KEY HISTORY FINDINGS FOR TRAUMA PATIENTS

Information about an injured person and the injury event can be critical to planning
management. Children, older adults and people with chronic disease have an increased risk of
complications from trauma. They may need to be watched for several hours even when they
appear well. Certain mechanisms are often associated with multiple injuries, some of which
may not be obvious right away. High-risk mechanisms include:
ƒƒ pedestrian being hit by a vehicle;
ƒƒ motorcycle crashes or any vehicle crash with unrestrained occupants;
ƒƒ falls from heights greater than 3 metres (or in children, twice the child’s height);
ƒƒ gunshot or stab wounds;
ƒƒ and explosion or fire in an enclosed space.

Use the SAMPLE approach to obtain a history. Remember that you may be able to obtain
information from bystanders, family, police, fire service or other health-care workers.

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

S: SIGNS AND SYMPTOMS

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

ƒƒ Is there any difficulty in breathing?

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

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 PARTICIPANT WORKBOOK

INTRO
ƒƒ Is there reported bleeding?
It is usually quite difficult for patients to estimate the volume of blood loss, but it may be
helpful to know how long there has been bleeding, how many bandages have been soaked

ABCDE
and if the bleeding is getting lighter or heavier.

ƒƒ Is there confusion or unusual sleepiness?

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

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

BREATHING
chest, abdomen or pelvis.

ƒƒ Is there nausea or vomiting?

This may indicate an abdominal or head injury.

ƒƒ Is there reported numbness or weakness?

This may indicate a spinal injury.

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

A: ALLERGIES

AMS
ƒƒ Any allergies to medications?

M: MEDICATIONS
ƒ Currently taking any medications?
SKILLS

Medications that affect blood clotting (e.g. aspirin, warfarin, clopidogrel) can make
bleeding more difficult to control and increase the risk of delayed bleeding. Blood pressure
medications can make it hard to manage shock. Obtain a full list of medications if possible
or ask family members to bring in medications.
GLOSSARY
REFS & QUICK CARDS

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Module 2: Approach to trauma

P: PAST MEDICAL HISTORY

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

ƒƒ Tetanus status?
A person who has not had a tetanus vaccination within the past 5 years and who has an
injury that damages the skin needs a tetanus vaccination.

ƒƒ Are other conditions present that put the person at higher risk for serious injury?

RISK FACTORS FOR POOR OUTCOMES FROM INJURY:

–– Age less than 5 years or greater than 55 years
–– Heart or lung disease
–– Diabetes
–– Liver failure (cirrhosis)
–– Severely overweight
–– Pregnancy
–– Immunosuppression (including HIV)
–– Bleeding disorder or taking blood-thinning medications (medications that prevent
clotting)

L: LAST ORAL INTAKE

ƒƒ When did the person last eat or drink?

E: EVENTS SURROUNDING INJURY

Certain mechanisms of injury are so high risk that patients should be observed closely, even if
they do not appear to be significantly injured.

ƒƒ Was there a fall from 3 metres or more (or twice the height in children)?
Falls are a common cause of injury for both adults and children. A greater distance fallen
increases the chance of serious injury. Falls in adults are often associated with older age,
alcohol intoxication, or the failure of workplace equipment, including scaffolding and
ladders. Children often fall from trees, windows or balconies.

ƒƒ Was a pedestrian or a cyclist hit by a vehicle?

Adults and children who are hit by a vehicle while walking or using non-motorized forms of
transport (such as bicycles) are always at high risk of serious injury. Young children may be
less able than adults to report events, even major events like being hit by a vehicle. Always
consider the possibility of unwitnessed trauma in young children. Children and adults
can sustain multiple injuries when hit by a vehicle – both from direct impact to the body,
especially the lower extremities, and from secondary impact if they are thrown against the
windscreen or road, which may cause injuries anywhere in the body, including to head, neck,
chest or limbs.
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 PARTICIPANT WORKBOOK

INTRO
ƒƒ In a motorcycle (or powered 3-wheeler) crash, was the rider thrown?
Motorcycles collisions often result in a rider being thrown. Ask if the motorcyclist was
wearing a helmet and how far away from the vehicle the rider was found. Common injury

ABCDE
sites include head (especially when no helmet was worn), spine, chest, abdomen and pelvis
(as the rider hits the handlebars), as well as limbs and skin (as the rider hits the road).

ƒƒ Was there a road traffic crash at high speed? Was the person thrown from or trapped
inside a vehicle? Did any vehicle occupants die in this crash?
With higher-speed crashes, greater force is transmitted to vehicle occupants increasing

TRAUMA
the risk of serious injury. Vehicle occupants may be injured by impact with the windscreen
or steering wheel, or by the forces that result from the sudden stopping of the vehicle. A
person thrown from a vehicle is at very high risk of serious injury. If a person was trapped
within a vehicle it is important to find out what part of the body was trapped (arm/leg, etc.)
and for how long. Consider crush injury in a person who has been trapped. A death at the
scene of a road traffic crash suggests that there was significant force exerted on the vehicle
and its passengers. All passengers involved in the crash, even if they appear unhurt, are at

BREATHING
high risk for serious injury.

ƒƒ In a motor vehicle crash, was the patient wearing a seatbelt?

Some types of injuries are more common in patients who were not wearing a seat-belt
(being thrown from the vehicle, head strike on the windscreen, chest strike on the steering
column). However, in very high-speed crashes, seat belts can also cause certain types of
injuries (cervical spine injury, abdominal injury).

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

AMS
and lacerations.

ƒƒ Was there a burn? If so, what type of burn was it?

Burns from fires (flame burns) are the most common. A history of flame burn in an enclosed
space can also suggest an inhalation or airway injury. Scald burns (due to hot liquids) are
common in children. Electrical injuries often come from high-voltage sources such as
overhead electrical wires coming in contact with the body. On the surface, these electrical
SKILLS

injuries may look small but they can cause extensive tissue and muscle damage. The
electrical current often crosses the body, taking the shortest path from the point of contact
with the skin to the ground, often leaving entry and exit burn marks. In the case of chemical
burns, information about the specific chemical may be needed to remove it properly.

ƒƒ For burns, was first aid provided at the scene?

GLOSSARY

It is important to know if the burning process was stopped, and in the event of a chemical
exposure, if decontamination was performed. If the burn is less than 3 hours old and no first
aid was provided, the wound will need to be washed with clean water to stop the burning
process. If there is a history of chemical exposure, protect yourself from the chemical and
ensure that it is properly removed from the skin.
REFS & QUICK CARDS

51
Module 2: Approach to trauma

ƒƒ Did the person sustain a crush injury? Is there severe pain or numbness? Is there dark
urine?
Crush injuries may damage skin, muscle, blood vessels and bone. Damaged muscle can
release a muscle by-product (called myoglobin) that can build up and damage the kidneys.
It is important to know how long a body part was crushed. Even a small crushed area can
cause the release of a dangerous amount of myoglobin (for example when a limb is caught
under falling debris for an extended time). If a person with a crush injury has dark urine, this
may be a sign of build-up of myoglobin in the kidneys. Tissue damage and swelling from
crush injury can also cause a build-up of pressure (particularly in limb-crush injuries) that
can limit blood flow to the muscles and nerves (compartment syndrome).

ƒƒ Did the person sustain a blast injury?

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

Workbook question 3: Approach to trauma

Using the workbook section above, list five questions you would ask when taking a
SAMPLE history from a person injured in a road traffic crash:
1. ����������������������������������������������������������������������

2. ����������������������������������������������������������������������

3. ����������������������������������������������������������������������

4. ����������������������������������������������������������������������

5. ����������������������������������������������������������������������

CHECK: TRAUMA SECONDARY SURVEY

Following the primary survey and SAMPLE history, the secondary survey is a detailed head-to-
toe examination designed to identify any additional injuries or issues requiring intervention.
The secondary survey gives the provider an organized way to assess the entire body for signs
of trauma that may not have been obvious on the primary survey. Remember that very painful
or frightening injuries may distract both patients and providers from recognising other injuries.
Always examine the entire body. If the secondary survey identifies a primary survey condition,
STOP AND RETURN IMMEDIATELY TO THE PRIMARY SURVEY to manage it.

52
 PARTICIPANT WORKBOOK

INTRO
Head, ears, eyes, nose, Look for:
and throat (HEENT) • Scalp wounds or bruising

ABCDE
• Skull deformities
• Blood in mouth or throat
• Unequal or unresponsive pupils indicating head injury
• Vision loss or changes and eye injuries
• Any problems with eye movements
• Blood or fluid from ear or nose, which can indicate tissue injury or
skull fracture

TRAUMA
• Tooth injury or poor alignment of teeth
• Signs of airway burns: ash, singed nasal hairs, new or worsening lip/
mouth swelling
Listen for:
• Stridor which could indicate that the airway will obstruct soon
• Gurgling indicating fluid in the airway

BREATHING
• Changes in voice, which can indicate airway or vocal cord injury
Feel for:
• Tenderness or abnormal movement of facial bones, suggesting
fracture
• Loose teeth that may accidentally be inhaled
• Defects or crepitus in the skull or facial bones concerning for fracture
Neck Look for:

SHOCK
• Reduced ability to move neck or pain on movement
• Bruising, bleeding or swelling
• Haematoma (bruising/bleeding under the skin) – this may eventually
cause airway obstruction
• Penetrating neck wounds
• Distended neck veins (which may indicate tension pneumothorax or
tamponade)

AMS
Feel for:
• Air in the skin or soft tissue – concerning for airway injury or
pneumothorax
• Tenderness or deformity along the spine – concerning for fracture
Chest Look for:
• Bruising, deformity, wounds
SKILLS

• Uneven chest wall movement–concerning for pneumothorax or flail

chest
• Burns around the entire chest (circumferential) which can cause
difficulty in breathing
Listen for:
• Breath sounds (decreased, unequal or absent, wheeze, crepitations)
GLOSSARY

• Muffled heart sounds – concerning for pericardial tamponade

Feel for:
• Tenderness
• Crepitus – concerning for fracture or pneumothorax
REFS & QUICK CARDS

53
Module 2: Approach to trauma

Abdomen Look for:

• Abdominal distension
• Visible abdominal wounds, bruising or abrasions
• Bruising on back or abdomen, which may indicate internal bleeding
• Circumferential burns to the abdomen (may cause severe problems
with breathing)
Feel for:
• Abdominal rebound tenderness (pain when releasing pressure on the
abdomen) or guarding (sudden contraction of the abdominal wall
muscles when the abdomen is pressed), suggesting serious injury
• Abdominal tenderness, which can indicate organ or blood vessel
injury
Pelvis and genitals Look for:
(always protect patient • Bruising/lacerations to pelvis
privacy during exam)
• Blood at the opening of the penis or rectum. May be a sign of sexual
assault.
• Vaginal lacerations or bleeding – these could indicate open pelvic
fracture, injury to the uterus, or may be a source of significant blood
loss. May be a sign of sexual assault.
• Penile lacerations
• Priapism (prolonged erection) can indicate spinal injury
• Urine colour changes (dark urine or obvious blood) that might
indicate muscle breakdown or kidney injury
Feel for:
• Tenderness or abnormal movement in pelvis
Extremities Look for:
• Swelling or bruising
• Deformity, which could indicate fracture
• Open fractures
• Amputation
• Circumferential burns
• Pale skin that could indicate limited blood flow
Feel for:
• Absent or weak pulses
• Cold skin that could indicate limited blood flow
• Tenderness
• Abnormally firm, painful muscular compartments in the extremities
can indicate compartment syndrome

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 PARTICIPANT WORKBOOK

INTRO
Spine/back Log roll the person with assistance, then:
Look for:

ABCDE
• Bruising
• Deformity
Feel for:
• Tenderness, crepitus and misalignment along the entire spine
(upper neck to lower back)
• Tenderness, crepitus or misalignment over any other areas with

TRAUMA
visible evidence of trauma
Skin Look for:
• Bruising
• Abrasions
• Lacerations
• Feel for peripheral pulses in all extremities

BREATHING
• Burns
–– Look for circumferential burns: depending on the location, these
can cause difficulty in breathing (if on the chest) or compartment
syndrome (if on the extremities)
Neurologic Check for:
• Decreased level of consciousness (using AVPU or GCS) and seizures/
convulsions, which may be signs of serious head injury
• Movement and strength in each limb

SHOCK
• Sensation on face, chest, abdomen, limbs; if there is a sensory deficit,
identify where it begins
• Priapism (persistent penile erection)
• Decreased sensation, decreased strength or priapism can indicate
spinal cord injury

AMS
SKILLS
GLOSSARY
REFS & QUICK CARDS

55
Module 2: Approach to trauma

Workbook question 4: Approach to trauma

Using the workbook section above, list one way that you would ASSESS the following
systems.

Head, ears, eyes, nose, throat:

Listen for: ���������������������������������������������������������������

Look for: ����������������������������������������������������������������

Feel for: �����������������������������������������������������������������

Chest:

Look for: ����������������������������������������������������������������

Listen for: ���������������������������������������������������������������

Feel for: �����������������������������������������������������������������

Pelvis and genitals:

Look for: ����������������������������������������������������������������

Feel for: �����������������������������������������������������������������

56
 PARTICIPANT WORKBOOK

INTRO
DO: IMPORTANT CONDITIONS TO RECOGNIZE AND MANAGE
BASED ON HISTORY AND SECONDARY SURVEY

ABCDE
Management of specific injuries found during secondary survey
CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT
Head injury • Headache Because the brain is encased in the rigid skull,
• Altered mental status any swelling or bleeding caused by brain
injury can rapidly become life-threatening.

TRAUMA
• Abnormal pupils
• Scalp lacerations and/or skull • Monitor level of consciousness (a marker
fractures of brain function) using the Glasgow Coma
Scale (GCS) or AVPU scale in children.
• Bruising to head (particularly [See SKILLS]
around eyes or behind ears)
• Any patient who has significant head injuries
• Blood or clear fluid coming from is at risk of having spine injuries as well.
nose or ears [See SKILLS]

BREATHING
• Weakness on one side of the • Always monitor immobilized patients for
body vomiting to avoid choking.
• Seizures/convulsions • If there is concern for an open skull fracture,
• Visual change give IV antibiotics.
• Loss of memory • Check blood glucose and give glucose if less
• Vomiting than 3.5 mmol/L or unable to measure.
• Any patient with GCS less than 9 should be
transferred for a CT scan within 2 hours of
injury, if possible.

SHOCK
Facial • Deformities or unusual • Give antibiotics for open facial fractures
fractures movement in the facial bones (laceration over a broken bone).
• Patient reports jaw not closing • Update tetanus vaccination.
normally or teeth not aligned • Suspect cervical spine injury and immobilize
• Problems with eye movements the cervical spine if needed. [See SKILLS]
• Remember to position patient to keep blood
from flowing into airway.

AMS
• Avoid nasopharyngeal airways and
nasogastric tubes when facial fracture is
suspected.
Penetrating • Any visible object in the eye • Avoid any pressure on the injured eye – this
eye injury • Painful red eye or a reported could worsen the injury
feeling of something in the eye; • Do not remove objects penetrating the eye.
it may be difficult to see small • Give antibiotics.
SKILLS

objects that have penetrated

• Update tetanus vaccination if needed.
the eye
• Keep the head elevated and place a loose
• Problems with vision
patch over both eyes (do NOT put pressure
• An abnormally shaped pupil or on the eye).
clear liquid draining from the
• Plan for handover/transfer to an advanced
eye may indicate a puncture
provider.
wound
GLOSSARY

• Evidence of facial trauma

REFS & QUICK CARDS

57
Module 2: Approach to trauma

Management of specific injuries found during secondary survey

CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT
Penetrating • Small lacerations or puncture Patients with penetrating neck wounds are
neck wound wounds may be the only sign of at risk of airway obstruction, so monitor the
serious injury airway closely. Neck wounds may also have
• Swelling (suggesting significant haemorrhage.
haematoma) • Maintain cervical spine precautions.
• Look carefully for penetrating [See SKILLS]
objects • Stabilize, but do not remove penetrating
objects.
• Apply firm pressure to bleeding site, being
careful not to block the airway.
• Do not insert anything into wound to check
the depth – this can cause further damage.
• Initiate rapid handover/transfer to a unit
with surgical care and advanced airway
management capabilities.
Chest injury • Difficulty in breathing Monitor closely for difficulty in breathing
• Crepitus or tenderness to due to lung injury which can develop over
palpation over the ribs time. Tension pneumothorax is treated
in the primary survey; however, chest
• Uneven chest wall movement or
injury may also be associated with simple
unequal breath sounds
pneumothorax which can progress to a
tension pneumothorax.
• Any patient with a pneumothorax should be
placed on oxygen and monitored closely for
development of a tension pneumothorax.
• Crepitus or tenderness may be signs of rib
fractures which are often associated with
underlying chest or abdominal injury.
• Plan for handover/transfer for chest tube
(pneumothorax) or advanced airway and
breathing management.
Abdominal • Abdominal pain or vomiting Severe pain or bruising to the abdomen
injury • Tender, firm or distended is concerning for organ injury or internal
abdomen on examination bleeding.
• Sudden abdominal wall muscle • If you suspect abdominal injuries, give IV
contractions when the abdomen fluids.
is touched (guarding) • Do not give the patient anything to eat or
• Very few or no bowel sounds on drink.
examination • If bowel is visible:
• Rectal bleeding –– leave it outside the body;
• Visible wound in the abdominal –– cover it with sterile gauze soaked in sterile
wall saline;
• Bruising around the umbilicus or –– give antibiotics.
over the flanks can be a sign of
internal bleeding • If there is any concern for abdominal injury,
plan for rapid handover/transfer to a unit
with surgical capabilities.

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INTRO
Management of specific injuries found during secondary survey
CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT

ABCDE
Spinal cord • Midline spinal pain/tenderness • Provide spinal immobilization to any person
injury • Movement problems: paralysis, with a history of trauma who is unconscious;
weakness, abnormal reflexes or who is conscious and has neck pain,
cervical spine tenderness, numbness or
• Sensation problems: tingling
weakness.
(“pins and needles” sensation),
loss of sensation –– Use a rolled sheet or neck collar to
immobilize the cervical spine. [See SKILLS]
• Loss of control of urine or stool

TRAUMA
ƒƒ Keep the patient lying flat in bed
• Priapism
to immobilize the rest of the spine.
• May have hypotension, [See SKILLS]
bradycardia
ƒƒ When examining or moving the trauma
• Crepitus when you touch the patient, the spine should be protected
spinal bones by using the log-roll manoeuvre.
• Spinal bones that are not [See SKILLS]
properly aligned

BREATHING
• Give IV fluids. [See SKILLS]
• Difficulty in breathing (upper
cervical spine injury) • Any patient with possible spinal trauma
needs handover/transfer to a specialist unit.
NOTES:
• Spinal trauma is not always obvious. Fractured spinal bones can injure the spinal cord, causing
paralysis. If the spinal cord injury is in the cervical spine, paralysis could involve the muscles that
control respiration and could lead to death. Examination findings should be carefully documented so
that future providers can evaluate if the patient’s condition has changed.

SHOCK
• Spinal injuries can also cause shock. This can occur when nerves that control the contraction of the
blood vessels in the body are damaged. When the walls of a blood vessel relax, the vessel dilates
and pressure drops, leading to poor perfusion and shock. Risk is higher if there is also blood loss,
so patients must be monitored closely. Always consider spinal injury in a patient with shock that
does not improve with treatment.
• Spine boards should only be used to move patients. Leaving patients on spine boards for long
periods of time can cause pressure sores. Remove patients from boards as soon as they arrive at
the facility and can be laid flat.

AMS
Internal • Bruising around the umbilicus or A large quantity of blood can be lost into the
bleeding over the flanks can be a sign of chest, pelvis, thigh, and into the abdomen
(not seen internal bleeding before bleeding is recognized.
on primary • Pelvic fracture • Stop the bleeding if possible – bind pelvis or
survey) splint femur. [See SKILLS]
• Femur fracture
• Decreased breath sounds on one • Give IV fluid. [See SKILLS]
side in the chest (haemothorax) • Refer for blood transfusion and ongoing
SKILLS

• Signs of poor perfusion surgical management if needed.

(hypotension, tachycardia, pale
skin, diaphoresis)
GLOSSARY
REFS & QUICK CARDS

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Module 2: Approach to trauma

Management of specific injuries found during secondary survey

CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT
Pelvic • Pain with palpation of the pelvis • Give IV fluids and pain control. [See SKILLS]
fracture • Instability or abnormal • Compress pelvis gently to check for stability.
movement of the pelvic bones • Do not open and rock pelvis or perform
• Blood at opening of the penis or repeat exams as this can worsen internal
rectum bleeding.
• Stabilize the pelvis with a sheet or pelvic
binder. [See SKILLS]
• Plan for early handover/transfer to a unit
with blood transfusion capabilities.
Extremity • Deformity or crepitus of the Fractures can displace blood vessels and limit
fracture bone blood supply to the limb beyond the fracture.
with poor • Absent pulses beyond the • Look for signs of poor perfusion beyond the
perfusion fracture fracture.
• Capillary refill time of greater ƒƒ Feel the pulse.
than 3 seconds beyond the ƒƒ Check capillary refill.
fracture
ƒƒ Look for pale skin. [See SKILLS]
• Cold extremities beyond the
fracture with blue or grey skin ƒƒ If a fracture is found with weak pulses or
colour poor perfusion, re-establish perfusion
by reducing (manually re-aligning bone
ends to put limb back to its normal
position) and splinting the fracture.
[See SKILLS]
ƒƒ Always check and document pulses,
capillary refill and sensation before and
after any reduction.
• Plan for urgent handover/transfer to a
specialist unit.
Open • Deformity or crepitus of the Consider any patient to have an open fracture
fracture bone with overlying laceration if there is a wound (more than just a skin
abrasion) near a fracture site. Open fractures
are emergencies because they can lead to
severe bone infections.
• Control haemorrhage with direct pressure.
[See SKILLS]
• Reduce the fracture immediately if there is
poor perfusion. [See SKILLS]
• Irrigate the wound well. [See SKILLS]
• Dress wound.
• Give antibiotics and tetanus vaccination.
• Splint the wound.
• Plan for handover/transfer to a specialist unit.

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INTRO
Management of specific injuries found during secondary survey
CONDITION SIGNS AND SYMPTOMS IN-DEPTH MANAGEMENT

ABCDE
Open • Laceration The goal of wound care is to stop bleeding,
wound • Abrasion prevent infection, assess damage to
underlying structures and promote healing.
• Wounds in the underarm area,
genital area, buttocks or back • Stop bleeding. [See SKILLS]
are easily missed • Clean wounds thoroughly with soap and
• Pumping or squirting blood can clean water or antiseptic to remove any dirt,
indicate arterial bleeding foreign bodies or dead/dying tissue. (Give

TRAUMA
local anaesthetic before cleaning the wound
if available.)
• Dress wounds with sterile gauze, if available.
• Check perfusion beyond the wound
(capillary refill and/or distal pulses) before
and after dressing wounds.
• Splint extremities with large lacerations to

BREATHING
help with wound healing and pain control.
[See SKILLS]
• Stabilize but do not remove penetrating
objects.
• For snake bite, immobilize the extremity. [See
WOUND MANAGEMENT in SKILLS]
• For animal bites, consult advanced provider
to assess for risk of infection and rabies
exposure. Depending on vaccination

SHOCK
status, management can be extremely
time-sensitive.
• Give tetanus vaccination if needed.

page 15

REMEMBER… Always assess, treat and monitor pain.

AMS
SKILLS
GLOSSARY

Applying direct pressure to a wound

Applying direct pressure to a wound

REFS & QUICK CARDS

61
Module 2: Approach to trauma

SPECIAL CONSIDERATIONS
Management by injury mechanism
CONDITION CONCERNING SIGNS IN-DEPTH MANAGEMENT
AND SYMPTOMS
Crush injury • Fractures, bruising, Crush injuries can have serious complications. Look for
soft tissue damage compartment syndrome (a build-up of pressure within
• Evidence of the muscle compartments that can limit blood supply
compartment to muscles and nerves) and kidney damage due to
syndrome (pain, by-products of muscle injury.
firm muscle • It is important to monitor urine output and look for red-
compartments, brown urine (a concern for possible kidney damage).
numbness, • Give IV fluids to help the kidneys maintain urine output.
decreased pulses or
pale skin) • Splint fractures to keep bone ends from causing further
damage.
• Small amounts of
red-brown urine • Plan for early surgical referral to release the pressure if
compartment syndrome develops.
• Patients may have many systemic problems related to
muscle damage and should always be handed over to an
advanced provider.
Blast injury • Injury to air-filled An explosive blast can cause injuries in three ways:
organs (such as 1. Visible injuries from shrapnel (fragments of metal
lung, stomach and released by an explosive device) or burns from heat or
bowel) chemicals released;
• Delayed symptoms
2. Internal (often hidden) injuries from the change in
of tachypnoea,
pressure caused by the blast. The stomach and bowel,
hypoxia, chest
lungs, and ears are commonly injured; and
pain, cough with or
without blood 3. Additional blunt injuries that result when the body is
• Abdominal pain, thrown by the blast.
nausea, vomiting • Examine carefully for pneumothorax.
with or without • Give oxygen if there is difficulty in breathing. [See SKILLS]
blood
• Update tetanus.
• Tympanic
• Burns should be dressed and fluid needs calculated
membrane (ear
based on burn area. [See SKILLS]
drum) rupture:
hearing loss, • If the patient has abdominal pain, consider bowel
ringing in the ears, perforation, give IV fluids [See SKILLS]
pain, ear bleeding • Prepare for rapid surgical referral.
• Other injuries,
burns, exposure to
chemicals or toxins

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 PARTICIPANT WORKBOOK

INTRO
Management by injury mechanism
CONDITION CONCERNING SIGNS IN-DEPTH MANAGEMENT

ABCDE
AND SYMPTOMS
Burn injury • Skin colour can Burns can affect the whole body and cause soft tissue
range from pink, injury, swelling and shock resulting from fluid loss due
red, pale, or black, to the burn. The goal of burn management is to stop the
depending on the burning process, watch for swelling and compensate for
burn depth. The fluid loss. In significant burn injury, fluid leaks into the skin
burn may or may and surrounding tissue causing swelling and shock.

TRAUMA
not have blisters. • Burns involving the airway can rapidly cause airway
• The following may obstruction.
suggest inhalation • It is crucial to replace fluid loss and anticipate ongoing
or airway injury. losses.
–– Soot (ash) around –– In order to calculate the IV fluid requirements, it is
nose or mouth, or important to determine the depth of the burn and the
singed (burned) percentage of body surface area (BSA) that is burned.
[See SKILLS]

BREATHING
nasal hairs
–– Swelling to lips or • Do not forget to give tetanus vaccination and pain relief
mouth for burn injuries.
–– Voice changes • Remove all jewelry and elevate the burned limb if
possible.
• Burns are at high risk for infection, even with good care.
Clean and dress the wound carefully. [See SKILLS]
BURNS REQUIRING RAPID HANDOVER/TRANSFER:

SHOCK
• Serious burns to >15% of body [See SKILLS]
• Burns involving the hands, face, groin area, joints, or
circumferential burns
• Inhalation injury
• Burns with other associated trauma
• Any burn in very young or elderly people
• Significant pre-burn illness (such as diabetes)

AMS
SKILLS
GLOSSARY
REFS & QUICK CARDS

63
Module 2: Approach to trauma

Workbook question 5: Approach to Trauma

Using the workbook section above, list what you would DO to manage the following
injuries.

INJURY MANAGEMENT

Pelvic fracture
1. ������������������������������������������������������

2. ������������������������������������������������������

3. ������������������������������������������������������

4. ������������������������������������������������������

Burn injury in
an adult 1. ������������������������������������������������������

2. ������������������������������������������������������

3. ������������������������������������������������������

4. ������������������������������������������������������

Abdominal
injury 1. ������������������������������������������������������

2. ������������������������������������������������������

3. ������������������������������������������������������

4. ������������������������������������������������������

64
 PARTICIPANT WORKBOOK

INTRO
SPECIAL POPULATIONS

ABCDE
TRAUMA IN PREGNANCY
Any female patient aged 10–50 years should have a pregnancy test. Pregnancy causes
many changes in physiology and there are added considerations for fetal well-being.
Even minor trauma may cause harm to the mother and fetus. Women suffering trauma
in the third trimester are at risk for placental abruption (where the placenta can separate

TRAUMA
from the uterus wall, resulting in bleeding), uterine rupture, and premature labour.
Remember resuscitation of the mother resuscitates the fetus.

KEY ELEMENTS OF PATIENT HISTORY

ƒƒ Gestational age (age of the fetus or number of weeks since last menstrual period).
ƒƒ Any pregnancy complications.

BREATHING
PRIMARY SURVEY
ƒƒ Airway: swelling in pregnancy can make airway obstruction more likely, so monitor
closely.
ƒƒ Breathing: the diaphragm is pushed up by the pregnant uterus, leaving less lung
space for breathing.
ƒƒ Circulation: check for vaginal bleeding; a pregnant uterus can also compress large

SHOCK
blood vessels, causing hypotension. Place on left side with cervical spine precautions.
[See SKILLS]
ƒƒ Disability: always consider eclampsia if seizures/convulsions occur.
ƒƒ Exposure: keep patient warm.

COMMON CONDITIONS CAUSED BY TRAUMA

AMS
ƒƒ Preterm (early) labour with or without premature rupture of membranes (loss of the
fluid surrounding the baby).
ƒƒ Placental abruption or uterine rupture: causing blood loss and shock.
ƒƒ Seizures/convulsions.

SPECIAL MANAGEMENT CONSIDERATIONS

SKILLS

ƒƒ Plan early for handover/transfer to a specialist unit with obstetric care.

ƒƒ If the uterus can be felt at the level of the umbilicus (belly button), this generally
indicates that the patient is at least 20 weeks pregnant.
ƒƒ If the woman is more than 20 weeks (5 months) pregnant, the pregnant uterus can
compress the inferior vena cava, the large vessel that brings blood back to her heart,
and can cause shock. When lying the pregnant patient flat, always place on the left
GLOSSARY

side (on a spine board if immobilization necessary). [See SKILLS]

ƒƒ Trauma in late pregnancy may trigger early labour. Prepare for neonatal resuscitation
as well when trauma occurs in late pregnancy.
REFS & QUICK CARDS

65
Module 2: Approach to trauma

Workbook question 6: Approach to Trauma

Using the workbook section above, list the common conditions in a pregnant woman
that can be caused by trauma.

1. ����������������������������������������������������������������������

2. ����������������������������������������������������������������������

3. ����������������������������������������������������������������������

4. ����������������������������������������������������������������������

5. ����������������������������������������������������������������������

66
 PARTICIPANT WORKBOOK

INTRO
SPECIAL CONSIDERATIONS IN CHILDREN

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

TRAUMA
normal paediatric vital signs and additional details. pag

AIRWAY
• When neck trauma or cervical spine injury is suspected, use jaw thrust to manually
open airway while maintaining cervical spine immobilization. Children have big heads
and large tongues that may easily obstruct their airways. Young children and infants

BREATHING
may require a pad under the shoulders to align the airway. [See SKILLS]

SHOCK
AMS
BREATHING
SKILLS

• If the child is not breathing adequately after opening the airway, assist breathing with
a bag-valve-mask, ideallyNeutral position in infants
with oxygen.
• Give a breath every 4 seconds (15 breaths per minute) for older children and a breath
every 3 seconds (20 breaths per minute) for infants. [See SKILLS]
GLOSSARY
REFS & QUICK CARDS

67
Module 2: Approach to trauma

CIRCULATION
• For ongoing blood loss or evidence of poor perfusion in children with normal
nutritional status (see also SKILLS):
–– place IV;
–– give IV fluids and re-assess.
[See SKILLS]
• For malnourished children,
fluids MUST be adjusted.
[See SKILLS]
• For severe burn injury, initial
bolus is with dextrose-
containing fluids. [See SKILLS]
• If significant haemorrhage,
arrange for blood transfusion
or rapid handover/transfer
to a centre capable of blood
transfusion. Location of brachial pulse in a child
Location of brachial pulse in a child
DISABILITY
• Monitor child’s level of consciousness with the AVPU scale (Alert, responsive to Verbal
stimuli, responsive to Painful stimuli, Unresponsive). AVPU is preferred to GCS in young
children.
• Assess for and manage seizures/convulsions.
• Assess for and manage hypoglycaemia.

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

Estimate weight in children based on age

Weight in kilograms = [age in years + 4] × 2
or use weight-estimation tools such as PAWPER
tape, Mercy TAPE, or Broselow tape, etc.

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

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 PARTICIPANT WORKBOOK

INTRO
HEAD INJURIES
Head injuries are a common cause of death in children, and children frequently suffer

ABCDE
from acute brain swelling after a severe head injury. If a paediatric patient has signs of
traumatic brain injury, transport urgently to a facility with critical care and/or surgical
capacity.

CHEST INJURIES
Chest injuries can be life-threatening, and children require less force for more serious

TRAUMA
internal injuries. The ribs are more flexible than in adults, and there may be extensive
chest injuries without rib fractures.

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

BREATHING
threatening and can cause severe internal bleeding.

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

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

AMS
1. ����������������������������������������������������������������������

2. ����������������������������������������������������������������������

3. ����������������������������������������������������������������������
SKILLS

List the disability considerations in children who suffer trauma.

1. ����������������������������������������������������������������������

2. ����������������������������������������������������������������������
GLOSSARY

3. ����������������������������������������������������������������������
REFS & QUICK CARDS

69
Module 2: Approach to trauma

DISPOSITION CONSIDERATIONS
Trauma patients can have complex injuries that may be hidden, and can worsen and die very
quickly. Always refer seriously injured patients to a higher level of care for specialized treatment.

The following high-risk conditions always require handover/transfer to a specialist unit for
ongoing care:
ƒƒ Airway problem requiring intervention.
ƒƒ Signs of shock:
–– Tension pneumothorax: perform needle decompression prior to transfer (will need
urgent chest tube placement).
–– Pericardial tamponade: ensure IV fluids started and continued on transfer.

ƒƒ Altered mental status (drowsy, lethargic, confused or unconscious).

ƒƒ Trauma in pregnancy: place on left side for transport (needs specialist obstetric care).
ƒƒ Child with ABCDE problem, burn, or any head, chest or abdominal injury.
ƒƒ Any serious burn injury: assess the burn depth and total burn surface area, commence fluid
resuscitation (transfer preferably to a specialist burns unit). [See SKILLS]

Other considerations for transfer:

ƒƒ If a patient has required oxygen, arrange to continue it during transport and after handover.
ƒƒ If an injured person is displaying signs of shock, ensure IV fluid started and continued during
transfer. Ensure any external bleeding is controlled and monitored during transport.

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 PARTICIPANT WORKBOOK

INTRO
FACILITATOR-LED CASE SCENARIOS
These case scenarios will be presented in small groups. The following cases WILL NOT be

ABCDE
assessed and are for practice only. It is important that you practise these scenarios as you
will be assessed on how you lead a case in the following modules. For each case scenario
the group must identify the critical findings and management needed and formulate a one-
line summary for handover, including assessment findings and interventions. You should
use the Quick Cards for these scenarios.

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

1. What do you need to do in your initial approach?

BREATHING
2. Use the primary survey to assess and manage this patient. Ask the facilitator about look,
listen and feel findings; use the Quick Card for reference as needed.

ASSESSMENT FINDINGS INTERVENTION INTERVENTIONS

NEEDED? TO PERFORM:

SHOCK
AIRWAY YES NO

BREATHING YES NO

CIRCULATION YES NO

AMS
DISABILITY YES NO

EXPOSURE YES NO SKILLS

3. Formulate a short summary of this patient for handover.

CASE #2: PAEDIATRIC TRAUMA

GLOSSARY

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

71
Module 2: Approach to trauma

1. What do you need to do in your initial approach?

2. Use the primary survey to assess and manage this patient. Ask the facilitator about look,
listen and feel findings; use the Quick Card for reference as needed. Use the table below for
your notes.

ASSESSMENT FINDINGS INTERVENTION INTERVENTIONS TO

NEEDED? PERFORM:

AIRWAY YES NO

BREATHING YES NO

CIRCULATION YES NO

DISABILITY YES NO

EXPOSURE YES NO

A. Calculate the total burn surface area in this child. Try to shade in the children’s burn
diagram for burn area estimation.

B. Explain how you will decide if this child needs IV fluids?

C. Calculate how much fluid is needed, explaining your method.

D. What fluid would you use?

3. Formulate a short summary of this patient for handover.

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

ABCDE
1. Which of the following is a component of the trauma primary survey?
A. Examine the arms for any fractures
B. Check the skin color and temperature
C. Examine the ears for any drainage of blood or clear liquid

TRAUMA
D. Check skin pinch

2. You are assessing a man who was in a car crash. He is very confused, but the remainder of his
primary survey is normal. How do you perform a SAMPLE history if the patient is too confused
to answer your questions?
A. You do not need to do a SAMPLE history in a trauma patient

BREATHING
B. Ask the patient repeatedly until he is able to answer
C. Ask bystanders or family member for the information
D. Assume that there is no important information

3. A 23-year-old man is carried in after diving head first into a river. He is speaking and his
airway is open but he cannot walk or move his arms or legs. What is the first thing you must do?

SHOCK
A. Place an IV line
B. Examine him for other injuries
C. Immobilize the cervical spine
D. Give him a tetanus vaccination

4. You are evaluating a 21-year-old male who was in a motorcycle crash. He was thrown from
the motorcycle and suffered injuries to his face, chest and legs. When you compress his pelvis,

AMS
he screams in pain. His vital signs are: blood pressure 90/40 mmHg, heart rate 120 bpm,
respiratory rate 25/min. What should be your next step?
A. Place in a pelvic binder
B. Administer tetanus vaccine
C. Provide antibiotics
SKILLS

D. Clean the abrasions with soap and water

5. A young woman has been brought in after an explosion. She has an open airway, a respiratory
rate of 30/min, heart rate 125 bpm, blood pressure of 85/50 mmHg, has moist pale skin and
she complains of abdominal pain. She has small wounds to her skin but there is no obvious
bleeding. What would you do to manage this patient?
GLOSSARY

A. Place two large-bore cannulae and give 1 litre of fluid

B. Offer her a drink of water
C. Check her temperature
D. Provide antibiotics
REFS & QUICK CARDS

73
Notes
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 PARTICIPANT WORKBOOK

INTRO
Module 3: Approach to difficulty
in breathing

ABCDE
Objectives

TRAUMA
On completing this module you should be able to:
1. recognize signs of difficulty in breathing (DIB);
2. list the high-risk causes of difficulty in breathing;
3. perform critical actions for high-risk causes of difficulty in breathing.

BREATHING
Essential skills
ƒƒ Basic airway manoeuvres
ƒƒ Basic airway device insertion
ƒƒ Management of choking
ƒƒ Oxygen administration

SHOCK
ƒƒ Bag-valve-mask ventilation
ƒƒ Needle decompression for tension pneumothorax
ƒƒ Three-sided dressing for sucking chest wound

KEY TERMS

AMS
Write the definition using the Glossary at the back of the workbook.

Accessory muscle use:

Anaemia:
SKILLS

Asthma:

Chronic obstructive pulmonary disease (COPD):

GLOSSARY

Circumferential burns:

Crepitus:
REFS & QUICK CARDS

75
Module 3: Approach to difficulty in breathing

Cyanosis:

Diabetic ketoacidosis (DKA):

Diaphoresis:

Difficulty in breathing (DIB):

Disposition:

Drowning:

Haemothorax:

Heart attack:

Heart failure:

Hives:

Hyperventilation:

Inflammation:

Ischaemia:

Large-bore IV:

Needle decompression:

Pericardial effusion:

Pleural effusion:

Pleuritic:

Pneumonia:

Pulmonary embolism:

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 PARTICIPANT WORKBOOK

INTRO
Stridor:

ABCDE
Tachycardia:

Tachypnoea:

Tracheal shift:

TRAUMA
Tripod position:

Wheezing:

BREATHING
Overview
Difficulty in breathing (DIB) is a term used to describe a range of conditions from a feeling of
shortness of breath to abnormal breathing movements, or any increased effort required to
breathe. DIB can result from problems in the upper or lower airways, the lungs, the heart or
the muscles used for breathing; or from conditions that may cause faster breathing (such as
anaemia or chemical imbalance).

SHOCK
DIB can be caused by:
ƒƒ upper or lower airway obstruction (blockage by an object; by spasm of the airways, such as
with asthma; by swelling due to allergy; infection or injury);
ƒƒ fluid in the airspaces of the lung (such as from pneumonia or pulmonary oedema);
ƒƒ air or fluid outside the lung causing lung collapse or compression (such as pneumothorax
or effusion);

AMS
ƒƒ blood clots in the vessels supplying the lungs;
ƒƒ any other cause of decreased oxygen carried in the blood (such as anaemia);
ƒƒ conditions that increase respiratory rate such as toxic ingestion, chemical imbalance (for
example in diabetic ketoacidosis) or anxiety.
SKILLS

The goal of INITIAL ASSESSMENT is to identify reversible causes of difficulty in breathing,

and to recognize conditions that require urgent intervention or rapid transfer.
The goal of ACUTE MANAGEMENT is to ensure the airway stays open and breathing is
adequate to deliver oxygen to the organs.
GLOSSARY
REFS & QUICK CARDS

77
Module 3: Approach to difficulty in breathing

This module will guide you through:

ƒƒ ABCDE key elements
ƒƒ ASK: key history findings (SAMPLE history)
ƒƒ CHECK: secondary exam findings
ƒƒ Possible causes
ƒƒ DO: management
ƒƒ Special considerations in children
ƒƒ Disposition considerations

REMEMBER...
• ALWAYS START WITH THE ABCDE APPROACH, intervening as needed.
• Then do a SAMPLE history.
• Then do a secondary exam.

ABCDE: KEY ELEMENTS FOR PATIENTS WITH DIFFICULTY IN

BREATHING
For the patient with difficulty in breathing, the following are key elements that should be
considered in the ABCDE approach.

AIRWAY
A A person with difficulty in breathing may have airway swelling caused by
a severe allergic reaction (anaphylaxis) or choking (obstruction from a
foreign body). Stridor suggests serious airway narrowing.

BREATHING
B Hypotension with absent breath sounds on one side – especially with
distended (swollen or enlarged) neck veins or tracheal shift – may indicate
tension pneumothorax. Wheezing may indicate asthma or severe allergic
reaction.

CIRCULATION
C Shock, heart attack, heart failure and severe infection can all present
with poor perfusion and difficulty in breathing. Poor perfusion sends
signals to the brain to increase the rate of breathing, which can feel and
look like difficulty in breathing. Check for signs of shock by checking capillary refill, heart rate
and blood pressure. Swelling in the legs or crackles in the lungs can indicate heart failure and
fluid overload as a cause of difficulty in breathing.

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INTRO
DISABILITY
D Patients with decreased level of consciousness may not be able to protect
their airways. Drugs, infection or injury can directly affect the part of the

ABCDE
brain that controls breathing. Assess for paralyzing conditions affecting
the breathing muscles.

Check level of consciousness with the AVPU scale:

A: Alert
V: Responds to Voice

TRAUMA
P: Responds to Pain
U: Unresponsive

EXPOSURE
E Expose the patient fully to assess for abnormal chest wall movement and

BREATHING
any signs of trauma. Penetrating trauma to the back, chest, underarms or
abdomen may cause lung injury and is often missed.

ASK: KEY HISTORY FINDINGS FOR PATIENTS WITH

DIFFICULTY IN BREATHING

SHOCK
Use the SAMPLE approach to obtain a history from the patient and/or family.

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

S: SIGNS AND SYMPTOMS

AMS
ƒƒ When did the symptoms start and was onset sudden? Do they come and go and how
long do they last? Have they changed over time and has there been a similar episode
previously?
Sudden difficulty in breathing can suggest airway obstruction such as by a foreign body;
swelling of the airway from allergic reaction or infection; trauma to the airway, lungs, heart
or chest wall; or inhalation of hot gases or smoke. Acute heart problems such as heart attack,
SKILLS

abnormal heart rhythm or valve problems can cause rapid onset DIB. A history of rapid or
deep breathing may suggest poisoning, high acid levels in the blood (infection or diabetic
ketoacidosis) or anxiety. DIB that starts slowly is more common with infection and chronic
conditions such as a gradual build-up of fluid around the lungs (as occurs in TB and heart
failure), fluid around the heart (from TB or kidney disease), lung cancer or diseases affecting
the function of the chest wall. Recurrent difficulty in breathing associated with wheeze may
GLOSSARY

suggest asthma or COPD.

ƒƒ Did anything trigger the difficulty in breathing and what makes it better or worse?
A history of allergies may suggest that the airway is blocked by swelling due to a severe
allergic reaction. Inhaling smoke or hot gas (such as in fires) or some chemicals may cause
REFS & QUICK CARDS

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Module 3: Approach to difficulty in breathing

DIB through upper airway injury and swelling. Exposure to some chemicals (such as certain
pesticides) can cause fluid to build up in the airways and can cause weakness in the muscles
involved in breathing. Difficulty in breathing that gets worse when the person lies flat can
be due to fluid in the lungs.

ƒƒ Is there any tongue or lip swelling, or voice changes?

Swelling to the mouth, lips, tongue or upper throat, or a change in voice can suggest a
severe allergic reaction or other inflammation of the airway.

ƒƒ Are there abnormal sounds with breathing?

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

ƒƒ Is there pain associated with the difficulty in breathing?

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

ƒƒ Is there fever or cough?

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

ƒƒ Is there foot or leg swelling or recent pregnancy?

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

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

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

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INTRO
P: PAST MEDICAL HISTORY
ƒƒ Is there a history of asthma or chronic obstructive pulmonary disease (COPD)?

ABCDE
Asthma and COPD often cause episodes of difficulty in breathing. A history of prior
hospitalization or intubation for these conditions suggests a high-risk patient.

ƒƒ Is there a history of heart disease or kidney disease?

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

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

ƒƒ Is there a history of diabetes?

BREATHING
Diabetes can cause diabetic crisis (diabetic ketoacidosis or DKA). DKA causes fast breathing
that may be reported as difficulty in breathing.

ƒƒ Is there a history of smoking?

Smoking increases the risk of asthma, COPD, lung cancer and heart attack.

ƒƒ Is there a history of HIV?

SHOCK
HIV infection increases the risk of other infections.

L: LAST ORAL INTAKE

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

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

ƒƒ Was the patient found in or near water?

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

ƒƒ Has there been exposure to pesticides or other chemicals?

GLOSSARY

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

ƒƒ Has there been any recent trauma?

DIB with trauma is concerning for rib fractures, pneumothorax, haemothorax, and heart or
REFS & QUICK CARDS

lung bruising.

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Module 3: Approach to difficulty in breathing

Workbook question 1: Difficulty in breathing

Using the workbook section above, list five questions about past medical history you
would ask when taking a SAMPLE history.
1._______________________________________________________________________

2._______________________________________________________________________

3._______________________________________________________________________

4._______________________________________________________________________

5._______________________________________________________________________

CHECK: SECONDARY EXAMINATION FINDINGS FOR

PATIENTS WITH DIFFICULTY IN BREATHING
DIB may present with changes in respiratory rate, respiratory effort, or low oxygen saturation.
Always assess ABCDE first. The initial ABCDE approach identifies and manages life-threatening
conditions. The secondary exam looks for changes in the patient’s condition or less obvious
causes which may have been missed during ABCDE. If the secondary examination identifies an
ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it.

LOOK
Look for signs of respiratory failure:
ƒƒ Accessory muscle use and increased work of breathing.
ƒƒ Difficulty speaking in full sentences.
ƒƒ Inability to lie down or lean back.
ƒƒ Diaphoresis (excessive sweating) and mottled skin.
ƒƒ Confusion, irritability, agitation.
ƒƒ Poor chest wall movement.
ƒƒ Cyanosis (blue skin colour, especially lips and fingertips).

Look at the pupils for size and reactivity:

ƒƒ Very small pupils suggest possible opioid overdose or exposure to chemicals (including
pesticides).
ƒƒ Unequal or abnormally shaped pupils suggest head injury which can cause abnormal
breathing.

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INTRO
Look at the face, nose and mouth:
ƒƒ Cyanosis around the lips or nose suggests low oxygen levels in the blood.

ABCDE
ƒƒ Pale inner surface of lower eyelids suggests severe anaemia.
ƒƒ Swelling of the lips, tongue and mouth suggests an allergic reaction.
ƒƒ Soot around the mouth or nose, burned facial hair or facial burns suggest smoke inhalation
and airway burns.
ƒƒ Bleeding or swelling of the airway may be due to trauma.

TRAUMA
Look at the neck and chest:
ƒƒ Distended neck veins can be due to a back-up of blood due to heart failure, tension
pneumothorax or pericardial tamponade.
ƒƒ Excessive muscle use in the neck and chest (between the ribs) suggests significant
respiratory difficulty.

BREATHING
ƒƒ If the trachea is shifted to one side, think about tension pneumothorax or tumour.
ƒƒ Swelling or redness of the neck suggests infection or trauma.
ƒƒ Examine the entire neck and chest carefully for bruising, wounds or other signs of trauma.

Look at the rate and pattern of breathing:

ƒƒ People with wheeze may take longer to breathe out because of narrowing of the lower
airways in the lung.

SHOCK
ƒƒ Fast breathing can be due to dehydration, severe infection, chemical imbalance in the
blood, poisoning or anxiety.
ƒƒ Slow and shallow breathing might be due to opioid overdose. Look for very small pupils
and altered mental status.
ƒƒ Chest wall injury is often associated with pain that limits the ability to take deep breaths.

AMS
ƒƒ A flail chest occurs when multiple rib fractures cause a segment of the rib cage to be
separated from the rest of the chest wall. The segment may appear to be moving in the
opposite direction from the rest of chest wall during breathing.

Look at the legs:

ƒƒ Swelling to the both lower legs suggests heart failure as a cause of difficulty in breathing.
SKILLS

ƒƒ Swelling to one leg may be due to a blood clot in the leg. If there is also difficulty in breathing,
this may mean that part of the clot has traveled to the lung.

Look at the skin:

ƒƒ Bites can be a source of allergic reaction.
ƒƒ Rashes, such as hives, can indicate allergic reaction. When associated with difficulty in
GLOSSARY

breathing, rashes can indicate widespread (systemic) infection.

ƒƒ Pallor (pale skin) can indicate anaemia as a cause of DIB.
ƒƒ Circumferential burns (a burn that goes entirely around a body part) to the chest can restrict
chest wall expansion and limit breathing.
REFS & QUICK CARDS

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Module 3: Approach to difficulty in breathing

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

Listen to the heart sounds:

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

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

Percuss the chest wall [See SKILLS]:

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

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INTRO
Workbook question 2: Difficulty in breathing

ABCDE
Using the workbook section above, list three signs you should LOOK for in a patient
with difficulty in breathing.
1._______________________________________________________________________

2._______________________________________________________________________

TRAUMA
3._______________________________________________________________________

List four things you should LISTEN for in a patient with difficulty in breathing.
1._______________________________________________________________________

2._______________________________________________________________________

BREATHING
3._______________________________________________________________________

4._______________________________________________________________________

List three things you should FEEL the chest wall for in a patient with difficulty in
breathing.

SHOCK
1._______________________________________________________________________

2._______________________________________________________________________

3._______________________________________________________________________

AMS
POSSIBLE CAUSES OF DIFFICULTY IN BREATHING
The causes of difficulty in breathing can be organized by body area: airway, lung, heart, or
whole body.

Key airway causes

SKILLS

CONDITION SIGNS AND SYMPTOMS

Foreign body in the • Acute difficulty in breathing
airway • Visible secretions, vomit or foreign body in the airway
• Abnormal sounds from the airway (such as stridor, snoring, gurgling)
• Coughing
GLOSSARY

• Drooling
Severe allergic • Swelling of lips, tongue and mouth
reaction • Stridor and/or wheezing
• Rash or hives
• May have tachycardia and hypotension
• Exposure to known allergen
REFS & QUICK CARDS

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Module 3: Approach to difficulty in breathing

CONDITION SIGNS AND SYMPTOMS

Airway swelling (due • Stridor
to inflammation/ • Hoarse voice
infection)
• Drooling or difficulty swallowing (indicates severe swelling)
• Unable to lie down
• May have fever (with infection)
Airway burns • History of exposure to chemical or fire
• Burns to head and neck (or singed facial hair or soot around nose or
mouth)
• Stridor
• Change in voice

Key lung causes

CONDITION SIGNS AND SYMPTOMS
Pneumonia • Fever and cough
• Gradually more laboured breathing
• Pain worse with breathing (pleuritic)
• Abnormal lung examination (crackles)
Asthma/COPD • Wheezing
• Cough
• Accessory muscle use
• Tripod position (see figure)
• May have history of smoking or allergies
Pneumothorax • Decreased breath sounds on one side
• Sudden onset
• Hollow sounds (hyperresonance) to percussion on affected side
[See SKILLS]
• May have pain that worsens with breathing
• May have history of trauma or evidence of rib fracture
• Hypotension with distended neck veins and decreased breath sounds
on one side indicate tension pneumothorax.
Haemothorax • Decreased breath sounds on affected side
• Dull sounds with percussion [See SKILLS]
• May have a history of trauma, cancer or tuberculosis
Shock (if large haemothorax)
Pleural effusion • Decreased breath sounds on one or both sides
• Dull sounds with percussion [See SKILLS]
• May have history of cancer, tuberculosis, heart disease or kidney disease
• Acute or chronic difficulty in breathing
Acute chest syndrome • History of sickle cell disease
in a patient with • Chest pain
sickle dell disease
• Fever
• Hypoxia

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INTRO
p

ABCDE
TRAUMA
BREATHING
Tripod position

Tripod position

SHOCK
Key heart causes
CONDITION SIGNS AND SYMPTOMS
Heart attack • Pressure, tightness or crushing feeling in the chest
• Diaphoresis and mottled skin
• Nausea or vomiting

AMS
• Signs of heart failure
• History of smoking, heart disease, hypertension, diabetes, high
cholesterol, family history of heart problems
Heart failure • Worse with exertion
• Worse when lying flat
• Swelling to both legs
• Distended neck veins
SKILLS

• Crackles may be heard in the lungs

• May have chest pain
Pericardial • Signs of poor perfusion (tachycardia, tachypnoea, hypotension, pale
tamponade skin, cold extremities, capillary refill greater than 3 seconds)
• Distended neck veins
• Muffled heart sounds
GLOSSARY

• May have dizziness, confusion, altered mental status

• History of tuberculosis, trauma, malignancy, kidney failure
REFS & QUICK CARDS

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Module 3: Approach to difficulty in breathing

Key systemic causes

CONDITION SIGNS AND SYMPTOMS
Anaemia • Pale skin and inner lower eyelids
• Tachycardia
• Tachypnoea
• History of haemorrhage, malnourishment, cancer, pregnancy, malaria,
sickle cell disease, renal failure
Opioid overdose • Clinical or recreational opioid use
• Altered mental status
• Very small pupils
• Slow, shallow breathing
Diabetic ketoacidosis • May have known history of diabetes
• Deep or rapid breathing
• Frequent urination
• Sweet smelling breath
• High glucose in blood or urine
• Dehydrated

Workbook question 3: Difficulty in breathing

Using the workbook section above, list the possible cause of difficulty in breathing
next to the history and physical findings below.

HISTORY AND PHYSICAL FINDINGS LIKELY CAUSE

A 20-year-old man presents with
difficulty in breathing, wheezing and:
• swelling of lips, tongue and mouth
• rash or hives (patches of pale or red,
itchy, warm, swollen skin)
• tachycardia and hypotension
• history of allergies
• exposure to known allergen
A 50-year-old woman presents with
difficulty in breathing, signs of poor
perfusion (tachycardia, tachypnoea,
hypotension, pale skin, cold extremities,
capillary refill >3 seconds) and:
• distended neck veins
• muffled heart sounds
• history of tuberculosis

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INTRO
DO: MANAGEMENT

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

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

BREATHING
transfer.
Choking Use age-appropriate chest thrusts/abdominal thrusts/back blows.
[See SKILLS]
Allergic reaction Remove the allergen, if possible. For severe allergic reaction with difficulty
breathing give intramuscular adrenaline as soon as possible. Give oxygen
for severe cases. [See SKILLS]
Asthma/COPD Administer salbutamol as soon as possible. Give oxygen if indicated.
[See SKILLS]

SHOCK
Fever Give antibiotics as soon as possible if infection might be the cause of
difficulty in breathing. If the patient has signs of poor perfusion, give IV
fluids with caution to avoid fluid overload. [See SKILLS]
Heart attack Give aspirin. While oxygen is no longer recommended in all patients
with heart attack, it should initially be given to patients with shock or
difficulty in breathing. [See SKILLS] For those patients who already have
nitroglycerin, you can assist them in taking it if perfusion is adequate.

AMS
Chronic, severe Give IV fluids more slowly and check the lungs for crackles (fluid overload)
anaemia frequently. [See SKILLS] These patients may need handover/transfer for
blood transfusion.
Diabetic ketoacidosis Give IV fluids. [See SKILLS] A person with diabetic ketoacidosis is
extremely ill and requires urgent transfer to an advanced provider.
Opioid overdose Support breathing with a bag-valve-mask as needed. Give naloxone.
SKILLS

[See SKILLS]
Pleural effusion or Give oxygen. [See SKILLS] Arrange for handover/transfer immediately.
haemothorax Many of these patients will need a chest tube or other drainage.
Trauma All trauma patients with difficulty in breathing should be given oxygen. IV
fluid should be given to help fill the heart if either pericardial tamponade
or tension pneumothorax is suspected. Needle decompression should
GLOSSARY

be performed if tension pneumothorax is suspected. Treat sucking chest

wounds with a 3-sided dressing. [See SKILLS] The patient will need urgent
handover/transfer for a chest tube if needle decompression is performed
or a 3-sided dressing is applied.
Acute chest Give oxygen, IV fluids, antibiotics. May need transfer for advanced
syndrome management.
REFS & QUICK CARDS

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Module 3: Approach to difficulty in breathing

Workbook question 4: Difficulty in breathing

Using the workbook section above, list what you would DO to manage a person who
presents with:

DIB, coughing. You suspect choking.

1. ����������������������������������������
2. ����������������������������������������

DIB, high fever, cough. You suspect

serious infection. 1. ����������������������������������������
2. ����������������������������������������

DIB, hoarse voice and stridor on

breathing in. You to suspect airway 1. ����������������������������������������
inflammation.
2. ����������������������������������������
3. ����������������������������������������

SPECIAL CONSIDERATIONS IN CHILDREN

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

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

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INTRO
Workbook question 5: difficulty in breathing

ABCDE
Using the workbook section above, list the paediatric danger signs.

1._______________________________________________________________________

2._______________________________________________________________________

TRAUMA
3._______________________________________________________________________

4._______________________________________________________________________

BREATHING
5._______________________________________________________________________

6._______________________________________________________________________

7._______________________________________________________________________

SHOCK
8._______________________________________________________________________

DISPOSITION CONSIDERATIONS

AMS
ƒƒ Keep in mind that the effects of inhaled medications such as salbutamol last for only
approximately 3 hours. Patients need to be monitored closely.
ƒƒ If a patient with a severe allergic reaction is given adrenaline, the reaction can return when
the adrenaline wears off. Patients need to be monitored closely.
ƒƒ Naloxone only lasts about 1 hour. Most opioid medications last longer than this, so patients
may need repeat naloxone doses.
SKILLS

ƒƒ Following immersion in water (drowning), a person may develop late signs of breathing
problems after several hours and should be observed closely.
ƒƒ Never leave patients who might need definitive airway placement unmonitored during
handover/transfer. Ensure that a new provider is monitoring the patient before leaving.
ƒƒ Make transfer arrangements as early as possible for any patient who may require assisted
ventilation.
GLOSSARY
REFS & QUICK CARDS

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FACILITATOR-LED CASE SCENARIOS

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

CASE #1: ADULT WITH DIFFICULTY IN BREATHING

A 22-year-old man arrives by taxi. He was robbed on the street, and was stabbed in the left
chest with a knife. He is now having severe difficulty in breathing.

1. What do you need to do in your initial approach?

2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about
look, listen and feel findings; use the Quick Cards for reference as needed.

ASSESSMENT FINDINGS INTERVENTION INTERVENTIONS

NEEDED? TO PERFORM:

AIRWAY YES NO

BREATHING YES NO

CIRCULATION YES NO

DISABILITY YES NO

EXPOSURE YES NO

3. Formulate one sentence to summarize this patient for handover.

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INTRO
CASE #2: PAEDIATRIC PATIENT WITH DIFFICULTY IN BREATHING
A mother brings in her 6-year-old son for difficulty in breathing. The mother states that her son

ABCDE
has been having difficulty breathing for the past 3 days. She says he makes funny noises when
he breathes.

1. What do you need to do in your initial approach?

TRAUMA
2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about
look, listen and feel findings; use the Quick Card for reference as needed.

ASSESSMENT FINDINGS INTERVENTION INTERVENTIONS

NEEDED? TO PERFORM:

BREATHING
AIRWAY YES NO

BREATHING YES NO

SHOCK
CIRCULATION YES NO

DISABILITY YES NO

AMS
EXPOSURE YES NO

3. Formulate one sentence to summarize this patient for handover.

SKILLS
GLOSSARY
REFS & QUICK CARDS

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MULTIPLE CHOICE QUESTIONS

Answer the questions below. Questions and answers will be discussed in the session

1. You are evaluating a 34-year-old female complaining of difficulty in breathing, coughing, and
fever for 3 days. Which of the following actions should you do first?
A. Check blood pressure
B. Administer antibiotics
C. Start an IV
D. Check the lung sounds

2. A 67-year-old man with a history of a heart attack is complaining of difficulty in breathing

that is worse whenever he lies flat. His legs are both swollen, which has become worse in the
past 2 weeks. What is the most likely cause of his difficulty in breathing?
A. Heart failure
B. Asthma
C. Pneumothorax
D. Pneumonia

3. There was a fire in a nearby house and a patient is brought to you with burned nasal hairs
and shortness of breath. What should you do first?
A. Give oxygen
B. Give intramuscular adrenaline
C. Start an IV line
D. Perform needle decompression

4. A 30-year-old woman was stung by a bee and now has difficulty in breathing, facial swelling,
and a rash. She has a history of severe allergic reactions to bee stings. What medication should
you give her?
A. Naloxone
B. Benzodiazepine
C. Adrenaline
D. Aspirin

5. You are assessing a 10-year-old boy for difficulty in breathing. You notice that the skin on his
fingertips and around his mouth has a blue color. What is this finding called?
A. Retractions
B. Nasal flaring
C. Crepitus
D. Cyanosis

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INTRO
Module 4: Approach to shock

ABCDE
Objectives
On completing this module you should be able to:

TRAUMA
1. recognize signs of shock/poor perfusion;
2. perform critical actions for patients with shock;
3. assess fluid status;
4. select appropriate fluid administration based on patient age, weight and condition;
5. recognize malnourishment, anaemia and burns and adjust fluid resuscitation.

BREATHING
Essential skills
ƒƒ Oxygen administration
ƒƒ IV line placement
ƒƒ Fluid status assessment

SHOCK
ƒƒ IV fluid resuscitation
ƒƒ Burn management
ƒƒ Needle decompression
ƒƒ Three-sided dressing
ƒƒ Direct pressure for bleeding control

AMS
ƒƒ Uterine massage for bleeding control
ƒƒ Trauma secondary survey

KEY TERMS
SKILLS

Write the definition using the Glossary at the back of the workbook.

Bolus:

Bradycardia:
GLOSSARY

Capillary refill:

Cholera:
REFS & QUICK CARDS

95
Module 4: Approach to shock

Diaphoresis:

Dehydration:

Diabetic ketoacidosis (DKA):

Dilation (of blood vessels):

Disposition:

Ectopic pregnancy:

Fluid status:

Fontanelle:

Gastroenteritis:

Large-bore IV:

Lethargy:

Oral rehydration solution (ORS):

Perfusion:

Pericardial tamponade:

Resuscitation:

Shock:

Skin pinch testing:

96
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INTRO
Overview
Poor perfusion is when the body is not able to get enough oxygen-carrying blood to vital

ABCDE
organs. When organ function is affected, this is called shock and can lead rapidly to death.
Infants, children and older adults are more likely to be affected by shock.

Causes of poor perfusion which may lead to shock include:

ƒƒ loss of blood (haemorrhage);
ƒƒ loss of fluid due to diarrhoea, vomiting, extensive burns or excess urination (such as caused

TRAUMA
by high blood sugar);
ƒƒ poor fluid intake. Small children, the elderly and the very ill may be unable to drink enough
fluids without assistance and are at risk of dehydration;
ƒƒ abnormal relaxation and enlargement (dilation) of the blood vessels (with the same amount
of blood inside the vessel) can lower blood pressure. This can occur in severe infection,

BREATHING
spinal cord injury and severe allergic reaction;
ƒƒ poor filling of the heart can result from blood or other fluid in the sac around the heart
(pericardial tamponade), or increased pressure in the chest that can shift and block the
vessels returning blood to the heart (tension pneumothorax);
ƒƒ failure of the heart muscle to pump effectively can be due to a heart attack (vessel blockage
that causes acute heart muscle damage); inflammation or other disease of the heart muscle
itself; an abnormal rhythm or valve problems. (Shock due to failure of the heart to pump

SHOCK
effectively is sometimes called cardiogenic shock.)

The goal of INITIAL ASSESSMENT is to identify shock and any reversible causes of shock.
The goal of ACUTE MANAGEMENT is to restore perfusion (oxygen delivery to the organs)
and address ongoing fluid loss where possible.

AMS
This module will guide you through:
ƒƒ ABCDE key elements
ƒƒ ASK: key history findings (SAMPLE history)
ƒƒ CHECK: secondary examination findings
ƒƒ Possible causes
SKILLS

ƒƒ DO: management
ƒƒ Special considerations in children
ƒƒ Disposition considerations

REMEMBER...
GLOSSARY

ƒƒ ALWAYS START WITH THE ABCDE APPROACH, intervening as needed.

ƒƒ Then do a SAMPLE history.
ƒƒ Then do a secondary examination.
REFS & QUICK CARDS

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Module 4: Approach to shock

ABCDE: KEY ELEMENTS IN SHOCK

For the person in shock, the following are key elements that should be considered in the ABCDE
approach.

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

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

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

DISABILITY
D Confusion in a person with poor perfusion suggests severe shock. Paralysis
may indicate a spinal cord injury causing shock.

EXPOSURE
E Look for signs of bleeding, trauma, and excessive sweating (diaphoresis).
Hives can indicate allergic reaction, and other rashes can indicate systemic
infection.

ASK: KEY HISTORY FINDINGS IN SHOCK

Use the SAMPLE approach to obtain a history from the patient and/or family.

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

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INTRO
S: SIGNS AND SYMPTOMS
ƒƒ Has there been vomiting and/or diarrhoea? For how long?

ABCDE
Fluid losses through vomiting and diarrhoea can be severe and can lead to shock. The
amount of vomiting or diarrhoea can help give a rough estimate of the risk for shock, so
always ask about frequency of episodes.

ƒƒ Has the person had blood in stool or vomit?

Bleeding in the stomach and/or intestines can be severe before it is recognized. A person

TRAUMA
can lose a significant portion of his or her blood volume in the intestines. Blood may appear
black in both vomit and stools.

ƒƒ Has there been any vaginal bleeding?

Vaginal bleeding may be related to pregnancy in women of childbearing years. Always
ask about pregnancy status, last menstrual period, any missed periods, or known recent
pregnancy. Blood loss from normal delivery or miscarriage can cause shock. A pregnancy

BREATHING
developing outside the uterus (ectopic pregnancy) can also be life-threatening if it ruptures.
Ectopic pregnancy rupture can occur before a woman even knows she is pregnant. Other
causes of vaginal bleeding are masses in the cervix or uterus.

ƒƒ Has the person had any chest pain?

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

SHOCK
shock.

ƒƒ Has there been fever?

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

ƒƒ Has there been any exposure to toxins, medications, insect stings or other substances?

AMS
Severe allergic reactions can lead to shock. Additionally, many medications, including blood
pressure and seizure/convulsion medications, can cause shock.

ƒƒ Has there been altered mental status or unusual sleepiness?

The brain is one of the last organs to be affected by poor perfusion, so altered mental status
may be a sign of severe shock.
SKILLS

A: ALLERGIES
ƒƒ Does the person have any known allergies?
Allergic reactions can lead to shock by causing abnormal relaxation of the blood vessels.
GLOSSARY
REFS & QUICK CARDS

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Module 4: Approach to shock

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

P: PAST MEDICAL HISTORY

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

ƒƒ History of recent surgery or induced abortion?

Internal bleeding or infection after surgery can lead to shock.

ƒƒ History of heart disease (heart attack or heart valve problems)?

Patients with heart disease are at risk for worsening heart function that may lead to shock
or worsen shock from other causes.

ƒƒ Is there a history of HIV?

HIV increases the risk of infection.

L: LAST ORAL INTAKE

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

E: EVENTS SURROUNDING ILLNESS

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

ƒƒ Has there been any recent illness?

Any infection can cause a blood infection that can spread throughout the body and lead
to shock.

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INTRO
Workbook question 1: Shock

ABCDE
Using the workbook section above, list six questions about signs and symptoms you
would ask when taking a SAMPLE history.
1._______________________________________________________________________

2._______________________________________________________________________

TRAUMA
3._______________________________________________________________________

4._______________________________________________________________________

5._______________________________________________________________________

6._______________________________________________________________________

BREATHING
CHECK: SECONDARY EXAMINATION FINDINGS IN SHOCK
A person with shock will have signs of poor perfusion, which may include a fast heart rate, a
low systolic blood pressure, fast breathing, pale and cool skin, slow capillary refill, dizziness,
confusion, altered mental status, decreased urine output or excessive sweating.

SHOCK
REMEMBER: Perfusion can be limited even before blood pressure falls, especially in the young.
Low blood pressure with poor perfusion is a very serious sign.

Always assess ABCDE first. The initial ABCDE approach identifies and manages life-threatening
conditions. The secondary exam looks for changes in the patient’s condition or less obvious
causes that may have been missed during ABCDE. If the secondary examination identifies an
ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it.

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

ƒƒ Check breath sounds and respiratory rate:

–– Abnormal or noisy breathing can indicate pneumonia as a source for system-wide
SKILLS

infection causing shock.

–– High sugar levels can result in chemical imbalance (diabetic ketoacidosis) that the body
tries to address by faster or deeper breathing. This condition may also result in sweet or
‘fruity’ smelling breath. Since elevated blood glucose levels cause increased urination,
severe dehydration and shock can result.
ƒƒ Check for bleeding:
GLOSSARY

–– All external bleeding should be controlled with direct pressure. [See SKILLS] Arterial
bleeding may appear as pulsing or high pressure bleeding, and significant blood volume
can be lost in minutes.
REFS & QUICK CARDS

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Module 4: Approach to shock

–– Vaginal bleeding may be an important source of blood loss from pregnancy-related

bleeding (even in those who think they are not pregnant) or from masses in the cervix
or uterus.

ƒƒ Check fluid status:

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

ƒƒ Check for pale conjunctiva (the inside of the lower eyelid):

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

ƒƒ Check mental status:

Confusion in a patient with other signs of poor perfusion suggests severe shock.

ƒƒ Check for fever:

Fever in a patient with shock suggests severe infection.

ƒƒ Check blood sugar:

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

ƒƒ Check for severe abdominal pain or a very firm abdomen:

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

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

ƒƒ Check stool:
Any significant diarrhoea can cause dehydration. A large amount of watery, “rice-water”
stool suggests cholera, which can rapidly cause severe dehydration and shock. Black, dark,
or reddish colored stool can suggest stomach or intestinal bleeding.

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INTRO
page 222222
page
page

ƒƒ Check for malnourishment [see SKILLS]:

If the person appears malnourished, fluid must be adjusted
[see SKILLS]. Be sure to ask about recent changes in weight.

ABCDE
TRAUMA
Assessing for pitting edema in children with malnutrition

BREATHING
Assessing
Assessing
Assessing
forfor
pitting
for
pitting
pitting
edema
edema
edema
in children
inin
children
children
with
with
with
malnutrition
malnutrition
malnutrition
Visible severe wasting in a child
Visible severe wasting in a child
ƒƒ Check for swelling, rash or excessive sweating:
Swelling of mouth or body can indicate an allergic reaction. Rashes can indicate allergic
reaction (hives) or systemic infection. Swelling of both legs can indicate heart failure.
Sweating may occur with moderate to severe shock.

SHOCK
Workbook question 2: Shock
Using the workbook section above, list what you need to check for in a person with
shock.

AMS
1._______________________________________________________________________

2._______________________________________________________________________

3._______________________________________________________________________

4._______________________________________________________________________
SKILLS

5._______________________________________________________________________

6._______________________________________________________________________

7._______________________________________________________________________
GLOSSARY

8._______________________________________________________________________

9._______________________________________________________________________

10.______________________________________________________________________
REFS & QUICK CARDS

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Module 4: Approach to shock

POSSIBLE CAUSES OF SHOCK

POOR PERFUSION DUE TO DILATED BLOOD VESSELS
CONDITION SIGNS AND SYMPTOMS
Severe infection • Fever
• Tachycardia
• Tachypnoea
• May have hypotension
• May or may not have obvious infectious source: visible skin infection, cough
and crackles in one area of the lungs (often with tachypnoea), burning
with urination, urine that is cloudy or foul smelling, or any focal pain in
association with fever
Spinal cord injury • History or signs of trauma
• May have spinal pain/tenderness, vertebrae not in line, or crepitus
(crunching) when you touch the spinal bones
• Movement problems: paralysis, weakness, abnormal reflexes
• Sensation problems: tingling (“pins and needles” sensation), loss of
sensation
• Unable to control urine and stools
• Priapism
• May have hypotension or bradycardia
• Difficulty in breathing with an upper cervical spine injury
Severe allergic • Swelling of the mouth
reaction • Difficulty breathing with stridor and/or wheezing
• Skin rash
• Tachycardia
• Hypotension

POOR PERFUSION DUE TO FLUID LOSS

CONDITION SIGNS AND SYMPTOMS
Diabetic • May have known history of diabetes
ketoacidosis (DKA) • Rapid or deep breathing
• Frequent urination
• Sweet-smelling breath
• High glucose in blood or urine
• Dehydration
Severe • Abnormal skin pinch
dehydration • Decreased fluid consumption or increased fluid loss (vomiting, diarrhoea,
excessive urination)
• Dry mucous membranes
• Tachycardia
Burn injury • Red, white or black areas of skin depending on depth of burn
• May have blistering
• May have signs of inhalational injury

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INTRO
POOR PERFUSION DUE TO BLOOD LOSS
CONDITION SIGNS AND SYMPTOMS

ABCDE
External bleeding • History of trauma
• Visible bleeding
• Use of blood-thinning medications
Large bone • History of trauma
fracture • Pain or abnormal movement of the pelvis, blood at opening of penis or
rectum (pelvic fracture)

TRAUMA
• Deformity or crepitus of the femur, shortening of the leg with the injury
(femur fracture)
Abdominal • Bruising around the umbilicus or over the flanks can be a sign of internal
bleeding bleeding
• Abdominal pain
• Very firm abdomen

BREATHING
Bleeding in • Blood in vomit or stool
the stomach or • Black vomit or stool
intestines
• History of alcohol use
Haemothorax • Difficulty in breathing
• Decreased breath sounds on affected side
• Dull sounds with percussion on affected side
• Shock (if large amount of blood)

SHOCK
Ectopic pregnancy • History of pregnancy, missed menstrual cycle or any woman of childbearing
age
• Abdominal pain
• Vaginal bleeding
Postpartum • Recent delivery
haemorrhage • Heavy vaginal bleeding:
–– Pad or cloth soaked in <5 minutes

AMS
–– Constant trickling blood
–– Bleeding >250 ml
–– Soft uterus/lower abdomen
SKILLS
GLOSSARY
REFS & QUICK CARDS

105
Module 4: Approach to shock

POOR PERFUSION DUE TO PROBLEMS WITH THE HEART

CONDITION SIGNS AND SYMPTOMS
Heart failure • Difficulty breathing with exertion or when lying flat
• Swelling to both legs
• Distended neck veins
• Crackles may be heard in the lungs
• May have chest pain
Heart attack • Pressure, tightness, pain or crushing feeling in the chest
• Diaphoresis and mottled skin
• Difficulty in breathing
• Nausea or vomiting
• Pain moving to jaw or arms
• Signs of heart failure
• History of smoking, heart disease, hypertension, diabetes,
high cholesterol, family history of heart problems
Abnormal heart rhythm • Very fast or very slow pulse
• Irregular pulse
Heart valve problem • History of rheumatic fever or heart disease
• Murmur
Pericardial tamponade • Signs of poor perfusion (tachycardia, tachypnoea,
hypotension, pale skin, cold extremities, capillary refill greater
than 3 seconds)
• Distended neck veins
• Muffled heart sounds
• May have dizziness, confusion, altered mental status
• History of tuberculosis, trauma, cancer, kidney failure
Tension pneumothorax • Hypotension WITH the following:
–– Difficulty breathing
–– Absent breath sounds on affected side
–– Hyperresonance with percussion on affected side
–– Distended neck veins
–– May have tracheal shift away from affected side

REMEMBER... hypoglycaemia can look like shock. Signs and symptoms include:
• Sweating (diaphoresis)
• Seizure/convulsion
• Blood glucose <3.5 mmol/L
• Altered mental status (ranging from confusion to unconsciousness)
• History of diabetes, malaria, or a severe illness, especially in children

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INTRO
Workbook Question 3: Shock

ABCDE
Using the workbook section above, list the possible cause of shock next to the history
and physical findings below.

HISTORY AND PHYSICAL FINDINGS LIKELY CAUSE

A 35-year-old woman presents with shock,
fever and:

TRAUMA
• burning with urination
• cloudy urine

A 20-year-old woman presents with shock,

abdominal pain and:
• missed menstrual cycle
• vaginal bleeding

BREATHING
A 17-year-old man presents after a motor
vehicle crash with shock, bruising to the pelvis
and:
• a femur fracture

DO: MANAGEMENT

SHOCK
FIRST PERFORM ABCDE ASSESSMENT AND INTERVENE FOR LIFE-
THREATENING CONDITIONS.
Start by giving IV fluid (normal saline or Ringer’s Lactate in adults and children with normal
nutritional status). Then work to address underlying causes. Place IV access rapidly (two
large-bore IVs) and start IV fluids. Place IV access rapidly (two large-bore IVs), start IV fluids and

AMS
assess response. Repeat with additional boluses if needed. [See SKILLS] If you cannot place an
IV, immediately call for a provider who can place a nasogastric tube (a tube that goes from the
nose into the stomach) or intraosseous line (a needle that is placed directly into the bone). See
if the patient can safely take oral fluids in the meantime.

CAUTION! For severely malnourished or severely anaemic people, or anyone with signs
SKILLS

of volume overload, do NOT follow the fluid protocol below. Use adjusted protocol. [See
SKILLS]
GLOSSARY
REFS & QUICK CARDS

107
Module 4: Approach to shock

GIVING FLUID IN SHOCK

NO malnutrition, overload or severe anaemia

IV FLUID IMMEDIATELY IV FLUID START ORS via NG

No No
AVAILABLE? AVAILABLE NEARBY? NASOGASTRIC TUBE

YES <30 MINUTES

YES
REASSESS IMMEDIATELY
START IV FLUIDS
AFTER BOLUS

<30 MINUTES

REASSESS IMMEDIATELY TRANSFER No DID PERFUSION

AFTER BOLUS IMMEDIATELY IMPROVE?
CONTINUE ORS
VIA NG
DID PERFUSION IMPROVE? No RE-BOLUS
YES

YES CONTINUE
E

IV
FLUIDS

If vaginal bleeding after delivery (postpartum haemorrhage) is suspected as a cause of

shock: ALL patients need rapid handover/transfer to an advanced obstetric provider. While
arranging for transport and during transport, it is important to try to stop the bleeding.
Give BOTH intramuscular and IV oxytocin. This is a loading dose. After these doses, continue
oxytocin IV until one hour after the bleeding stops. [See SKILLS] Bleeding frequently happens
if the uterus is not fully contracted (does not feel hard on palpation). Perform uterine massage
[See SKILLS] until the uterus is hard. You should use BOTH oxytocin and uterine massage to
stop the bleeding. If the placenta delivers,
collect it in a leak-proof container and
keep with the patient to allow the
advanced obstetric provider to examine it.
Visually check externally for a perineal or
vaginal tear. If found, apply direct pressure
with sterile gauze and put legs together.
Even if the bleeding stops, these patients
still need rapid handover/transfer to an
advanced obstetric provider (see figure).

Uterine massage for postpartum hemorrhage

Uterine massage for postpartum hemorrhage

108
 PARTICIPANT WORKBOOK

INTRO
Postpartum Haemorrhage

ABCDE
1. Arrange immediate transfer to qualified obstetric provider!

2. Attempt to control bleeding while arranging and during transfer.

Massage uterus until it is hard.

Heavy bleeding after Give oxytocin IM.

TRAUMA
delivery? Give IV fluids and IV oxytocin.
Empty bladder.

3. Check:

Continue uterine massage.

BREATHING
NO
Has the placenta When uterus is hard, the placenta will
delivered? likely deliver.
Collect placenta and keep with patient.
YES
Continue oxytocin.

Continue to massage uterus until hard.

Continue oxytocin.

SHOCK
Is there a perineal or YES
Apply pressure with sterile gauze,
lower vaginal tear? put legs together.

Continue oxytocin for at least 1 hour

NO
Still bleeding? after bleeding stops.

Continue IV fluids with oxytocin.

AMS
YES
Insert second IV line.

4. Transfer immediately
SKILLS

REMEMBER... fluid only addresses the immediate problem of perfusion. Patients with shock
need rapid handover/transfer to a unit capable of addressing the causes of shock and providing
advanced management, including transfusion.

REMEMBER... fluid status assessment is critical. Patients who have signs of poor perfusion but
overall volume overload can be particularly difficult to manage. Patients with malnutrition,
severe anaemia, and excess fluid in the lungs due to heart, liver, or kidney failure can present
GLOSSARY

this way. These patients still need fluids, but the fluids must be given cautiously and, especially
in malnourished children, according to a specific protocol. [See SKILLS]
REFS & QUICK CARDS

109
Module 4: Approach to shock

DO: MANAGEMENT OF SPECIFIC CONDITIONS

• Always perform ABCDE first. Patients in shock need oxygen.

• In all forms of shock, the primary management is administration of IV fluids
appropriate for age and condition.
• The specific conditions below require additional considerations.

CONDITION MANAGEMENT CONSIDERATIONS

Burns • Burns disrupt the skin barrier and can cause significant fluid
losses that can lead to shock. These patients have different fluid
replacement needs. [See SKILLS]
Hyperglycaemia • If concern for diabetic ketoacidosis, treat with IV fluids.
[See SKILLS] A person with diabetic ketoacidosis is extremely ill
and requires rapid transfer to a unit where IV infusion and close
monitoring are available.
Fever • Give fluids and start antibiotics. [See SKILLS] If infectious
diarrhoea (like cholera) is suspected, use gloves, aprons and
relevant isolation precautions and report it to the local public
health agency. If signs of poor perfusion do not improve with
fluids, consider rapid handover/transfer.
Spinal cause • Give IV fluids and refer for ongoing management at a unit that
can provide spinal care. [See SKILLS]
Stomach or intestinal • Start IV fluids and refer for blood transfusion. [See SKILLS]
bleeding
Ectopic pregnancy • Give IV fluids and refer for blood transfusion and obstetric care.
[See SKILLS]
Postpartum haemorrhage • Give oxytocin and IV fluids and plan for rapid transfer to facility
with blood transfusion and obstetric care capabilities.
• Give IV fluids and massage uterus until it is hard. [See SKILLS]
• Give oxytocin. [See SKILLS]
• If the placenta has delivered, collect it in a leak-proof container
and keep with patient for inspection by advanced provider.
• Check for perineal and vaginal tears and apply direct pressure.
Tension pneumothorax • Perform needle decompression immediately to relieve the
pressure, give oxygen and IV fluids. [See SKILLS] Any patient
who has had a needle decompression will need rapid handover/
transfer to a unit that can place a chest tube.
Pericardial tamponade • Give IV fluids to help fill the heart against the building pressure
in the heart sac. [See SKILLS] Plan for rapid handover/transfer to
a provider who can drain the pericardial fluid.

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INTRO
CONDITION MANAGEMENT CONSIDERATIONS
Suspected heart attack • Give aspirin if indicated. Place an IV and give fluids, re-assessing

ABCDE
the patient frequently. [See SKILLS]
• While oxygen is no longer recommended in all patients with
heart attack, it should initially be given in patients with shock or
difficulty in breathing, even when heart attack is the suspected
cause.
• Plan for rapid handover/transfer to advanced provider.
Heart failure • Give IV fluids more slowly, checking the lungs for crackles

TRAUMA
(fluid overload) frequently. Stop IV fluids if fluid overload
develops (difficulty in breathing, crackles in the lungs, increased
respiratory rate, increased heart rate). [See SKILLS]
• Plan for rapid handover/transfer to an advanced provider.
Severe allergic reaction • Give intramuscular adrenaline [See SKILLS]. These patients will
also need IV access and fluids as their condition can rapidly
worsen once the adrenaline wears off. You may give a second

BREATHING
dose if the effects wear off. [See SKILLS] If the airway is swollen or
there is difficulty in breathing, patients may need rapid transfer.
Traumatic injury or rapid • Stop the bleeding, give IV fluids, and conduct a thorough
blood loss suspected trauma assessment. [See SKILLS] Refer for blood transfusion and
ongoing surgical management.

Workbook question 4: Shock

SHOCK
Using the workbook section above, list what you would do to manage this patient.

A 6-year-old boy is brought in 1.����������������������������������������

with fever. He is in shock and
does not appear malnourished. 2.����������������������������������������
Your facility has supplies to put

AMS
in an IV.
3.����������������������������������������

A young man is brought in after a

motorcycle crash. He has a large 1.����������������������������������������
cut to his arm that is bleeding
and there is a large pool of blood 2.����������������������������������������
SKILLS

under him. He is in shock when

you examine him.
3.����������������������������������������

A 30-year-old woman is brought

in after accidentally eating 1.����������������������������������������
prawns. She has a known
shellfish allergy, her body is 2.����������������������������������������
GLOSSARY

covered in a red, itchy rash and

she is in shock.
3.����������������������������������������
REFS & QUICK CARDS

111
Module 4: Approach to shock

SPECIAL CONSIDERATIONS IN CHILDREN

Shock can occur quite rapidly in children and is life-threatening. Children have a
relatively larger surface area (compared to their body volume) and are thus likely to
become dehydrated more rapidly. Infants and young children are particularly at risk as
they are unable to say when they are thirsty and cannot drink more on their own.
Assessing shock in children: The clinical definition of shock in children varies. The 2016
WHO guidelines for the care of critically ill children use the presence of three clinical
features: cold extremities, capillary refill greater than 3 seconds, and weak and fast pulse.
There are also other important signs of poor perfusion, including low blood pressure,
fast breathing, altered mental status, and decreased urination (always ask parents how
much urine the child is passing). [See SKILLS]

Signs of dehydration in children

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

Abnormal skin pinch in a child

Common causes of shock and dehydration in children include:

• Vomiting and diarrhoea:Abnormal skin pinch
Gastroenteritis in a sudden
causes child onset of vomiting and
diarrhoea with some abdominal pain and fever. Large amount of watery diarrhoea
may suggest cholera, and needs to be reported to public health authorities.
• Vomiting without diarrhoea: Vomiting without diarrhoea or fever may suggest raised
pressure on the brain (trauma, tumour, brain swelling), or intestinal blockage. It is
important to examine the child for signs of trauma. Vomiting associated with fever
may suggest infection.
• Overwhelming infection: Fever can cause children to become dehydrated quickly. In
addition, overwhelming infection can cause blood vessels to dilate, worsening shock.

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INTRO
Special management considerations:

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

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

BREATHING
1._______________________________________________________________________

2._______________________________________________________________________

3._______________________________________________________________________

4._______________________________________________________________________

SHOCK
5._______________________________________________________________________

6._______________________________________________________________________

7._______________________________________________________________________

8._______________________________________________________________________

AMS
DISPOSITION CONSIDERATIONS
ƒƒ People with shock can worsen and die quickly. They must be monitored very closely.
ƒƒ Additionally, the same illnesses that cause shock interfere with the body’s ability to manage
SKILLS

fluids, so these patients must be monitored very closely for signs of difficulty in breathing.
ƒƒ Patients with shock may be confused and anxious. Ensure they are safe and contained
during transfer.
ƒƒ Patients with shock are often transferred for transfusion or general or obstetric surgery.
Always communicate directly with the receiving facility to make sure that these resources
are actually available at the time of transfer.
GLOSSARY
REFS & QUICK CARDS

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Module 4: Approach to shock

FACILITATOR-LED CASE SCENARIOS

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

CASE #1: ADULT SHOCK

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

1. What do you need to do in your initial approach?

2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about
look, listen and feel findings; use the Quick Card for reference as needed.

ASSESSMENT FINDINGS INTERVENTION INTERVENTIONS

NEEDED? TO PERFORM:

AIRWAY YES NO

BREATHING YES NO

CIRCULATION YES NO

DISABILITY YES NO

EXPOSURE YES NO

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INTRO
3. Formulate one sentence to summarize this patient for handover.

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

TRAUMA
1. What do you need to do in your initial approach?

BREATHING
2. Use the ABCDE approach to assess and manage this patient. Ask the facilitator about
look, listen and feel findings; use the Quick Card for reference as needed.

ASSESSMENT FINDINGS INTERVENTION INTERVENTIONS

NEEDED? TO PERFORM:
AIRWAY YES NO

SHOCK
BREATHING YES NO

CIRCULATION YES NO

DISABILITY YES NO AMS

SKILLS

EXPOSURE YES NO
GLOSSARY

3. Formulate one sentence to summarize this patient for handover.

REFS & QUICK CARDS

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Module 4: Approach to shock

MULTIPLE CHOICE QUESTIONS

Answer the questions below. Questions and answers will be discussed in the session.

1. A 7-year-old boy has had lethargy, vomiting and diarrhoea for the past 4 days. His vital signs
are: blood pressure 80/40 mmHg, heart rate 140 beats per minute, respiratory rate 18 breaths
per minute. The patient vomits when you try to give anything by mouth. What is your most
immediate management?
A. Start an IV line and give fluids
B. Continue to attempt oral rehydration
C. Place a nasogastric (NG) tube and hydrate through it
D. Rapidly transfer to a referral hospital

2. You are taking care of a 28-year-old man who was shot in the abdomen. He is lethargic and
the vital signs are as follows: blood pressure 80/40 mmHg, heart rate 130 beats per minute,
respiratory rate 20 breaths per minute. There is heavy bleeding from the gunshot wound and
the abdomen is rigid and tender. What is the first intervention you should give this patient?
A. IV fluids
B. Intraosseous line
C. Surgery
D. Adrenaline

3. A child that presents with sunken eyes, small amounts of dark urine, dry mucous membranes
and abnormal skin pinch testing is most likely suffering from:
A. Pneumonia
B. Head injury
C. Dehydration
D. Hypoglycaemia

4. A 60-year-old man states he has been weak and dizzy for the past week. His vital signs are:
blood pressure 90/50 mmHg, heart rate 125 beats per minute, respiratory rate 16 breaths per
minute. His skin is cool and pale. He states that his stools have been black for the past 2 days.
What is the most likely cause of his shock?
A. Stomach bleeding
B. Abdominal trauma
C. Dehydration
D. Severe infection

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INTRO
5. You are assessing a 23-year-old man who was stabbed in the chest. You expose the chest
to find one stab wound in the right chest with minor bleeding. He is complaining of severe
difficulty in breathing and there are no lung sounds on the right side. His neck veins are

ABCDE
distended and his skin is cool and sweaty. His vital signs are: blood pressure 86/56 mmHg,
heart rate 136 beats per minute, respiratory rate 28 breaths per minute. What is your next step?
A. Chest tube placement
B. Needle decompression
C. Blood transfusion

TRAUMA
D. Start IV fluids

BREATHING
SHOCK
AMS
SKILLS
GLOSSARY
REFS & QUICK CARDS

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