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MARCH Algorithm For Treatment Priorities
The first step in “Indirect Threat Care” is to stop all severe bleeding. Without the blood in the body the patient will quickly die. So address this important item first. Use things like tourniquets, packing gauze, quickclot and pressure bandages to accomplish this.
Next up is ensuring the patient has an open airway. Use manual maneuvers like a head tilt chin lift or jaw thrust maneuvers to open the airway and move the tongue off the back of the throat. If you are unable to hold the airway open continuously you can use adjuncts such as the NPA or OPA to free you up to do other things or treat other patients. Consider using the recovery position if the patient doesn’t have severe spinal injury.
Not only does blood have to go round and round but air needs to go in and out of the lungs to sustain life. So next up we will address any problems with the patient being able to move air in and out. If there is a hole in the side of the chest we need to put an occlusive dressing on this to allow the lungs to stay inflated or re-inflate if they are already collapsed. If we address the hole in the chest but still don’t have air movement in and out, we may need to ventilate the patient with positive pressure ventilation using a BVM. If you loose lung sounds on one side of the chest this may indicate a tension pneumothorax which would need a needle decompression.
Under this section we will now reassess any bleeding control measures we have taken, convert tourniquets to wound packing if indicated, apply pelvic binders and then begin fluid replacement or blood product administration for those trained to do so. We can also address more minor and less life threatening bleeding at this time.
If the person is in shock, has lost blood, is wet with bloody clothes, or they are laying on the ground they may rapidly loose body heat. Just because you are hot doesn’t mean the patient is warm enough. And if the body temperature drops the body can no longer produce blood clots which is a real problem for bleeding patients. Take bloody or wet clothes off your patient, get them up off the ground and keep them covered up.
Also monitor for head injuries. Patients can become combative, confused and may need more urgent care if they have brain swelling or a brain bleed. This brain swelling or bleeding can cause abnormal breathing so make sure you continue to reassess these previous steps and ventilate your patient as necessary.
Learn How To Take Vital Signs
Diagnostics are the tools and techniques used to determine a patients severity and determine the extent of the injury or illness.
Vital Signs are the measurements of essential body functions such as breathing, heart rate and blood pressure to determine the current state of the patient.
Heart rate or pulse rate is a measure of how many times your heart beats in a minute. This is written as BPM for Beats Per Minute. Normal pulse ranges are listed below.
Adult (>12 yrs): 60-100 BPM
Pediatric (1-12 yrs): 80-140 BPM
Infant (1-12 months): 100-190 BPM
Neonate (<1 month): 140-205 BPM
Respirations or breathing rate is the number of times a person breaths in and out in one minute. Normal breathing rates are listed below.
Adult (>12 yrs): 12-20 per minute
Pediatric (1-12 yrs): 20-30 per minute
Infant (1-12 months): 20-30 per minute
Neonate (<1 month): 30-50 per minute
A blood pressure measures two numbers: the static base pressure in your arteries between heart beats (diastolic pressure) and then the peak pressure in your arteries at the climax of your heart beat (systolic pressure). These pressures are measured in millimeters of mercury and are written “mmHg.”
Normals pressures are listed below. Normal pressures can fluctuate a bit and each patients has a slightly different pressure which is normal for them.
Adult (>12 yrs): 120/80
Pediatric Systolic BP Formula: 2 x age in years + 80
Measured by a pulse oximeter, this vital sign is often shortened to “o2 sats.” This number is expressed as an average percentage of the hemoglobin in your blood that have oxygen attached to them. Simply put, you should have an oxygen saturation between 94-100% meaning that most of the cells in your blood that are supposed to carry oxygen are actually doing what they are supposed to do…carrying oxygen. When using a pulse ox it is important to know that these devises can easily give you false information. Watch our video to the right to get a better understanding of how this tool works and also how it can fail.
Normal Oxygen Levels: 94-100%
Mild Hypoxia – 89-93%
Moderate Hypoxia – 84-88%
Severe Hypoxia – <84%
A patients blood sugar level (blood glucose level) indicates how well the patient is nourished with food and how well the patient can then process that food to make energy. These are key aspects we need to pay attention to during an assessment. We especially need to pay attention to this if the patient is unresponsive or has an altered mental status. A low or extremely high blood sugar can cause confusion, unresponsiveness or even stroke like symptoms.
Normal Glucose Levels: 80-120 mg/dL
Minimum Normal Glucose Levels:
Adults: 80 mg/dL
Child: 60 mg/dL
Infant: 40 mg/dL
Keep in mind that everyone’s thresholds will vary a bit depending on health and metabolism. A glucose may also be abnormally high right after a meal which may be a completely normal finding as the body attempt to process the carbs and sugars from the recent food ingested.